Neighborhood Adversity, Child Health, and the Role forCommunity Development

abstractDespite medical advances, childhood health and well-being have notbeen broadly achieved due to rising chronic diseases and conditionsrelated to child poverty. Family and neighborhood living conditions canhave lasting consequences for health, with community adversity affect-ing health outcomes in significant part through stress response andincreased allostatic load. Exposure to this “toxic stress” influencesgene expression and brain development with direct and indirect neg-ative consequences for health. Ensuring healthy child developmentrequires improving conditions in distressed, high-poverty neighbor-hoods by reducing children’s exposure to neighborhood stressors andsupporting good family and caregiver functioning. The communitydevelopment industry invests more than $200 billion annually in low-income neighborhoods, with the goal of improving living conditions forresidents. The most impactful investments have transformed neighbor-hoods by integrating across sectors to address both the built environ-ment and the social and service environment. By addressing manyfacets of the social determinants of health at once, these efforts suggestsubstantial results for children, but health outcomes generally have notbeen considered or evaluated. Increased partnership between thehealth sector and community development can bring health outcomesexplicitly into focus for community development investments, help opti-mize intervention strategies for health, and provide natural experimentsto build the evidence base for holistic interventions for disadvantagedchildren. The problems and potential solutions are beyond the scope ofpracticing pediatricians, but the community development sector standsready to engage in shared efforts to improve the health and develop-ment of our most at-risk children. Pediatrics 2015;135:S48–S57

AUTHORS: Douglas P. Jutte, MD, MPH,a,b,c Jennifer L. Miller,PhD,b,c and David J. Erickson, PhDd

aUC Berkeley-UCSF Joint Medical Program, University ofCalifornia, Berkeley, School of Public Health, Berkeley, California;bBuild Healthy Places Network, San Francisco, California; cPublicHealth Institute, Oakland, California; and dFederal Reserve Bankof San Francisco, San Francisco, California

KEY WORDSallostatic load, community, community development, intervention,neighborhood, public health, social determinants of health, toxicstress

All authors conceptualized and designed the article, drafted andrevised the manuscript, and approved the manuscript assubmitted.

The views expressed here are the authors’ and do not representthe Federal Reserve Bank.

www.pediatrics.org/cgi/doi/10.1542/peds.2014-3549F

doi:10.1542/peds.2014-3549F

Accepted for publication Dec 19, 2014

Address correspondence to Douglas P. Jutte, MD, MPH, BuildHealthy Places Network, 870 Market Street, Suite 1255, SanFrancisco, CA 94102. E-mail: dpjutte@berkeley.edu

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2015 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they haveno financial relationships relevant to this article to disclose.

FUNDING: Drs Jutte and Miller were supported by funding fromthe Robert Wood Johnson Foundation.

POTENTIAL CONFLICT OF INTEREST: The authors have indicatedthey have no potential conflicts of interest to disclose.

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On many fronts, pediatrics has beensuccessful in improving the health ofchildren. Medical advances and publichealth measures have reduced the oc-currence of acute life-threatening dis-eases that were once the predominantcause of childhood mortality and mor-bidity. According to measures other thanacute illness, however, children are notfaring as well. Chronic and noncom-municable diseases are on the rise,1 andracial and socioeconomic disparitiescontinue to widen, not only in standardmeasures of health but also across therange of life circumstances that contrib-ute to well-being such as education andemployment. More than 1 in 5 US childrenlive in poverty; among Latino and African-American children, it is ∼1 in 3.2

These social disparities have the samesort of impact on poor children as doesbullying of the weak by the strong. So-cial inequality is the population equiv-alent of the social hierarchies that existamong schoolchildren on the play-ground. Pediatricians are uniquely po-sitioned to see the effects of thesegrowing threats to child developmentand well-being. At the same time, wepediatriciansmay feel poorly equipped,in thecontextofourclinicalpractices, toaddress the biggest health challengesour patients face.3

What can pediatricians do to addressthe community-level social hierarchiesso prevalent in our society? We knowthat the family and neighborhood livingconditions that our patients face canhave lifelong consequences for theirhealth. Recent advances from acrossfields of science reveal that exposure toadversity (particularly the sustained,unmediated adversity producing “toxicstress”) becomes biologically embed-ded, influencing gene expression andbrain development. It has both directhealth consequences as well as indirecthealth effects due to the resultant lowereducational attainment, lower economicstatus, and poorer health behaviors.4–7

The effect of these latter factors is mul-tiplied because they place children intohigher risk environments as they movethrough adolescence and adulthood.The result is significant differences inlife expectancy and health outcomesthroughout the life span and multigen-erational disadvantage. Simply put, one’sbody is the sum record of the challengesand opportunities faced throughout life.

Too many neighborhoods have too fewopportunities and toomany challenges.This fact is hurting the health of manyAmericans, and children bear the bruntbecause so many live in poverty. By un-derstanding the developmental mecha-nismsbywhichadversitygets “under theskin,”8,9 we are better able to designinterventions to improve child develop-mental and health outcomes. Pedia-tricians witness the effects of thesedisparities. We are in a unique position,therefore, to advocate for change.

To address health disparities, we can-not simply intervene with medical care,even medical care in early childhood.10

We will also not be successful in ame-liorating the effects of poverty by pro-viding single-focus interventions, suchas pre-K education. Such interventionsare extremely important but do not—in isolation—overcome the deepereffects of sustained adversity.11 In-stead, a critical strategy requires im-provement in the overall neighborhoodconditions and life circumstances intowhich children are born and spendtheir early childhood years.12

The tools to improve neighborhoodconditions are beyond the means orcapabilities ofmedical careproviders oreven public health practitioners. How-ever, thefieldofcommunitydevelopmenthas been building the expertise to allowus to transform neighborhoods in waysthat will have a profound effect onchildren’s health, both during childhoodand throughout life.

The community development industryhas a growing number of examples in

which disordered, high-poverty neigh-borhoods have been transformed toprofoundly improve the trajectories andlife chances of the children living inthem.13 These efforts have broughtmultiple elements together, often utiliz-ing many funding streams and facilitat-ing collaboration among partners fromdifferent sectors of society. For example,they unite affordable housing, bettereducation, functional transportation,and reliable public safety. These suc-cessful efforts are a great public policysuccess story. It is a success story,however, that is not well known.

Community development improves childhealth outcomes but, generally speak-ing, improving health has only rarelybeen an explicit goal of these projects. Infact, in most cases, there has been noresearch on health outcomes. Theseefforts may represent solutions to thebiggest child developmental challengewe face today: entrenched, multigener-ational poverty and the impact ofgrowing up in high-poverty neighbor-hoods. The present article proposes thenext steps for taking this approach toscale and maps out the critical role thatthehealthsectorcanplay tobringhealthoutcomes more explicitly into focus inthese projects, to optimize interventionstrategies, and to use these naturalexperiments to build the evidence basefor what works.

EVIDENCE FOR NEIGHBORHOODCONTEXT AND CHILD HEALTH

Neighborhood Matters to HealthOutcomes

Relationships with parents and care-givers form an emotionally protectiveenvironment for early childhood de-velopment. Communities or neighbor-hoods, similarly, are an influentialenvironment, positive or negative, foradolescents,14 adults, and families.15,16

Neighborhood disadvantage, therefore,harms young children in part throughits impact on family functioning.17–19

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Research into the mechanisms and theimpact of neighborhood conditions onhealth has now been underway for.2decades.20 Key neighborhood factorsaffecting individual and family well-being include social integration, per-ceived control, financial strain,21 socialcapital, residential stability, and safetyor exposure to violence.20 Althougha handful of studies have suggestedcaution regarding the nuance of theselinks,22–24 a substantial body of re-search now supports this connection:neighborhood conditions have an im-portant and independent impact onlong-term health outcomes.

Living in high-poverty, distressed neigh-borhoods, such as those that underminesocial ties and threaten safety throughconflict, abuse, or violence, negativelyaffects health status into middle and oldage.12,25 Indeed, studies have drawn linksbetween neighborhood disadvantageand cardiovascular disease,26–28 can-cer,28 obesity,20,26,27 depression,20,27,28

self-reported health status,21,27,29,30 andrisk behaviors such as smoking,26,27

risky or early sex,27,31 and alcohol use.27,28

Disparities in life expectancy of up to25 years between neighborhoods justa fewmiles apart have been highlightedin cities such as Oakland, California, andNew Orleans, Louisiana.32,33 A child’s zipcode is more important than his or hergenetic code in determining futurehealth and life chances.34

Mediators of Neighborhood Impact

Neighborhoodadversity seems toaffecthealth outcomes to some degree byaffecting health behaviors26 and sig-nificantly through the impact of toxicstress and associated increases in“allostatic load” (eg, stress and fear inresponse to the perception of neigh-borhood danger).29

Gustafsson et al studied the relationshipbetween neighborhood features andallostatic load. They determined allostaticloadbyusinganumberofmeasurements,

including blood pressure, blood lipidsand glucose, and cortisol levels at ages16, 21, 30, and 43 years, studying thecumulative effects on subjects across∼3 decades. Social and material adver-sity were determined and cumulativeneighborhood adversity was calculatedwith indicators including the percentageof residents considered low-income, un-employed, living in single-parent house-holds, and with low occupational statusor low educational attainment. Cumula-tive neighborhood disadvantage was sig-nificantly related to higher allostatic load,suggesting that biological dysregulation(or wear-and-tear) accrued over thelife course as a result of neighborhooddisadvantage.35 These recent findingsare consistent with the few other stud-ies available examining the long-termimpact of neighborhood exposure. Forexample, Vartanian and Houser30 used38 years of longitudinal data from thePSID (Panel Study of Income Dynamics)and a sibling fixed effects model to showthat living in more advantaged neigh-borhoods as a child was associated withimproved self-report of health in adult-hood. Remarkably, the relative affluenceof adult neighborhood residence hadlittle or no effect. This finding suggeststhat intervention in residential condi-tions during childhood represents acritical period for effective impact. UsingNHANES data, Theall et al36 reachedsimilar conclusions. They, too, found thatteenagers living in higher risk neigh-borhoods had abnormal biological mea-sures that have been associated withincreased allostatic load.

One of the biggest challenges in studieson the health impact of neighborhooddisadvantage has been to disentangleand determine the effects of neighbor-hoodadversity, independentof individual-level adversity. Ross and Mirowsky29

found that neighborhood adversityresults in worse self-reported health,even when controlling for individuallevels of poverty. Hurd et al14 found

similar outcomes with regard to adoles-cent mental health. The research ofTheallet al36 and Schulz et al37 demon-strated the impact of neighborhood pov-erty on allostatic load in teenagers andadults, respectively. Both accounted forindividual and/or family poverty andfound that neighborhood was an inde-pendent predictor. Similarly, Gustafssonet al35 linked cumulative neighborhooddisadvantage through adolescence tohigher allostatic load later in life, in-dependent of individual social adversityor current neighborhood of residence.The longitudinal study of Johnson et al25

examined the long-term effects ofneighborhood exposure in youngadults (ages 20–30 years) followed upfor 38 years. After accounting for in-dividual and family factors, living inlow-income neighborhoods early inlife was strongly associated with pooradult health. Their findings suggestthat fully one-fourth of differences inhealth in mid- to late-life can be at-tributed to neighborhood differencesduring young adulthood.

From Neighborhood Impact toNeighborhood Intervention

Public health’s response to the role ofneighborhood on health often assumesthat the key mechanism of neighbor-hood impact is lack of access to ser-vices and resources. Examples includework on obesity prevention that fo-cuses on introducing grocery stores orfarmers’ markets in “food deserts” orwork to bring health services to commu-nities lacking clinics. Although these op-tions are important, access to healthierfood and medical services is not enough.We must transform neighborhoods intocohesive, stable, and appealing envi-ronments for the well-being of familiesand the healthy development of chil-dren. It is good fortune that health hasa partner in the field of community de-velopment, which has been doing pre-cisely that since its establishment in the1960s.

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COMMUNITY DEVELOPMENTHISTORY AND SCALE

The term “community development” de-scribes a largely nonprofit sector of theeconomy that provides interventions toimprove low-income communities andthe lives of the people who live in them.The interventions are primarily invest-ments allowing individuals and familiesto build wealth and help communitiesprovide service-enriched affordable hous-ing, clinics, schools, grocery stores, andother facilities to make neighborhoodsmore viable. In addition, community de-velopment fosters small businesses asa means of developing local entrepre-neurs; more small businesses in low-income neighborhoods provide localjobs and can create a powerful, positiveripple effect that improves the local econ-omy for all.

The dollars invested are substantial.The federal government has several in-vestment tax credit and block grant pro-grams that amount to nearly $16 billionannually.38 Those subsidy dollars, alongwith funds from state and local govern-ments and foundations, provide the seedcapital that allows community develop-ment to attract additional market-ratecapital from insurance companies, pen-sion funds, and especially banks. Banksare motivated by the anti-“redlining”Community Reinvestment Act of 1977requiring banks to demonstrate invest-ment in low-income neighborhoods. To-tal funds invested as a result of this actare hard to measure, but according to1 count from federal bank regulators,it was more than $200 billion in 2009alone.39

The achievements of this communitydevelopment investment have beensubstantial. Community developershave built .3 million homes housingsome 10million low-income individualsand families since the late 1980s, usingthe Low Income Housing Tax Credit. Thishousing is a far cry from the commonimage of government housing projects

as instant slums.40 Instead, as we de-scribe later, community developmentdollars have led to high-quality housing invibrant communities. When high-qualityhousing is coupled with integrated so-cial services, it can serve as an anchorinvestment in neighborhoods that haveexperienced decades of disinvestment.People begin to care about neighbor-hoods they can be proud of, where theyfeel connected and involved.

A Brief History of CommunityDevelopment

Perhaps the earliest efforts at commu-nity development occurred in the late19th century when US cities grew ex-plosively, with new arrivals from ruralareas or immigrants from other coun-tries. These newcomers crowded intocities looking for work. Competition forjobs pushed wages down, and compe-tition for shelter pushed rents up. Asa result, the new urban working pooroften foundhomes inslums,ghettos,andbarrios.Wesee thispatternacrossmanycities and many times: in Chicago in the1880s, Rio de Janeiro in the 1960s, andShanghai in the 1990s. Erickson,38 in TheHousing Policy Revolution: Networksand Neighborhoods, provides a historyof community development.

People living in these neighborhoodswere poor but hadmany intangible assets,asenseofcommunity,andentrepreneurialspirit. Community development was bornin that liminal space between great needand great opportunity. The settlementhouses of the late 19th and early 20thcenturies responded by providing com-prehensive education, job training, andskills. Immigrants took advantage of theopportunities and built a better life forthemselves and their children.

Modern community development hasits roots in the War on Poverty initiativebegun under the Johnson administra-tion in the 1960s. Federal programssought “maximum feasible participa-tion” of low-income communities to help

themselves. Part of that process requiredcommunity organizations to create astrategy for improving community con-ditions, which were called communityaction plans. Many of the plans morphedinto institutions, called community actionagencies, which evolved over time to be-come community development corpo-rations (CDCs). Senator Robert Kennedychampioned the first CDC, the BedfordStuyvesant Restoration Corporation inNew York, in the mid-1960s. Today, thereare.4600 CDCs across the country.41

CDCs are primarily real estate devel-opers. They are joined in the communitydevelopment network by community de-velopment financial institutions (CDFIs)thatoperate likenonprofitbankscreatingtailored financial transactions for com-plexdeals.CDFIsstartedoutassmall-loanfunds, many originating with the re-tirement savings of Catholic religiousorders. Today, in the United States alone,there are .800 CDFIs with more than$30 billion under management, many ofthem large and sophisticated. The LowIncome Investment Fund, for example,has deployed more than $1.5 billionbenefitting 1.7 million low-income indi-viduals.42 CDCs and CDFIs also work withbanks, for-profit real estate developers,state and local governments, and othernonprofits in true public–private part-nerships to improve neighborhoods.

Health and CommunityDevelopment

Until recently, communitydevelopersdidnot consider health to be among theirresponsibilities. More recently, com-munity developers and public healthvisionaries who recognize that zip codehas more influence over health thanone’s genetic code have realized thata partnership between industries con-cernedwith health and those concernedwith neighborhood development couldbe fruitful. Indeed, Risa Lavizzo-Mourey,president of the Robert Wood JohnsonFoundation, the nation’s largest health

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foundation, wrote recently that “weare likely to look back at this timeand wonder why community develop-ment and health were ever separateindustries.”13

Examples of CommunityDevelopment’s Impact on Childrenand Families

The community development sectoroffers significant resources earmarkedfor addressing what the medical andpublic health fields consider the socialdeterminants of health.43 The key ques-tion is whether neighborhoods can ac-tually be improved enough and in theright ways to make a difference inchildren’s lives. Can they be transformedto provide families the environmentsthey need to support healthy child de-velopment and end the cycle of poverty?

Over the past several years, the FederalReserveSystem, inpartnershipwith theRobert Wood Johnson Foundation, hasled a series of meetings around theUnited States to explore how commu-nity development and the health sectorcan partner to create meaningful changesin disadvantaged neighborhoods, andto do so at scale.10 Although rigorousevaluation data on health outcomeshave not yet been gathered, there area number of neighborhood transfor-mation projects with results that arepowerfully suggestive.10,40 The mostsuccessful projects tackle neighborhooddistress and dysfunction on numerousfronts simultaneously, addressing mul-tiple social determinants of health (al-though those in community developmentwould generally not have used thatterm). By addressing both place andpeople (ie, physical infrastructure andhuman capital/community processes),these projects achieve results that aremore than just the additive benefit ofseparate component parts. Each projectis also tailored to its community, in-volving residents and utilizing the uniqueassets of each neighborhood. There are

commonalities across these projects,however, that could be replicated to“routinize the extraordinary.”40 A keycommon feature is that each project hashad a “community quarterback,” usuallya single organization often led by a dy-namic individual, that holds the visionfor the project, convenes stakeholdersand potential partners, coordinatespartners’ activities across sectors andfunding streams, provides staffing, andtracks results.44 Recognizing the impor-tance of community quarterbacks incatalyzing and coordinating transfor-mational change, the Citi Foundationthrough its Partners in Progress pro-gram recently awarded more than $3.25million to 13 organizations across theUnited States to play such a role.45

The present article describes 3 suchprojects that have dramatically improvedneighborhoods: East Lake in Atlanta,transformed by what subsequently be-came Purpose Built Communities; theMagnolia Community Initiative in LosAngeles, a multisector network in part-nershipwith residents; and NeighborhoodCenters Inc, responsible for transformingseveral neighborhoods in the greaterHouston area.

Purpose-Built Communities/Eastlake

In the early 1990s, the East Lake neigh-borhood of Atlanta grappled with ex-treme poverty, high crime rates andviolent crime, poor educational attain-ment, and high unemployment. Theneighborhood was called “Little Vietnam,”not because it was home to Vietnameseimmigrants, but because it was like awar zone.46,47 Prompted by a study link-ing neighborhood to the likelihood ofresident incarceration in the New Yorkstate prison system, Atlanta philanthro-pist Tom Cousins devoted the resourcesof his family foundation to transformingEast Lake.48 Using both community de-velopment and private funding, the EastLake Foundation built mixed-income hous-ing in place of the existing substandard

public housing, built a charter school,and brought in shops and the YMCA.47

The effort of this public–private part-nership took ∼10 years, with a lead or-ganization dedicated solely to ensuringthat all elements were properly se-quenced and coordinated (ie, a commu-nity quarterback), but the results areimpressive. There was a 73% reductionin crime and a 90% reduction in violentcrime. The estimated economic benefitof reduced crime (including reducedcosts to victims and savings from esti-mated reduced lifetime criminality of thestudent body) was $10 to $14 million in2007 dollars.49 The employment raterose from 13% to 70%. Although some ofthe original residents did not return tothe reconstructed East Lake neighbor-hood, most did. The neighborhood alsoattracted many new middle-income neigh-bors. The new Drew Charter School isnow 1 of the top-performing schools inthe city, while still serving predominantlylow-income children (80% of the studentsreceive free and reduced-cost lunch). In-creased lifetime earnings as a result ofhigher educational attainment were pro-jected to be $14 million (in 2007 dollars)per graduating class of 85 students ornearly $165 000 per child over the courseof his or her life.

The project was successful because itused a coherent and integrated strat-egy.50,51 As the Robert Wood JohnsonCommission to Build a Healthy Americanoted, “Instead of attacking poverty,urban blight, and failing schools piece-meal, a group of community activistsand philanthropists in Atlanta took onall of these issues at once.”52 Inter-estingly, in the early stages of this effort,neither health nor health care wasidentified as key components, although ahealth-related focus has been incorpo-ratedmore recently. The approach usedin the East Lake neighborhood hasbecome the basis for multiple effortsacross the country, including New Orleans,Indianapolis, and Omaha.

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Magnolia Community Initiative

The Magnolia Community Initiative fo-cuses on a 5-square-mile area, com-prising 4 zip codes and 500 squareblocks south of downtown Los Angeles;this neighborhood is home to 35 000children. The Magnolia Community Ini-tiative was launched with the goal ofreducing child abuse and neglect. In-stead of focusing on identifying in-dividual at-risk children and providingindividual services, the initiative tooka population-based approach, seekingto improve conditions within the neigh-borhood so as to provide robustimprovements in conditions for allchildren. The initiative supports resi-dents within neighborhoods to takepersonal actions that improve the well-being of their own family and theirneighbors. Moreover, the network oforganizations that comprise the initia-tive set aspirational goals for itself: thatthe children living in the catchment area“will break all records of success intheir education, health and the quality ofnurturing care they receive from theirfamilies and communities.” Four goalsthat are recognized contributors tolifetime outcomes for children wereidentified: “educational success, goodhealth, economic stability and safe andnurturing parenting.”53

The initiative established the MagnoliaPlace Family Center, a community huboffering colocated services related toall 4 of the core goals and bringingtogether agencies and service pro-viders offering medical care, parentingclasses, legal services, access to af-fordable financial services at a bank,and mental health services. The state-of-the-art center, opened in 2008, alsooffers spaces for family activities andparent/child activities. More than 70city, county, andnonprofit organizationsthat comprise the network operate atthe center and throughout the largercommunity.54 An explicit feature of themultisector partnership is that new

partners (organizations or individuals)are asked to bring to the communitythe contributions that enable them tofulfill their goals. The initiative does notincentivize or compensate partners;instead, they participate in the initia-tive as part of fulfilling their own mis-sions. They focus on working togetheras a system using linkage, empathy,and holistic elicitation of client andresident assets and needs to supportachieving the 4 core goals. The networkutilizes the expertise in diverse servicesectors on how to mitigate toxic stressand optimize well-being. Progress isrigorously tracked by using a commu-nity dashboard (Fig 1) that followsoutcomes on a population basis.55

Neighborhood Centers Inc.

The focus for Neighborhood CentersInc (NCI), based in Houston, Texas, issmoothing the way for immigrants andother newcomers to succeed, thrive, andcontribute as they integrate into life inHouston and other Texas communities.56

Using an asset-based approach,57 thegoal of NCI, which operates 74 centers in60 Texas counties, is to change lives. Theystart not from what is “broken” in com-munities, says CEO Angela Blanchard, butfrom what is working.58 This methodinvolves facilitating residents and socialservice partners in the community todefine a vision, needs, and existing re-sources; bringing the appropriate part-ners to the table; securing funding andother resources; and coordinating a com-plex collaborative process that meldsthese elements into a transformativewhole.59

In many neighborhoods, this goal in-volves building or revitalizing a neigh-borhood center. These centers thenbecome community hubs,60 offering anarray of services that community mem-bers requested, including everythingfrom tax preparation61,62 and affordablebanking services, jobs assistance, andfitness classes, to help with citizenship

applications, English classes, and char-ter schools. Community residents re-ceive services and support, but they alsohave the chance to give back to theircommunity, becoming leaders, entre-preneurs, and volunteers.63

Core areas of focus for the NCI modelare: economic development; citizenshipand immigration services; family healthand education; civic engagement; andprograms for youth and seniors.64 NCIserves a sustained coordinating roleand also works to build the communityinfrastructure and organizational ca-pacity to manage this complexity.59 NCIis 1 of 21 recipients of the US Departmentof Education’s Promise Neighborhoodsplanninggrants65 and is, inmanyways, thequintessential community quarterback.

WHAT’S NEXT

By bringing the health care and publichealthfields togetherwiththecommunitydevelopment and social investment sec-tors, we can resist social hierarchies andcreate communities that help childrengrow up healthier. Combined, these sec-tors spend trillions of dollars to improvepeople’s lives, their health, and theireconomic well-being. Such endeavorsmay be the best way to address thosefeatures of urban life in the United Statesthat have ledwhole neighborhoods to getstuck in seemingly intractable povertyand disarray. The fields of communitydevelopment and health, when engagedtogether, can positively alter the socialdeterminants of health.

The Build Healthy Places Network hasbeenestablishedtoengageandconnectthose working in the health and com-munity development sectors to catalyzethe spread of neighborhood-transformingprojects such as those described earlier.66

The networkwill establish an institutionalhome for the new partnerships andknowledge from health and communitydevelopment collaborations. It will de-velop the health metrics critical to pro-viding community developers with tools

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th-eyn-

FIGURE 1Sample of the Magnolia Community Initiative data dashboard (November 2013). Information derived from the Early Development Index assessed in schools,a biannual community survey, and regular parent and organizational surveys. IEP, Individualized Education Program; orgs, organizations.

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eed to incorporate health into their workand will explore new financing strategiesto help take this approach to scale (eg,social impact bonds).

Build the Evidence Base

To date, with a few exceptions, the healthoutcomes that result from communitydevelopment investment, even in thedynamic,multifacetedprojectsdescribedhere, have not been systematically mea-sured. Health and public health expertiseand research can provide the evidencebase to determine which investments andwhat kinds of projects have the biggestimpact, with the goal of guiding projectdecision-making and design. Further-more, on a scale not otherwise possible,health researchers can use large-scalecommunity development projects plan-ned or already in progress to answercritical questions about the impactof community-level interventions onchild development. Evidence from the“natural experiments” in neighborhooddevelopment can deepen and extendour understanding of child cognitive,psychosocial, and physical develop-ment. The cost savings that accrue inhealth care, education, criminal justice,and other arenas as a result of com-munity development investments arenot currently assessed in a systematicway. Health researchers can help deter-mine how best to measure andmonetizethese “social returns on investment.”Finally, evidence for improved healthoutcomes and reduced social costshas the potential to attract substantialnew dollars from private capital, in-cluding health-focused investors, healthfoundation mission–driven investing,social impact bonds, and social impactinvestors.

Connect Partners

As we have seen, projects to transformdistressedneighborhoodsrequirebroad,cross-sector collaboration at the locallevel. At the national level, those already

doing this work need the opportunity tolearn from one another, both togetherand across sectors. The newnetworkwillconnect newly formed initiatives withmore experienced peers, try to overcomechallenges such as sectoral languagebarriers, and find new ways to managethe complexities of multiple fundingstreams. The network will work tobring these initiatives toscale, extendingthemintodisadvantagedneighborhoodsaround the country by linking newpartners armed with new knowledge.

Make Child and Family Healtha More Explicit Focus of CommunityDevelopment

The key to unlocking the immense po-tential for health in the community de-velopmentsector lies inmakingchildandfamily health more explicitly the focus.The new frameworks and conceptsemerging from work on toxic stress andbrain development andonneighborhoodadversity mark a new path for addres-sing disparities in childhood develop-ment and long-term health, but it is alsoa powerful new organizing paradigm forcommunity development. Increasingly,community developers consider impro-ving the social determinants of healthas the way to improve local economies.The Robert Wood Johnson FoundationCommission to Build aHealthier Americais trying to accelerate this evolution bymaking the full integration of health intocommunity development 1 of its 3 rec-ommendations to improve the health ofthe nation.60

SUMMARY AND CALL TO ACTION:ENDING THE BULLYING SOCIETY

What role does the field of pediatricshave in addressing the types ofcommunity-level social hierarchiesdescribed here? If we take to heart newunderstandings of childhood develop-ment,allostatic load,andthe independentimpact of neighborhood on health, if weaccept that the vast percentage of health

outcomes are not the product of healthcare, and,moreover, if we conceive of ourwork as that of ensuring healthy childdevelopment, rather than simply treatingchildren once they becomeunhealthy, wemust extend the scope of our practicesbeyond the clinic or hospital walls. Al-though we cannot directly address someof the factors that are most important tochildren’s healthy development, we canpartner with others who do. The impactof neighborhood adversity on health, in-dependent of individual- or family-levelsocioeconomic factors, requires thatinterventions move beyond addressingindividual adversity alone. Our involve-ment as physicians can help focus anddirect intervention goals so that theyprovide the conditions for healthy earlychildhood development across the cog-nitive, physical, and psychosocial realms.These multifaceted interventions mustfoster both family and community health,providing children the right milieu inwhich to grow. Inside the examinationroom, we can work with children in thecontext of their family environment,screening for healthy and stablefamily functioning and for stressorson caregivers. Outside of the exami-nation room, we can work within thecommunity to ensure that familyfunctioning is supported with bothplace- and people-oriented resourcesand advocate for those resourceswhen not available.

The stakes for success in this partnershipcould not be higher. We are failing ourpatients—our children—if we do notprovide them the best possible start inlife. Reaching this goal means ensuringthat they live in neighborhoods thatpromote opportunity and reduce life’schallenges. By bringing together healthsector evidence, research skills and ex-pertise in childhooddevelopmentwith thebusiness and finance skills, resources,and capacity to rebuild neighborhoods ofthose in community development, wehave a real chance to do so.

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