Dwelling is not just a family in a fine house, it is a community in a fine place.—Mindy Thompson Fullilove1
Kelleher et al2 described Nationwide Children’s Hospital’s use of the medical model to present a case of the surrounding neighborhood, Southern Orchards, as a patient suffering from a “syndrome” comprised of concentrated poverty, housing instability, racial segregation, environmental toxins, violence, property crimes, and poorly performing schools. The patient is suffering from a diagnosis called “community trauma,” the etiology of which is structural violence: the harm that individuals, families, and communities experience from inequitable economic and social structures, social institutions, relations of power, privilege, and inequality that prevent them from meeting their basic needs.3,4
After completing a detailed neighborhood diagnostic assessment using multiple sources of data, the authors conclude that this syndrome was driven primarily by a lack of housing stability, created and sustained by an ongoing housing crisis and exacerbated by the subprime mortgage collapse of 2008. The treatment plan included a multifaceted strategy aimed at stabilizing the housing market and improving the built environment. These interventions included home repair programs, home ownership programs, home construction, career development, and rental agency development. The hospital acted as the lender and financier of housing interventions, community-based organizations provided the grassroots community connections to residents living in the neighborhood, and the Mayor’s Office of Economic Development facilitated a range of financial mechanisms to support these efforts.
The metaphor of the neighborhood as the patient is a novel approach and is accessible to clinicians and health care administrators. This case example illustrates how health care systems, in concert with community and civic partners, can function as anchor institutions to effect structural changes that may have positive impacts on population health. We find their approach to be highly commendable. Following the model advanced by Pinderhughes et al,3 we offer Homes for Health the following suggestions for next steps and areas for concentrated focus that may increase their return on investment:
The physical and built environment: Although much of the focus of this initiative has been on rehabilitating houses, creating spaces for positive interactions among neighbors that are reflective of the community culture, public spaces for play and improving the surrounding built environment in ways that are appealing to residents are important strategies for stimulating community pride and cohesiveness;
The economic environment: Use a multisectoral approach to address job readiness and job training that go beyond nonskilled labor and temporary stipend-earning jobs. Partnering with local community colleges, technical colleges, and universities to prepare a diverse workforce that is able to earn livable wages as well as training and including previously incarcerated members of the community will foster and sustain economic skills, capacity, and growth for Southern Orchards;
The sociocultural environment: Strengthen social relationships between neighbors and institutions by staying involved in community events and fostering additional collaborations that can shift and strengthen the relationship and trust between residents of the community and the institutions embedded within it. Creating intentional opportunities for residents of different income mixes to mingle and build the community is an important strategy to prevent income silos; and
Fostering residents’ political power through civic engagement is another strategy for enhancing residents’ sense of place. Voter registration, voter engagement, and political empowerment offer residents a locus of control into how their community evolves and changes and provide a conduit through which policies and systems that impact the neighborhood and its residents may be engaged.
Finally, it is imperative to recognize that the condition of this "patient" is a result of its social history of dispossession and trauma, the result of which has been the systematic displacement of many of its long-term residents. Over the last decade, this community has endured a structural dismemberment of community residents, who were forced to leave their homes. And as innovative and well-intended as the treatment plan is, it is equally important to recognize that this initiative is a redevelopment program built on that displacement. Therefore, we strongly urge those in this collaborative to think strategically about ways of finding those who have been displaced and testing strategies that reestablish connections with them so that they may benefit from these efforts, efforts that demonstrate a shift from redevelopment to rebuilding. In doing so, Southern Orchards may enjoy a restored sense of community, cultural identity, and history that goes a long way in promoting social justice to all Southern Orchards residents.
The Homes for Health initiative is an innovative and focused policy intervention designed to disrupt upstream environmental and economic mechanisms that perpetuate health inequalities, and it is part of a coherent strategy to improve and promote population health while reducing health care costs and mitigating poor health outcomes. We wish this collaborative well and look forward to hearing more about its progress.
Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.
FUNDING: No external funding.
COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2018-0261.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.