Culture of Health - Robert Wood Johnson Foundation
For more than 40 years the Robert Wood Johnson Foundation has worked to improve health and health care. We are working with others to build a national Culture of Health enabling everyone in America to live longer, healthier lives.
New menu labeling information will help families make healthier choices and may save billions of dollars in health care costs over the next 20 years.
Do you remember the spring of 2011? The iPhone 4 was all the rage. Plenty of people were still figuring out what a Tweet was. We were learning from Beyoncé that girls run the world.
Spring of 2011 was also when the Food and Drug Administration (FDA) first proposed national menu labeling rules. These rules would require that chain restaurants and other food retailers provide calorie counts and other nutrition information to their customers.
Today, seven years later, those rules finally take effect. This important milestone will make it significantly easier for parents and families to make healthier choices when eating out. The potential benefits to our nation’s health and economic well-being are substantial.
How did we get here? Why is this a big deal? And what’s the connection to Robert Wood Johnson Foundation's (RWJF) Culture of Health vision?
How’d we get here?
By traveling a long road.
Quick trivia question: what law is responsible for menu labeling? Believe it or not, it’s the Affordable Care Act (ACA).
The ACA, of course, is best known for expanding health care coverage for millions. Those provisions of the law mean a great deal to me personally. At the time of its passage, I was working for Unidos-US, then known as the National Council of La Raza. My colleagues and I worked hard to ensure that it reflected the health care needs of Latino and immigrant populations. But the ACA also reflects another priority: the importance of prevention, which can lower health care costs by keeping us from getting sick in the first place.
That’s where the menu labeling rules come in. Over the years, these rules have been tweaked and refined as the FDA sought additional public comment and offered more extensive guidance. Let’s unpack where it finally landed.
The ACA requires chain restaurants and “similar food retail establishments” and vending machines with at least 20 locations nationwide to post calorie information on their menus and menu boards and provide additional nutrition information (i.e., total fat, sodium) to customers upon request. These rules will apply to a wide variety of locations, such as supermarkets, convenience stores, delis ... even movie theaters and stadiums.
According to the FDA, new menu labeling rules will cover approximately 300,000 food retail establishments nationwide: that's an average of 6,000 locations per state.
The calorie information must be presented in a consistent format across all menus and for the entire menu item—for example, a menu offering a combination meal of sandwich, salad, and fruit will include the full range of calories for these items. This will ensure consistency and avoid confusion.
Finally, these rules are now the standard for chain retailers across the country. Retailers with fewer than 20 locations are not required to abide by these rules, though they may do so voluntarily.
Why is this a big deal?
Scope. The FDA’s regulatory impact analysis estimates that these rules will cover approximately 300,000 food retail establishments nationwide; that’s an average of 6,000 locations per state. Add in the fact that more than 60 percent of Americans report eating out at a restaurant at least once a week, while consuming about one-third of daily calories on food prepared away from home. Then consider that most people tend to significantly underestimate the number of calories in their meals, some by upwards of 500 or more calories. When you put it all together, it’s clear that these rules have the potential to make dining out a much healthier proposition.
Savings. FDA’s analysis predicts that these rules will result in a total net savings of $8 billion to the healthcare system over the next 20 years. In addition, a Harvard study found that menu labeling in restaurants alone could prevent up to 41,000 cases of childhood obesity and save over $4.6 billion in health care costs over ten years.
Impact. Menu labeling isn’t going to cure everything, but based on what we’ve learned from places that have already tried this approach, there is good reason for optimism. RWJF’s Healthy Eating Research program examined the impact of Seattle/King County’s menu labeling policy on calories purchased from a select group of chain restaurants. The results: adults and teens who used the information purchased up to 143 fewer calories compared to customers who did not, and a follow-up study found that the percentage of adults who saw and used calorie information had tripled two years after implementation. Research compiled in What Works for Health, part of our County Health Rankings and Roadmaps program, shows the benefits of restaurant menu labeling include increased awareness of and a reduction in calories purchased, as well as reduced caloric intake and reduced portion sizes.
What’s the connection to RWJF’s Culture of Health vision?
The choices we make are based on the choices we have, and we need to be clear about exactly what those choices are.
Over the last decade, the overall rise in rates of childhood obesity has slowed and some states, cities, and counties have reported declines. Yet the latest national data show that 18.5 percent of children were obese in 2015-16, the highest rate recorded by the National Health and Nutrition Examination Survey. Racial and ethnic inequities persist, with significantly higher rates among Latino and black children compared to their white and Asian peers.
These numbers are stark reminders that ensuring all children grow up at a healthy weight must continue to be a top priority.
A core component of RWJF’s work is ensuring that all children can be at their healthiest, so they can reach their full potential. Two principles guide that work. First, all children need the right environment that enables them to grow up healthy. And second, all families must have the opportunity to provide those environments for those children. Eating healthy is a big part of that vision, but we need help to make the right choices for ourselves and our families.
As someone who pays close attention to what I eat, especially when eating out, I pride myself on having a good grasp of what menu items are most nutritious. And yet there have been plenty of times when I’ve realized that I could have made healthier choices if only I’d had more and better information at my disposal.
Menu labeling is built on a simple premise—providing families with nutrition information to help them make smart decisions—but the effects can extend well beyond simply seeing and comparing numbers. If we’re better equipped to make healthy decisions, it’s easier to instill healthy habits in our kids, especially from an early age—which will make it easier for them to get proper nutrition and help them avoid obesity or related diseases like type 2 diabetes. And if food retailers see that we are making healthier purchases, they’ll have incentive to elevate the products that match those healthier preferences, because it will be good for their bottom lines.
Over the past seven years, we’ve come a long way in our understanding of how menu labeling can impact families for the better. So, the next time you’re checking out the menu at a chain restaurant or a grocery store or a ball game, take a look at the calorie numbers. That additional information, and those extra few seconds, can go a long way toward better health.
About the author
Jennifer Ng’andu is the interim managing director–program at RWJF, focusing on eliminating some of the most potent threats to a Culture of Health for children, their families, and communities. She helps carry out grantmaking activities to advance social and environmental changes that help individuals and communities engage in healthy practices and stave off obesity.
InnerCity Weightlifting, a non-profit with a unique business plan, understands that building a foundation of trust and hope is key to success after incarceration.
An hour before his next client is due, Edgardo “Chino” Ortiz is in the glass-walled break room of InnerCity Weightlifting (ICW) in Cambridge, Mass., poring over a study guide to become certified as a personal trainer. Fiercely focused on achieving that goal, he is rarely separated from his worksheets.
“Prescribe RICE,” he says, circling the acronym for “rest, ice, compression and elevation” on a sample quiz question about injury.
All across America, men and women with similar ambitions are prepping for careers in physical fitness. But few share the unique drive that fuels 33-year-old Chino’s determination. For him, getting certified as a fitness trainer is a life-changing turning point, built on his smarts, his talent, and his grit.
Chino recently completed a sentence of five years in a Massachusetts state prison for shooting a man in the leg over drugs. For most former offenders, finding a good job is notoriously difficult. But Chino’s future looks promising because of his connection to ICW.
Founded in 2010, ICW is a nonprofit with a unique business plan. It takes a skill that many develop while incarcerated—pumping iron—and turns it into a professional asset. With training, and lots of personal support, ICW helps former inmates restore their standing in society while they also earn a good income and learn the ropes of the fitness industry. In 2016, ICW won the Robert Wood Johnson Foundation (RWJF) Sports Award—given to professional teams, individuals and organizations that strengthen and serve communities through sport.
ICW works with former inmates who Boston police, probation, and social workers consider “most likely to be involved in firearm violence”—either as a perpetrator or a victim. ICW strives to derail a return to violence by offering men like Chino an opportunity to earn $25 an hour as personal trainers. With two Boston-area locations—Dorchester and Cambridge—ICW serves more than 110 teens and young men. “For the most part,” says ICW founder Jon Feinman, “everyone here has done some time.”
The gym in Cambridge is in Kendall Square, a prosperous neighborhood filled with glass-and-steel towers housing bioscience firms, venture capitalists, and high-tech start-ups.
Edgardo “Chino” Ortiz and Alexa Baggio
Chino’s noon appointment is with 30-year-old client, Alexa Baggio, a Brown University graduate who describes herself as a “serial entrepreneur.” She co-founded 2020 On-site, an innovative vision care company, and now runs an annual trade show for providers of human resource benefits.
Tee Grizzley’s “First Day Out,” a hip-hop song about a prisoner’s first day of freedom, blares from the gym’s sound system. A section of the floor is covered in Astroturf. Kettlebells sit in a corner. Scrawled in colored markers on a white wall are inspirational phrases: “When the load gets heavy, don’t pray for a lighter load, train for a stronger back,” and “Chess, not checkers,” a popular meme meaning life’s problems often require more complex, strategic solutions.
Chino sports a sleeve of tattoos that runs from his left wrist to his neck and short braids sticking out the back of a flat-brimmed Red Sox® cap. An avid Boston sports fan, he’s also wearing a New England Patriots® tee shirt. Alexa is tall and strong, wearing a black tank top over workout leggings, with sandy blonde hair in a topknot.
Chino puts her through her paces: planks; bench rows with a dumbbell in each hand; hip thrusts with a medicine ball in her lap. Twenty minutes into the hour-long workout, beads of sweat appear on Alexa’s forehead. Chino throws her a small towel and turns his ball cap backwards.
ICW has personal training contracts with the Boston Consulting Group (BCG), Athenahealth, and other big corporations where ICW trainers often lead group sessions for employees. But the one-on-one trainings, like the workout with Alexa, build the most important bonds. Alexa, a lifelong athlete who played collegiate tennis, says she stumbled upon ICW on the fitness app Mindbody. She wanted to get back in top shape, so she made a phone call and arranged to come in. The luck of the draw paired her with Chino. A self-described “gym rat,” Alexa is at the gym about three or four times a week.
For Chino, getting certified as a fitness trainer is a life-changing turning point, built on his smarts, his talent, and his grit.
“Chino is really good at adapting to people,” she says. “I am super into the idea that I can work out for myself, and actually do some good by contributing [to ICW’s mission]. That was like the extra thing. All Chino wants is to add value to the world, do a good job and make some money for his family so he can be independent and enjoy life. I am going to do my part to keep him busy.”
Feinman says the ICW program guides participants through four stages of development: Trust, hope, bridging social capital, and economic mobility—which ICW defines as the ability to make $30,000 a year in any job. Each stage focuses on skills, such as punctuality, networking, and personal responsibility, which will help the former inmates be successful at whatever they choose to do. Every stage is important, Feinman says, but building a foundation of trust and hope is key, because everyone needs a support network.
“What we’ve found is that if you just go straight from trust to economic mobility, you have a much higher chance of going back to jail than if you have hope and you have a network. That’s because jobs come and go. What allows me, a white guy from Amherst, and people like me [to persevere] when we lose a job and lose our income is we probably have a family, probably have a community, probably have a network that we can lean back on.”
Today, Chino has a strong support network that includes his family, his girlfriend, the folks at ICW, and prosperous clients who see him as more than just a former gangbanger.
One of those clients is Sarah Reed, chief operating officer and general counsel for MPM Capital, a life sciences investment firm. “I used to think adults can’t change,” she says. But working with Chino and ICW “changed my core belief system. He is really smart. If he had been born in my skin, he’d be running a corporation now.”
Generations of inequity have led to health disparities. Solutions that involve those affected and consider historical trauma will help close the gaps.
My sons are both in college, one at Howard University in Washington, D.C., and the other at Knox College in Galesburg, Illinois. Raising African American boys into adulthood was often stressful. Despite the many advantages and supports we had as a family while they were growing up, I worried about their safety, whether their schools would see and nurture their greatness despite the color of their skin, and whether they would be able to live up to their potential.
As a public health practitioner, I’ve also had the opportunity to observe the amazing efforts of so many caregivers and families with limited resources who heroically “make a way out of no way.” I’ve seen what it takes, for example, for a mom to just get her children to a doctor’s appointment when they each go to a different school because the schools in their neighborhood are not the best she wants for them. I’ve seen the enormous emotional, physical, and mental energy families with fewer economic resources spend simply on surviving day to day—and I know that statistically, the burden of poverty falls particularly heavily on children of color.
I’m now director of University of Wisconsin’s Population Health Institute, which has for nearly a decade compiled the annual County Health Rankings. The rankings have helped communities across the nation see how where we live makes a difference in how well and how long we live. This year we’ve added a layer of analysis that hits home for me, highlighting the meaningful health gaps that persist by race.
We wanted to cover both place and race because county-level rankings can mask the deep divides we have in the health of different groups within communities. Even in counties with the best rankings—and the highest overall level of opportunity for good health—not everyone in every part of the county has access to opportunities for safe housing, adequate physical activity or a good education.
For me, knowing we still have gaps to fill is a call to action, especially as we mark National Minority Health Month. So how do we overturn the current reality and give everyone a fair shot?
The U.S. has a long history of racism and discriminatory policies and practices that have limited the opportunities of people of color. These include practices like denying housing loans to people of color, forcibly removing Tribal nations from their lands, and funding public schools in ways that disadvantage less affluent communities. The result has been an accumulation of disadvantage through decades and generations. Some groups have been denied or had limited opportunities for housing, health care, education, employment, food, safe neighborhoods and fair inclusion in decision-making.
There has been progress in my own lifetime. And yet, even in the decades since legal desegregation, numerous policy decisions—including those that have led to mass incarceration—have advantaged some groups and disadvantaged others.
Communities that have been left behind for years are less likely to be economically stable now and for generations to come. And the differences in opportunity people in those communities experience have a deep impact on health, leading to disturbing ongoing disparities that start at birth, as the 2018 County Health Rankings Key Findings Report shows:
Compared to white babies, black babies are twice as likely to be born at low birthweight and about twice as likely to die before their first birthday. Low birthweight babies have elevated lifetime risks of diabetes, heart disease, and high blood pressure.
Rates for Black and Hispanic children in poverty are worse than for whites across all types of counties. Children living in poverty are less likely to have access to well-resourced and quality schools and have fewer chances to be prepared for living wage jobs that can lead to upward economic mobility and lifelong good health.
1 in 4 American Indian/Alaskan Native, black, and Hispanic youth do not graduate from high school in four years, compared to about 1 in 10 white and Asian youth. In communities of color with more children in poverty, there are more under-resourced and overcrowded schools. Children who attend sub-standard schools don’t have a fair chance at a good education, which has major implications for their future job opportunities, financial resources, social networks, and life choices.
The Road Forward
No one in the United States should have less of a chance to be healthy because of where they live, how much money they make, or the color of their skin. We know that if we build strong communities then our children will become more resilient and healthier adults.
As we work to put solutions in place, it is essential that we meaningfully involve the people who are experiencing poor health outcomes. Their input is key to identifying the right solutions and making them work for their communities. For example, Louisville, Kentucky, has brought together its arts, business, health, education, law enforcement and social service sectors and citizens of neighborhoods most affected by poor health. They’ve turned statistics and data into tools to rectify health inequity. Most recently, the Greater Louisville Project—which aims to improve education, jobs, and quality of place—estimated that the human, social, community and financial toll of poverty costs the city $200 million a year in economic growth. The city hopes to use the data it has collected on the barriers facing families in poverty to design coordinated interventions that reduce those obstacles.
It’s also essential to consider the impact of stress and historical trauma on people’s lives and health. For example, stresses disproportionately felt by Black women may be behind the distressing disparities in birth outcomes in the United States. Historical trauma has been connected to the high unemployment rates experienced by Native Americans and the gap in graduation rates between Native youth and White youth.
By embedding an understanding of historical trauma into its work to improve education outcomes for its young people, Menominee Nation in Wisconsin has been able to boost graduation rates. Trauma-informed care strategies—such as a morning “mood check-in” via computer and refuges such as “safe zones” in the corners of classrooms with grown-ups on hand to talk things out—keep students on track with their education. A goal is to arm young people with positive coping skills and avoid negative health behaviors like smoking, drinking and drug use.
In my own neighborhood of Sherman Park, community engagement and a historical view of trauma are both key components of an effort to spur economic development, remove obstacles for entrepreneurs of color, and improve opportunities to engage in healthy lifestyles. Following an “uprising” in 2016 after an officer-involved shooting, two local business leaders, Milwaukee philanthropies, state and local government and community residents, including me, are pooling investments to bring the Sherman Phoenix neighborhood center to life. In community conversations, neighbors spoke about the need for safe, welcoming neighborhood spaces and better opportunities. When the center is complete in fall 2018, it will offer space for small businesses-of-color, wellness services, and cultural activities.
I encourage every community to look at their County Health Rankings data and work together to find solutions so that everyone—regardless of their race and ethnicity—has the opportunity to be healthy. Community leaders can pave the way by listening, valuing relationships, facilitating and supporting change outside the health sector, and highlighting the ways everyone gains from programs that promote health equity. Together, we can make health disparities a thing of the past.
Sheri Johnson, Ph.D., is the director of the University of Wisconsin Population Health Institute. She has dedicated her 25+ year career to partnering with children, families, community organizations and systems to advance health and well-being.
The 20th United States Surgeon General Jerome Adams joined RWJF President and CEO Rich Besser to discuss how the power of partnerships can help transform communities and advance equity.
As a child, the United States Surgeon General Jerome Adams, MD, MPH, suffered from asthma so severe that he spent months at time in the hospital, even once being airlifted to a children’s hospital in Washington, D.C. During these stays he was struck by the fact that he’d never encountered a black physician. That finally changed when as an undergraduate he met a prominent African-American doctor who had overcome his own significant life obstacles. Seeing another African-American making important contributions to the field of medicine inspired the young Jerome Adams to decide, “I can do that too.”
With that resolve, he embarked on a path that led to becoming an anesthesiologist and culminated in his appointment as the nation’s 20th surgeon general.
Reflecting on his journey, Dr. Adams notes, “that’s why your efforts at the Robert Wood Johnson Foundation (RWJF) are so important. You’re providing mentorship and leadership opportunities to those who wouldn’t otherwise know how to navigate the world of public health.”
He shared these words during a visit to the Foundation where he discussed his role in building a Culture of Health with RWJF CEO Rich Besser. The conversation covered a range of issues in which Dr. Adams repeatedly stressed the role of partnerships in building healthier, resilient communities and addressing challenges such as the nation’s opioid epidemic. Here are a few takeaways from their conversation.
Intervene upstream to address the nation’s opioid epidemic.
Dr. Adams is open about his younger brother Phillip’s struggles with substance abuse. He had taken his 12- and 13-year-old sons to visit their uncle, who is currently spending 10 years in a Maryland state prison for stealing $200 to support his addiction. Phillip shared with his nephews that he suffered from untreated depression while in high school which led to self-medicating with alcohol, marijuana, and eventually other substances before he began committing crimes to support his habit.
“What’s most frustrating to me is that despite being a doctor, I couldn’t intervene alone. None of us can face this alone,” said Dr. Adams, noting that addiction touches everyone regardless of their race, sex, age, socioeconomic status or where they live.
“We need to understand that this is a complicated problem influenced by a variety of upstream factors, including childhood trauma and community resilience. The most cost-effective and humane way to address the opioid epidemic is through prevention and partnerships. For example, since local law enforcement is the number one touch point for connecting people struggling with addiction to mental health support services, we need to partner with them and help them understand their role in connecting people to the care they need.”
Dr. Adams believes in upstream interventions that address underlying risk factors such as adverse childhood experiences (ACES) which increase the risk for addiction. He also believes in shifting away from criminalizing addicts and instead, providing treatment options to support their long-term recovery.
The power of partnerships is key to building a Culture of Health.
Dr. Adams noted the importance of engaging non-traditional partners to create healthier communities, sharing his mantra “better health through better partnerships.”
“Local conversations and finding common ground is key to building a Culture of Health. We need to consider the roles of business, education, faith, and law enforcement in building healthier communities. I also challenge everyone to consider who else is not at the table that should be and reach out to them.”
He highlighted the role of the business sector in addressing workforce shortages, absenteeism, and productivity. While the businesses may view workplace health as an insurance expense, there is a larger role for them to play in instituting workplace wellness programs and by influencing policy at the community level. “We need to create a Culture of Health in all sectors. Businesses can play an important role in lifting up the health of their communities. By doing so, they can see better health, better productivity, and better return on investments.”
He also reflected on the partnership he formed with law enforcement during his tenure as Indiana’s state health commissioner. At the time, Scott County, Ind., was facing an unprecedented spread of HIV among intravenous drug users. Through his collaboration with law enforcement, Dr. Adams was able to institute an evidence-based syringe service program in one of the most conservative areas within Indiana. Doing so halted the spread of HIV in the community.
Frame issues so others understand their role in building a Culture of Health.
There’s tremendous opportunity in framing issues to help people understand their role in prevention, as well as health equity, according to Dr. Adams. “When I talk about health equity I mention veterans, those with disabilities, and people in rural areas,” he said. “Showing others how everyone benefits from addressing inequities is more effective than using moral arguments.”
Another example Dr. Adams shared to illustrate this was noting how overworked teachers may feel burdened by having to promote a variety of programs including healthy eating and physical fitness. The fact that teachers are evaluated and paid based on test scores can be the bridge to compel them to advocate for students’ physical activity. “If we tell them we have a physical fitness program to help get test scores up, they listen.” Such an intervention was implemented in an Indiana community while he was health commissioner. When teachers witnessed the positive results, they scrambled for access to exercise rooms before their students took exams.
“It shows how we need to frame issues to help people understand how supporting health can help them achieve their goals—versus expecting them to see things from our point of view. We need to use language that resonates with those we’re talking to in order to gain their support.”
Inadequate housing is a tremendous barrier to achieving good health—especially when dealing with a chronic illness. A team of researchers is examining largely rural counties in West Alabama to assess the impact of stable housing on the well-being of people living with HIV/AIDS.
We know that where we live, work, learn, and play greatly impacts our health. Especially important among these, and too often overlooked, is the impact of where we live. Housing is tied to health in powerful and inextricable ways. Think about the steps you take each morning to care for yourself, or each evening when you go to sleep. What would happen if you didn’t know where you would sleep that night, or weren’t sure how long you had until you were forced to find new shelter? Would you still take the time to go through your routines, if there was nothing routine about them? Would you set up relationships with health providers if you might not live in the same community next month—or even next week?
I faced homelessness twice and they were the most stressful experiences in my life. Lack of access to stable housing can feel like an insurmountable barrier to achieving good health and well-being—even more so when one is dealing with a chronic illness or other health challenges.
These experiences have given me unique perspective as I now work with a team to evaluate how housing impacts people living with HIV/AIDS in Alabama. My team includes Billy Kirkpatrick, PhD, Executive Director of Five Horizons Health Services, Inc. (formerly West Alabama AIDS Outreach) and George Mugoya, PhD, Associate Professor in the Department of Educational Studies in Psychology, Research Methodology and Counseling in the College of Education at the University of Alabama.
Safiya pictured (middle) with teammates Billy Kirkpatrick (left) and George Mugoya (right).
Our work is funded by the Interdisciplinary Research Leaders Program, a Robert Wood Johnson Foundation-supported leadership development program. The Interdisciplinary Research Leaders program supports teams of researchers and community leaders to use the power of action oriented research—that is research that is designed and done directly with the community, in order to drive change to create healthier, more equitable communities.
Research shows that homelessness and unstable housing contribute to poor health in people living with HIV/AIDS. In addition, being unstably housed contributes to high-risk behaviors. In fact, one-third of people living with HIV/AIDS are marginally housed across the country and many have a history of trading sex for money, drugs, or a place to stay.
We need to change this paradigm and begin to put housing at the core of health.
As my teammate Dr. George Mugoya notes, “It’s actually quite simple; if you don’t have housing, how can you take care of yourself? But if you do have stable housing, you will also have the ability to care for yourself, access health care services, and also reduce the transmission of the disease.”
Our research extends across 10 counties in West Alabama, nine of which are in rural communities. We are assessing the health impact of affordable housing programs, and identifying promising strategies for effective case management of people living with HIV/AIDS. Statewide we are evaluating community and policy advocacy programs and interviewing elected officials to gain a better understanding of the policy environment.
The 2011 Tuscaloosa–Birmingham tornado wiped away much of the affordable housing, and new housing being built is predominantly for the high-priced student market. As a result, there are fewer slots available for affordable housing, with waiting lists of up to two years in some cases. There is a long history of underinvesting in affordable housing in Alabama, which disproportionately impacts people living with HIV/AIDS.
While our research project is ongoing, we would like to share some preliminary lessons from our work to help inform the efforts of others who are striving to build healthier communities for all.
Moving from place to place often entails losing the connection to health services that are critical for treating a chronic disease. It is not unusual for case managers to get a new phone number for a client at the beginning of the week, and then not be able to reach them at the same number by the end of the week.
Identifying practices to better manage the transitory nature of people living with HIV/AIDS or reducing that instability through provision of stable housing, is critical.There are a few, limited opportunities to assist people living with HIV/AIDS in transition regarding living arrangements. Examples include a limited number of slots per state/service area from the federal program, Housing Opportunities for People Living with HIV/AIDS (HOPWA), housing vouchers and other programs from state Housing Authorities, emergency shelter options, and emergency aid from AIDS Service Organizations. It is crucial that people living with HIV/AIDS work closely with a case manager or social worker in order to get assistance with meeting their housing needs.
In a rural setting, when people are asked or forced to move, the distance can be substantial. For example in an urban setting you might have to move from one apartment to another within the same neighborhood. That’s hard enough. Yet in a rural community, losing housing often entails moving to another community—one that does not have your social support system or the same health services.
Stigma Associated With HIV Can Be Worse in Rural Areas
People living with HIV face stigma every day. They face unfounded fears from their friends, family, and community members, who may not be educated on how HIV is transmitted and ask them to do things like use plastic utensils or a different bathroom. These actions are isolating, and stem from a lack of understanding of the disease. The stigma can be worse in rural areas, where there are fewer people living with HIV and thus less familiarity with the disease. The stigma isn’t limited to the personal lives of these individuals. It finds its way into policy decisions, as well. As my colleague Billy Kirkpatrick highlights, “We also have stigma at our statehouse. It’s difficult to get policy decisions made when there are assumptions made about our clients. We need an educated populace.”
Many People Are Not Aware of How the Housing Crisis Impacts Those Living With HIV/AIDS
If you look at the statistics for homelessness, unstable housing among people living with HIV/AIDS may not be obvious. In Alabama, the rate of homelessness for people living with HIV is just 3 percent. However, when you probe deeper, you’ll find that 60 percent are not happy with their housing, a portion that represents a wide range of inadequate housing scenarios. Sometimes people feel unsafe; other times they are imminently homeless—meaning that they could soon be asked to leave the home of a friend or family member. The housing crisis among people living with HIV/AIDS is real and requires our attention and action.
Pursuing a Culture of Health means building communities where everyone has the opportunity to live a healthier life. Our team envisions an Alabama where people living with HIV/AIDS are empowered and able to thrive. This means access to stable housing, successful case management, and an educated populace who advocate for policies to support these goals.
Note: The author's teammates, Billy Kirkpatrick, PhD, and George Mugoya, PhD, contributed to this post.
As 2018 marks 50 years since the passage of the Fair Housing Act, I invite you to share your thoughts. What else should researchers, leaders and communities consider when it comes to the intersection of housing and health?
about the author
Safiya George, PhD, is Associate Professor and Assistant Dean for Research, Capstone College of Nursing, University of Alabama, Tuscaloosa, Alabama.
Residential segregation is a fundamental cause of health disparities. We need to take steps that will reduce health risks caused by segregation and lead to more equitable, healthier communities.
Editor’s Note: To commemorate the 50thAnniversary of the Fair Housing Act this month, we are republishing a post that originally appeared in 2016. Be sure to also check out the 2018 County Health Rankings which provide updated information on the impact of segregation as a fundamental cause of health disparities.
For some, perhaps the mere mention of segregation suggests the past, a shameful historic moment we have moved beyond. But the truth is, residential segregation, especially the separation of whites and blacks or Hispanics in the same community, continues to have lasting implications for the well-being of people of color and the health of a community.
In many U.S. counties and cities, neighborhoods with little diversity are the daily reality. When neighborhoods are segregated, so too are schools, public services, jobs and other kinds of opportunities that affect health. We know that in communities where there are more opportunities for everyone, there is better health.
The 2016 County Health Rankings released today provide a chance for every community to take a hard look at whether everyone living there has opportunity for health and well-being. The Rankings look at many interconnected factors that influence community health including education, jobs, smoking, physical inactivity and access to health care. This year, we added a new measure on residential segregation to help communities see where disparities may cluster because some neighborhoods or areas have been cut off from opportunities and investments that fuel good health.
The effects of residential segregation are often stark: blacks and Hispanics who live in highly segregated and isolated neighborhoods have lower housing quality, higher concentrations of poverty, and less access to good jobs and education. As a consequence, they experience greater stress and have a higher risk of illness and death.
Although there are pockets of high residential segregation scattered across the country, residential segregation of blacks and whites appears highest in the Northeast and Great Lakes region and lowest along the Southeastern seaboard. It should be noted that, for 35 percent of U.S. counties, the black population was too small to calculate the residential segregation measure.
It’s important to note that for some population groups, living among others who share their cultural beliefs and practices can help build social connections that can lessen the health risks of hardship and neighborhood disadvantage.
We think every community should be paying attention to the ways that residential patterns may be a barrier to good health. There are approaches that can help reduce the health risks caused by segregation and lead to more equitable, healthier communities:
Identifying the most pressing health needs in every community, and prioritizing those areas for investment.
Access to safe, affordable housing and financing for everyone, and eliminating housing discrimination.
Safe, reliable public transportation accessible to all.
Jobs with wages that enable people to take care of themselves and their families.
Improving access to healthy food in every community.
Getting to these and other solutions requires creativity, collaboration and authentic engagement of all people in a community—a top-down approach just won’t do.
Community organizers across Kansas City—after reviewing shocking data about the life expectancy gap between white and black residents, began frank and difficult discussions about systemic racism and its health implications. Armed with what they discovered, one of the city’s first actions was passing the Community Health Improvement Plan in 2001 as a direct response to the life expectancy gap. By examining disparities systematically and crafting solutions, the city has closed the life expectancy gap from 6.5 to 5 years.
The conversations and approaches will be different in every community. But we can start by learning from what’s working in places like Kansas City and Everett and many more. These communities are leading the way by creating a shared value for good health, where everyone has the opportunity to thrive, regardless of who they are and where they live.
Donald Schwarz, MD, MPH, MBA, is vice president, Program, guiding the Foundation's strategies and working closely with colleagues, external partners and community leaders to build a Culture of Health in America, enabling everyone to live the healthiest life possible. Read his full bio
A $1.4 million funding opportunity is available for community leaders, organizations, and researchers to help us understand the combination of factors that lead to resilient communities.
Nearly six months ago three catastrophic hurricanes devastated parts of the United States and her territories, and the lives of millions of people in America. Although they were all Category 4+ storms, the impact and aftermath have been markedly different. While the recovery is ongoing, many communities in Texas and Florida are finally returning to normal life: schools are open, transportation systems are running, and homes are being rebuilt. By stark contrast, in parts of Puerto Rico, people are still struggling to survive without clean water and electricity.
What accounts for these differences in recovery? There is plenty of conjecture: people point to the level of damage inflicted, soundness of infrastructure, the condition of the local economy, as well as institutionalized discrimination.
Disasters also come in many forms—natural disasters, to be sure, but also chronic poverty, broad lack of access to health care, and other hardships a community faces. When these adverse factors co-exist, recovery is exponentially harder.
About the Grant Opportunity
What we urgently need to understand is the confluence of factors that helps American communities develop resilience. “Resilience” is the capacity to prepare for, withstand, and recover from adversity. And, every community should have the ability to build resilience as chronic and acute challenges occur more and more frequently.
And that’s exactly what we aim to do through a new funding opportunity: Integrative Action for Resilience. It will provide two to four community-partnered research projects a total of $1.4 million in funding to study and advance the science of resilience.
For that reason, the Integrative Action for Resilience grant focuses on developing partnerships between communities and researchers. Ask yourselves: how prepared is your community for an emergency? What are you doing to make your community more resilient? We want to test new ways of developing good physical and mental health, community cohesiveness, as well as social, emotional, and economic well-being. These qualities are crucial to have in place for a community to absorb and rebound from trauma.
We want to learn how communities change conditions, strengthen systems, and tackle inequities, to become more resilient. But communities don’t always have the evidence base to make the most out of their policies. Community-partnered research can help to strengthen communities’ capacity while building the science of resilience. In turn, the research can inform community practice widely.
Community-Partnered Research: Who Should Apply?
A unique aspect of this funding opportunity is that we want to bring together people who have not worked together in the past in an effort to catalyze new ways of thinking about resilience and how to approach the research. We are not seeking joint proposals at this time. Instead, we are inviting two types of applicants to send us their qualifications.
The first type are those who are working on the front lines to mitigate the effects of sudden or long-term stress on their community. For example, we want to see applications from a non-profit organization who are implementing policies or procedures to tackle problems like natural disasters, disease outbreaks, violence, or discrimination, just to name a few. We are also interested in seeing applications from organizations that are working to develop community resilience leadership. These may include community engagement tactics, strategic decision-making, or effective communications during the time of a disaster. We want to learn how you are formulating and applying strategic plans in real life in an effort to improve a community’s overall resilience.
The second type of applicants we seek is researchers. The ideal research candidate will have experience working within communities and will have mixed quantitative and qualitative research methodologies. Ultimately, we want to turn the evidence into action, so communities far and wide can benefit.
After each applicant submits a letter stating their qualifications, we will invite selected people to attend a convening in June 2018 (expenses paid). The agenda is focused on resilience building and is designed to deepen our collective thinking on research questions as well as best practices. It is a chance for people to meet one another and learn about work that’s happening throughout the country.
The convening is an opportunity for researchers and community practitioners to meet, develop new partnerships, and jointly apply for funding.
Future disasters will inevitably come. By advancing the science and practice of resiliency, our hope is that the level of suffering experienced by Puerto Rico will remain a thing of the past.
about the author
Tracy Costigan, PhD, is responsible for the Foundation's organizational learning and coordinating institutional knowledge in support of effective and responsive strategies and programs. Read her full bio.
More than 50 years after the civil rights movement, an RWJF-funded survey shows we still have a lot to do to reduce discrimination and increase health equity. Dwayne Proctor reflects on these findings and the role of stories in the search for solutions.
One of my earliest and most vivid childhood memories is watching from my bedroom window as my city burned in the riots that erupted after Dr. Martin Luther King Jr.’s assassination 50 years ago.
The next afternoon, my mother brought me to the playground at my school in Southeast Washington, D.C., which somehow was untouched. As she pushed me in a swing, she asked if I understood what had happened the day before and who Dr. King was.
“Yes,” I said. “He was working to make things better for Negroes like you.”
My mother, whose skin is several tones darker than mine, stared at me in surprise. Somehow, even at 4 years old, I had learned to observe differences in complexion.
That is particularly interesting to me now, as I eventually came to believe that “race” is a social construct.
Of course racism and discrimination exist. They are deeply embedded in America’s history and culture—but so too is the struggle against them.
Over 50 Years After the Civil Rights Act, Discrimination Persists
We are now more than 50 years beyond the civil rights movement, yet change has been excruciatingly slow. For example, despite passage of the Fair Housing Act in 1968, housing discrimination persists. Forty-five percent of black people surveyed in an NPR/Harvard T.H. Chan School of Public Health/RWJF poll say they have faced discrimination when trying to rent a room or apartment or buy a house.
I see inequity wherever it exists, call it by name, and work to eliminate it. –Shalon Irving (July 9, 1980–January 28, 2017)
The numbers themselves are startling. But they take on added meaning when you consider the stories—millions of them—of real people, who face discrimination every day of their lives.
Sharing Your Story With the World
I’m reminded of the words of Carter Woodson, the black historian and educator who established Negro History Week, the precursor of Black History Month, which we are in the midst of celebrating. “You must give your own story to the world,” Woodson declared.
How true that is.
Through our stories we call attention to racism and discrimination and assert our fundamental human dignity.
And by telling our stories, we demand solutions.
I see storytelling as essential to building a Culture of Health, where everyone—no matter where they live, how much money they make, or who they are—has the opportunity to live the healthiest life possible. By acknowledging each other’s stories, we recognize that racism and discrimination are monumental barriers to our goal of achieving health equity. We simply can’t have a Culture of Health without health equity. Dr. King himself noted that “of all the forms of inequality, injustice in health care is the most shocking and inhumane.”
Everyday Discrimination Measurably Diminishes Health
Take the tragic story of Shalon Irving, a brilliant epidemiologist at the Centers for Disease Control and Prevention. Shalon was working to understand how structural inequality, trauma and violence made people sick. She asserted her commitment on her Twitter bio, noting “I see inequity wherever it exists, call it by name, and work to eliminate it.” In a tragic irony, Shalon’s life was abruptly cut short at the age of 36 when she collapsed and died three weeks after giving birth. In the weeks leading up to her death, Shalon’s futile attempts to bring attention to concerning postpartum symptoms were dismissed by medical professionals according to Shalon’s mother. Shalon’s socioeconomic advantages and expertise in health inequity could not protect her from the reality that black mothers in the United States die at 3 to 4 times the rate of white mothers.
Higher educational attainment—which can lead to higher incomes and the ability to live in healthier neighborhoods and to access high-quality health care—can’t protect African-Americans from the disparities leading to higher mortality rates. This was also the case for Clyde Murphy, a renowned civil-rights attorney who died of a blood clot in his lungs 41 years after graduating from Yale University. Soon after Clyde’s death, his African-American classmates Ron Norwood and Jeff Palmer each succumbed to cancer. In fact, it turned out that more than 10 percent of African-Americans in the Yale class of 1970 had died—a mortality more than 3 times higher than that of their white classmates.
Clyde and Shalon’s disturbing stories and the stories of too many others force us to confront the injustice of discrimination—how the toll of incessant stress and implicit bias within the health care system can progressively erode one’s health.
Love means acknowledging and respecting the pain of others. When people do that, they can focus on how to heal and move forward, together.
Through the NPR/Harvard T. H. Chan School of Public Health/RWJF poll we sought to gain a deeper understanding of daily personal experiences with discrimination from members of different ethnic, racial, and LGBTQ groups. As Woodson has suggested, this can help us better understand the reality of everyday discrimination that people face when looking for housing, interacting with police, seeking medical care, and getting a job.
Specific findings from the survey include:
Half or more of African-Americans say they have personally been discriminated against because they are black when interacting with police (60%); when applying for jobs (56%); and when it comes to being paid equally or considered for promotion (57%).
Four in 10 African-Americans say people have acted afraid of them because of their race, and 42% have experienced racial violence.
African-Americans also report attempting to avoid potential discrimination or to minimize their interactions with police. Nearly a third (31%) say they have avoided calling the police, and 22% say they have avoided seeking medical care, even when in need, both for fear of discrimination.
Similarly, 27% of black Americans say they have avoided doing things they might do normally, like driving a car or going out socially, to avoid encounters with police.
These poll findings—along with stories of Clyde and Shalon—underscore an urgent need to join in working harder than ever to shape solutions—solutions that spawn new stories where everyone enjoys an equal opportunity to live longer, healthier, and happier lives without the constant fear of discrimination.
One such story is unfolding in Louisville, Ky., where more than 60 community- and faith-based organizations are collaborating with the Campaign for Black Male Achievement to create better futures for young African-American men and boys. This coalition has created an initiative called “Zones of Hope” designed to restore a sense of place and connection for some of Louisville’s most marginalized neighborhoods, families, and young people. The idea is to reduce violence among young black men and boys (ages 16–27 years old) by increasing high school graduation rates, improving access to after-school programs, and expanding job opportunities. As Louisville’s Rashaad Abdur-Rahman noted at an RWJF-sponsored event examining discrimination’s effect on health, this project has transformed relationships; built new partnerships; and rallied the education, government, and justice systems—to invest in supporting boys and young men of color so they can achieve their full potential.
This is the kind of comprehensive, community-based approach that fills me with hope for better, brighter stories in the future.
Not believing in race means believing in love—and love means acknowledging and respecting the pain of others. When people do that, they can focus on how to heal and move forward, together.
Dwayne Proctor, PhD, senior adviser to the President, believes that the Foundation’s vision for building a Culture of Health presents a unique opportunity to achieve health equity by advancing and promoting innovative systems changes related to the social determinants of health. Read his full bio.
Atlantic City demonstrates how cross-sector coalitions built on trust are key to healthier communities. A new funding opportunity is seeking similar New Jersey coalitions that are tackling local priorities, especially in low-income communities.
Atlantic City, New Jersey, is a colorful place with a storied past. Today, its casinos, beaches and boardwalk make it a natural tourist destination, with a transportation infrastructure that puts it within easy reach of millions of people. The many languages spoken in the city are a testament to its vibrant diversity.
Despite its long-standing status as a tourist destination, the city has not always enjoyed a stellar reputation. Crime rates exceed national averages (although they’ve fallen over the past few years), and unemployment is nearly double the national rate. Gambling hasn’t brought much luck to a place that sits in a county ranked 17th in health outcomes among New Jersey’s 21 counties, according to 2017 County Health Rankings data.
How New Jersey Health Initiatives is working with communities across the state to improve the health and well-being of all New Jersey residents.
Yet Atlantic City does have a winner’s circle of passionate players who are deeply committed to turning their hometown around, growing its economy, and rebuilding its health. In 2015, New Jersey Health Initiatives (NJHI) awarded a fledgling coalition a four-year, $200,000 grant through AtlantiCare Foundation, an affiliate of the city’s largest health system. That coalition, Care AC, has been spawning new partnerships and an increasingly ambitious agenda ever since.
NJHI’s grant to Care AC exemplifies our goal of using resources to bring together the right people, build trust, and foster productive conversations that all lead to a stronger, healthier community. As we pursue the Robert Wood Johnson Foundation’s vision for a Culture of Health, we think that cross-sector coalitions are a vital tool for changing systems, policies, and the environment.
Assessing a Community’s Needs
Care AC understood these goals and convened a team—spanning health care, social services, community organizations, government, and business—to pursue them. In their first year, the group conducted a needs assessment, reviewing data from many sources that highlighted the community’s health barriers (at the time, County Health Rankings data indicated that Atlantic City’s home county had a 27% obesity rate; 24% of its children lived in poverty; and 17% of the population ranked as having “poor or fair health”; the data in 2017 differs only slightly and is available here.)
Care AC also recognized that assessing needs meant more than reviewing numbers. Or, as the coalition said in the Blue Print for Action that emerged from its year-long planning process, “statistics are great, but it is imperative to hear from agencies and community members—those with feet on the street.” So they surveyed more than three dozen civic and community organizations. Based on both data and grassroots insights, the coalition identified food insecurity, smart food choices, and physical activity as priorities for its second year.
An early success was convening Atlantic City agencies to address hunger, which resulted in a comprehensive list of food-related resources, finding ways to secure more food donations, and creating a summer feeding program. Care AC later launched its Corner Store Initiative, where Care AC educators conducted BMI assessments, offered tips on smart shopping, and handed out healthy food vouchers. One shopper initially looked askance at her $5 voucher—until an educator guided her to purchases that allowed her to put a meal of pasta and salad on the table. The initiative is providing access to foods and encouraging healthier eating habits by expanding food selection in corner stores near schools, giving students access to healthier snacks.
Another strategy was offering mini-grants of $500–$1,000 to small local agencies—with the catch that each one had to partner with another to be eligible for the award. We thought that was a terrific way to grow a network, while simultaneously improving the lives of residents. The Community Food Bank, for example, used its grant to launch a new food pantry at a family medicine clinic run by AtlantiCare. Grace and Glory, a yoga studio, partnered with the Boys & Girls Club of Atlantic City to provide summer yoga classes to school-age children.
Tackling Shared Problems by Thinking Upstream
While Care AC’s visibility grew, another collaboration was getting underway—the Homeless Assessment Response Team (HART). HART was seating law enforcement, transit, tourism, and health and social services together to look comprehensively at the needs of the city’s homeless population.
Some of the same partners were involved in both coalitions, recognized their overlapping challenges and goals, and started working together. This is the kind of collective commitment that improves health in the community. Folks who care about public safety, nutrition, business investment, or a city’s curb appeal may start from different places. But in Atlantic City, they all share a common interest in moving the homeless population out of the city’s parks and transit stations—into services and healthier living.
Equally important, the coalitions are tackling shared problems upstream—where they work, play, live, and learn.They don’t want to see the homeless displaced out of town or overlook their civil rights. Instead, they agree that deeply rooted challenges too often lead the same individual to cycle through jails, the emergency department, substance use treatment centers, and social services—only to land back on the street. Care AC, now in its third year, and HART, as service providers, share an obligation to change that pattern.
Streamlining and sharing data is essential to their collective efforts. The partners have agreed to ask a common set of questions when a vulnerable individual comes into any system. Eventually, they plan to enter that information into a shared database called the Homeless Information Management System so that everyone knows whether other clinical or social service providers have already been involved. Their goals are to enable more respectful handoffs, agree on a client’s priority needs, avoid resource-draining service duplication, and ultimately improve outcomes.
There’s no sugar-coating the difficulty of these goals. Privacy issues always loom large. And shifting from a competitive mindset to a collaborative one doesn’t come naturally to many providers, who are understandably concerned about protecting their own business models. But the bet in Atlantic City is that joining forces will pay off in a resulting healthier community that will benefit everyone.
New NJHI Funding Opportunity
Here at NJHI, we’re looking for more approaches like this. That’s why we’ve developed a new funding opportunity: Upstream Action Acceleration.
We’re looking for existing coalitions in New Jersey that are already tackling local priorities, especially in low-income communities, but are ready to start earlier, and go further. We want to hear from folks who share our expansive view of health, which recognizes the many influences rooted in where we live, work, play, and learn.
Among other areas, we welcome applications that focus on:
Adverse childhood experiences
New sector engagement (e.g., business, libraries, law enforcement)
Effective use of data
If you can work from the ground up, not just the top down, and have creative ideas for changing the policies, systems and environment that impact health in your community, please consider applying. Be sure you are setting a big table, because many sectors need to be represented, and many voices must be heard.
Bob Atkins is director of NJHI and an Associate Professor at Rutgers University with a joint appointment in Nursing and Childhood Studies. Bob is a lifelong New Jersey resident and is committed to building healthier communities across the state through effective collaborations and partnerships, meaningful conversations across sectors, and evidence-based innovations. Read his bio.
Diane Hagerman, Deputy Director of Programs, oversees NJHI’s communications functions while working directly with grantees to ensure they are able to realize the full potential of their projects. Read her bio.
Research suggests more sleep for teens could yield significant health and academic benefits. To achieve these benefits, schools across the nation are experimenting with later start times for middle and high schools.
“I fell asleep on the bus and usually wasn’t really awake until after first period ended,” says Andrew Schatzman, whose school day in Northern Virginia’s Fairfax County ("Fairfax") used to begin with a 6:30 a.m. pickup time. When district leaders moved the high school start time to 8:10 a.m., it made a big difference in his life. “He’s still a teenager, so nothing is easy, but now he’s ready to go,” says Andrew’s mom, Liz. “I’m awake enough to do what I have to do in first period,” adds Andrew.
Thanks to this change Andrew starts the school day rested and ready to learn, but millions of U.S. students do not share that experience.
Nearly half (46%) of the U.S. high schools that begin classes before 8 a.m. are filled with teenagers who have not received the 8+ hours of sleep that young people need. As adolescent brains develop, sleep patterns change. It’s a normal, natural occurring physiological milestone. Sleep researchers call it the development of an evening-type circadian phase preference. The rest of us call it becoming a night owl.
Regardless of the terminology, the result is the same: teenagers stay up late. They do not fall asleep sooner if school starts earlier. Instead, they get sleep-deprived.
Here are three important findings from the latest research:
1. Sleep Has a Huge Impact on Adolescent Health
Sleep patterns affect a sweeping range of physical and mental health conditions. Studies now show clear links between insufficient sleep and obesity, diabetes, depression, suicidal thoughts, and more. Experts are still working to determine exactly how sleep affects so many health issues, but it appears related to the production of hormones that regulate mood and satiety.
2. Later School Start Times Promote Academic Success
Teton’s decision is more than smart road safety policy. It is a terrific example of building a Culture of Health.
Teton, Fairfax, and other school districts moving to later starts are putting health at the center of all policy decisions, even those outside a traditional definition of health and health care.
In the past, school start times may have been considered an “education issue” and completely unrelated to health. We know better now.
The Robert Wood Johnson Foundation’s Culture of Health vision emphasizes that everything is interrelated: health, education, economic development and more. This one example touches motor vehicle safety, equity, and academic success, which can lead to a lifetime of improved health outcomes. Congratulations to Fairfax, Teton, and the dozens of other school districts that have moved toward later starts.
To find out if later school start times could help build a Culture of Health in your community, contact your school superintendent or school board representative. Ask if they have considered moving middle school and high school start times to 8:30 a.m. or later, matching the recommendation of the American Academy of Pediatrics, National Parent Teacher Association, and many other health and education advocacy organizations. If the idea hasn’t been considered, perhaps your school board could discuss the option at their next meeting—and you can be there!
Visit www.StartSchoolLater.net for more research and information, including case studies profiling Fairfax County and other schools that have successfully transitioned to later start times.
about the authors
Tracy Costigan, PhD, is responsible for the Foundation's organizational learning and coordinating institutional knowledge in support of effective and responsive strategies and programs. Read her full bio.
C. Tracy Orleans, PhD, leads the Foundation's efforts to develop and disseminate science-based strategies for addressing the major behavioral causes of preventable death and chronic disease. Read her full bio.
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