Working in Concert for Health Healthy and Sustainable Communities Jacquolyn Duerr, MPH California Department of Public Health Division of Chronic Disease and Injury Control/Safe and Active Communities June 2012 While in Division/Safe and Active Communities Branch, I have worked with DADP for several years in two key areas: Compliance with Stake Act to reduce youth access to tobacco Building joint public health and AOD state and local capcaity to conduct epidemiology and surveillance efforts

Overview California Health Challenges Determinants of Health What is a healthy community? Why Cross Sector Prevention is Critical? The HiAP concept HiAP Task Force Tobacco (and alcohol and food) retail campaign Links to alcohol, tobacco, and drug prevention Questions?

California’s Health Challenge Chronic disease accounts for >75% health care costs (U.S.) Injuries are leading cause of death for people ages 1-44 Tobacco, poor diet, and physical inactivity top 3 causes of deaths; alcohol is 4th leading cause of death Inequities exist across health outcomes Income, education, race/ethnicity Obesity rates high, threaten life expectancy 1/9 CA children, 1/3 teens, and ½ adults overweight or obese Obesity in CA children and adolescents has tripled in last 30 years If obesity continues to rise, youth of today may have shorter lives than their parents (NEJM 2005, Olshansky et al) between 1988 and 2007, adult smoking prevalence decreased by 35% from 23% to 14% Source: 2007 Death Statistical Master File

Costs of Chronic Disease in CA More than 96 cents of every dollar spent in Medicare… 2003 2023 (Projected) Treatment Expenditures $27B $72B Lost Productivity $106B $359B Total $133B $431B …and 83 cents of every dollar spent in Medicaid Chronic diseases also eat up a huge proportion of our health care dollars, and have very significant impacts not only on direct health care costs, but also on lost productivity and, of course, quality of life. By 2020, nearly 1out of every 5 dollars in GDP will be health care related. Resources limitations alone meant that we cannot treat our communities to good health. Milken Institute - based on MEPS/NHIS

Determinants of Health By the #’s Genes and biology: e.g., sex and age Health behaviors: e.g., alcohol use problems, injection drug use (needles), unprotected sex, and smoking Social environment or social characteristics: e.g., discrimination, income, and gender Physical environment or total ecology: e.g,  where a person lives, poor housing, and neighborhood retail/marketing Health services or medical care: e.g, access to quality health care and having or not having insurance Determinants of health are factors that contribute to a person's current state of health.   These factors may be biological, socioeconomic, psychosocial, behavioral, or social in nature.  Scientists generally recognize five determinants of health of a population. These re the set of factors that contribute to the social patterning of health, disease, and illness. Genes, biology and health behaviors account for around 25% of the population health. Medical care another 15-20 overall Social and societal factors and influences account

Place Matters High school grads: 65% Unemployment: 12% Poverty: 25% Home ownership: 38% Non-White: 89% High school grads: 90% Unemployment: 4% Poverty: 7% Home ownership: 64% Non-White: 49% Environments where we live matter Source: Alameda County Department of Public Health

We know that alcohol outlet density is associated with health problems and and crime Wetter” neighborhoods have higher levels of drinking, accidents and violence. Scribner, Richard: Alcoholism: Clinical & Experimental Research, February 2000.  There is a 15-16% difference in individuals' drinking attitudes and 11% difference in individuals' alcohol consumption attributable to density of alcohol outlets in their neighborhoods (ibid)   The number of alcohol outlets is related to violent assaults.  A study done in 1995 in Los Angeles showed that each additional alcohol outlet was associated with 3.4 additional assaults per year.  Scribner, R., Mackinnon, D. & Dwyer, J.: “The risk of assaultive violence and alcohol availability in Los Angeles County.”  American Journal of Public Health (85) 3: 335-340.  1995

First, Do Prevention Second, Do It In Concert Public health’s oath—Stop the problem before it creates risk and vulnerability Prevention $ not growing; <less than 2-3% of overall health budget and ↓↓ We cannot treat our way to health Community/stakeholders do not work on silos; they focus on 911 concerns Same solution solves multiple problems Broad support/constituencies and impacts Youth get it!

We all have a role to play in creating healthy communities. The HiAP Concept We all have a role to play in creating healthy communities. Environments in which people live, work, study and play impact health Decisions made by “non-health” agencies play a major role in shaping environments Consideration of health allows agencies to make more informed policy and program decisions and to identify win-wins Health in All Policies is a collaborative approach to improve health by incorporating health considerations into the decision making processes of all sectors and policy areas HiAP is rooted in an understanding of the social determinants of health; that is, an acknowledgement that the environments in which we live impact our health by influencing the opportunities available to make decisions that can either support or detract from health. Public health agencies alone can only do so much to create environments that support health. Other, non-health, agencies play a role in shaping environments. Planning, education, criminal justice, finance, and other agencies make decisions every day that impact where we live. A health in all policies approach brings all these agencies to the table to consciously consider the impacts their decisions have on health. We often refer to this as applying a health lens to decision making.

What is a Healthy Community? Meets basic needs of all Safe, sustainable, accessible and affordable transportation options Affordable, accessible and nutritious foods and safe drinkable water Affordable, high quality, socially integrated and location-efficient housing Affordable, accessible and high quality health care Complete and livable communities including quality schools, parks and recreational facilities, child care, libraries, financial services and other daily needs Access to affordable and safe opportunities for physical activity Able to adapt to changing environments, resilient, and prepared for emergencies Opportunities for engagement with arts, music and culture Quality and sustainability of environment Clean air, soil and water, and environments free of excessive noise Tobacco- and smoke-free Green and open spaces, including healthy tree canopy and agricultural lands Minimized toxics, greenhouse gas emissions and waste Affordable and sustainable energy use Aesthetically pleasing Adequate levels of economic, social development Living wage, safe and healthy job opportunities for all, and a thriving economy Support for healthy development of children and adolescents Opportunities for high quality and accessible education Health and social equity Social relationships that are supportive and respectful Robust social and civic engagement Socially cohesive and supportive relationships, families, homes and neighborhoods Safe communities, free of crime and violence

Why We Need HiAP [Pictures: From low-income neighborhoods (LA, Kern, Marin),] All too familiar sight and a reminder why special focus needs to be placed on poor communities, neighborhoods. Hard to be physically active; hard to find healthy food; disproportionately affected by chronic diseases, obesity, etc. We’ve got a special initiative called Communities of Excellence in Nutrition, PA and Obesity Prevention, shortened down to CX3. (3 = Nut, PA, OP) Initiative done in with our funded local health departments (23 Network funded; 8 other funding, e.g., CCROP/TCE, + local resources (San Diego, SLO, San Joaquin) Purpose: Document neighborhood conditions as it related to the food environment. The CX3 Data/Project is designed to provide cutting-edge, relevant data to make neighborhoods healthier: Promote Equity (expose disparities); Promote Public Health & Safety; Make sure discussion about Sustainable Communities benefits Disadvantaged Neighborhoods It’s meant to be a tool for healthy change

Why We Need HiAP If we look at different neighborhoods, we can see how the environment might influence people’s daily decisions. Environments can encourage consumption of unhealthy foods , or healthy foods, by impacting their availability and accessibility.

Why We Need HiAP Teens with access to a safe park are more likely to engage in regular physical activity. Environments can discourage physical activity, with locked or unsafe areas to play, or encourage physical activity. Babey et al, 2005. UCLA healthy policy research brief, using 2003 CHIS data

Why we need HiAP

The Health in All Policies Task Force Executive Order S-04-10 Directs Strategic Growth Council to establish Health in All Policies Task Force Purpose: “to identify priority programs, policies, and strategies to improve the health of Californians while advancing the SGC’s goals…” Process: facilitated and staffed by CDPH Executive Order S-04-10 directed the Strategic Growth Council to establish a health in all policies task force In order to identify priority programs, policies, and strategies to improve the health of Californians while advancing the SGC’s goals, which I’ll come back to in a minute. The executive order established a rapid timeline for the task force, requiring a report by December. Recall that the executive order was released in late february. The executive order named our dept, cdph, to facilitate and staff the task force. 16

Strategic Growth Council Multi-agency council developed to enhance collaboration among state agencies in their work to: Improve air and water quality Protect natural resources and agriculture lands Increase the availability of affordable housing Improve infrastructure systems Promote public health Encourage sustainable land use planning Meet California’s climate change goals Composition Secretaries of 5 State Agencies: Business, Transportation and Housing Agency, Environmental Protection Agency, Governor’s Office of Planning and Research, Health and Human Services Agency, Natural Resources Agency Public member Healthy communities share attributes of sustainable and equitable communities Many strategies to improve health are same as strategies to reduce GHG Co-benefits = Win-Win The Strategic Growth Council, the Task Force’s parent body, is a legislatively established multiagency council with sustainability goals, which include improving air and water quality, protecting natural resources and agricultural lands, and encouraging sustainable land use planning. The Task Force fits well under the auspices of the Strategic Growth Council because healthy communities have much in common with sustainable and equitable communities, and many actions that promote health also advance sustainability. For example, replacing car trips with walking and biking reduces air pollutant emissions and reduces greenhouse gases, both of which are SGC goals.

Convening the Task Force SGC convened HiAP Task Force on March 17, 2010 Designated 19 Agencies, Departments, and Offices Air Resources Board Office of the Attorney General Business, Transportation, and Housing Agency Dept of Community Services and Development Dept of Education Environmental Protection Agency Dept of Finance Dept of Food and Agriculture Dept of Forestry and Fire Protection Office of Gang and Youth Violence Policy Health and Human Services Agency Dept of Housing and Community Development Labor and Workforce Development Agency [Natural Resources Agency] Dept of Parks and Recreation Office of Planning and Research Dept of Social Services Dept of Transportation Office of Traffic Safety The Task Force got its official start in March, when the SGC designated 19 agencies to participate on the Task Force. The Task Force has broad representation across sectors, from education, labor, criminal justice, housing, transportation, natural resources, planning, environment, and finance, to health and social services Task Force representatives tend to be high level officials, including several agency undersecretaries, deputy directors, and public information officers. Having high-ranking participants allowed designees to speak on behalf of their organizations, but also made scheduling difficult!

Process: Aspirational Goals All California residents: have the option to safely walk, bike, or take public transit to school, work, and essential destinations live in safe, healthy, affordable housing have access to places to be active, including parks, green space, and healthy tree canopy are able to live and be active in their communities without fear of violence or crime have access to healthy, affordable foods at school, at work, and in their neighborhoods California’s decision makers are informed about the health consequences of various policy options during the policy development process The Task Force identified several aspirational goals to provide a structure for the recommendations being developed. These aspirational goals might be better called vision statements, especially because they helped make abstract concepts more concrete by providing something task force members and the public could “see”. For example, the aspirational goal in the area of active transportation is that all California residents have the option to safely walk, bike, or take public transit to school, work, and essential destinations

Report to the SGC      Topic areas Active transportation Housing and indoor spaces Parks, urban greening, and places to be active Community safety through violence prevention Healthy food Healthy public policy      The Task Force clustered our final recommendations on six policy areas. The first 5 deal with healthy environments: transportation, housing, urban greening, community safety, and food The 6th deals with how we, as a state, create, amend, and support policy, and how we can promote health through our policy processes. For example: embedding health criteria into grants discussing health impacts in guidance documents developing indicators for health impacts of “non-health” policies The final Task Force recommendations fall into two main categories, promoting healthy communities and promoting healthy public policy, and all the recommendations have links to health and the SGC. 11 recommendations prioritized for near-term implementation Develop 1 – 3 year implementation plans Track progress using process measures Cross-cutting themes Interagency Collaboration Equity Community Engagement Data

Current Work 11 recommendations prioritized for near-term implementation Develop 1 – 3 year implementation plans Track progress using process measures Cross-cutting themes Interagency Collaboration Equity Community Engagement Data In December of 2010, our recommendations and report were accepted by the SGC, which requested that the TF come back with a smaller set of priority recommendations for which we would develop implementation plans ; a key criteria for narrowing further was near-term feasibility. We are now developing these implementation plans, which will be implemented over the next 1 – 3 years. TF also identified 4 cross-cutting themes to be addressed in implementation plans

Implementation Priority: Community Safety through Violence Prevention  Develop and disseminate guidance on Crime Prevention through Environmental Design (CPTED) Safety is key to meeting SGC goals Community design features can prevent crime “Eyes on the street” Lighting Design of public spaces California-specific guidance Endorsed by SGC in January 2012

Possible Areas to Explore  Retail outlets and zoning: Links between alcohol and healthy food access Education: Links between attendance rates, overall health outcomes, and alcohol abuse Community safety: Links between liquor outlet density and violence Transportation: Links between traffic-related injuries and deaths and alcohol, including pedestrian and bicyclist safety Built environment: Links between neighborhood characteristics and alcohol consumption 23

CPI REGIONAL FORUMS Healthy Retail Environments: An Integrated Approach Andrea Valdez, California Tobacco Control Program Sacramento ~ June 5, 2012

Potential Areas of Integration Tobacco Alcohol Healthy Foods Licensing Discounts Package size Density Healthy Retailers External signs

Using Lessons Learned--Take Small Steps at the Start Getting started Start planning together Join/foster cross sector efforts 2. Getting to know you Start with simple joint projects Learn each other’s language/priorities 3. Getting down to business Follow your community’s lead Initiate a joint or cross sector effort

Today Is Not Soon Enough If We Can Do Our Work in Concert, We Can Make a Powerful Sound and Light Let’s Get Started ! Today Is Not Soon Enough

For More Information Linda Rudolph, MD, MPH--HiAP linda.rudolph@cdph.ca.gov Julia Caplan, MPP, MPH--HiAP julia.caplan@cdph.ca.gov HiAP Task Force website: http://www.sgc.ca.gov/hiap Jacquolyn Duerr, MPH—CDIC jacquolyn.duerr@cdph.ca.gov Andrea Valdez, MPP—Tobacco Control andrea.valdez@cdph.ca.gov

Questions?