[Watch] Exploring the Intersection of Health and Economic Equity


Fed Communities Staff

Pediatrician with young patient

As COVID-19 spread throughout the country, its impact rippled through all facets of communities and the economy. As a result, the interdependency between health and the overall economy was made even more evident than it previously was. The pandemic reminds us of the importance of health as we work towards economic equity. On May 13, 2021, the Federal Reserve Bank of St. Louis held a Connecting Communities webinar focused on the impact of COVID-19, historical and structural barriers to health equity, the relationship between health and economic equity, and practices to encourage equitable health. Watch the video below.

Good health enables individuals and families to engage in their social and economic lives. It allows them to contribute and benefit from the economy; although, the ability to achieve this level of health is not equal for all. Differences in health outcomes exist across many factors, including economic status, education, race and ethnicity, and geography. Working towards health equity means that every person has the opportunity to attain their full health potential, and no one is disadvantaged from achieving this potential because of their position in society or other socially-determined circumstances.


  • Bobby Milstein, director of system strategy, ReThink Health
  • Jason Purnell, vice president of community health improvement, BJC Healthcare
  • Ruth Thomas-Squance, senior director of field building, Build Healthy Places Network
  • Nishesh Chalise, director of community-based policy and analysis, Federal Reserve Bank of St. Louis
  • Matuschka Lindo Briggs, director of special projects and strategic support, Federal Reserve Bank of St. Louis moderator
Connecting Communities Exploring the Intersection of Health and Economic Equity (video, 1:20:40).
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Matuschka Lindo Briggs

Good afternoon and welcome to Connecting Communities. Today’s webinar is Exploring the Intersection of Health and Economic Equity.

On slide two, I would now like to take the time to introduce our speakers for today. Dr. Jason Purnell, Vice President of Community Health Improvement at BJC Healthcare. Dr. Bobby Milstein, Director of System Strategy at ReThink Health. Dr. Ruth Thomas-Squance, Senior Director of Field Building at Build Healthy Places Network. Nishesh Chalise, Director of Community Based Policy and Analysis at the Federal Reserve Bank of St. Louis. And I’m Matuschka Lindo Briggs, Director of Special Projects and Strategic Support for the Community Development Department at the Federal Reserve Bank of St. Louis. And I will serve as your moderator for our session today.

Let’s move to slide three where we can take care of a few housekeeping items before we get started. So for the best webinar experience, we recommend you use the web stream to consume this live video event through your computer speakers. If you have technical issues, you are welcome to dial into the phone number, post it on the player page, but the video will not sync perfectly with the phone audio. This session will be recorded and the presentation will be available on our Connecting Communities website. Also, in connection with this session, you can find a variety of additional resources available at www.fedcommunities.org. We will be taking audience questions during the event today and we’d love to hear from you. So to submit a question, use the ‘Ask Question’ button located on the webinar player page. You should see it there right at the bottom at the left hand of your screen. Or you can email us at communities@stls.frb.org.

As we move to slide four, I need to go over our legal notice and disclaimer since this is a Fed webinar, which is that the opinions and statements expressed in this presentation are those of the speakers and are intended only for informational purposes. They do not reflect official positions of the Federal Reserve Bank of St. Louis or the Board of Governors of the Federal Reserve System.

And finally, I’d love to share our mission with you on slide five. The mission of the Federal Reserve’s community development function is to promote economic growth and financial stability for low to moderate income individuals and communities. You can look at the map to see where your community development team is located. Our work is done through a range of activities from conducting research and identifying emerging issues to developing resources and sharing ideas as well as fostering collaboration and building partnerships.

Now, before I hand the reigns over, we would like to have our audience answer a few polling questions. So you’re going to see a poll come on your screen here in a second. And just a reminder, all you have to do is click on your answer and then don’t forget to go to the bottom and hit submit. So our first question, “What sector do you work in?” Non-profit, social services, financial services, philanthropy, health or other.

I’m going to give you all a little while here to look at those polls and submit your answer. Don’t forget to hit the submit button, after you hit non-profit, social services, financial services, philanthropy, health or other. All right, let’s take a look at those results.

All right, it looks like 39% non-profit and social services. And then we have 24% financial services. All right, that’s great to see, and we welcome all of you here today. Now let’s move on to our next polling question.

“The health expenditure per capita in 2018 for Organization for Economic Co-operation and Development countries is $3,994. How much do you think is the US’ health expenditure cost per capita?” Is it less than $4,000? Approximately $6,000. Approximately $8,000. Approximately $10,000. Or approximately $12,000. How much do you think is the US’ health expenditure cost per capita? Less than $4,000, $6,000, $8,000, $10,000 or $12,000? Go ahead and hit submit.

It’ll be interesting to see how close most of you come to this one here. Okay. Correct. So it’s approximately $10,000. It’s actually $10,586. All right, we’re going to do our last polling question here.

“Have you or someone you know delayed medical treatment for one of the following reasons?” Lack of health insurance. Cost of visit or services. Lack of time to visit the doctor. Access to transportation. Never delayed medical treatment at all. Again, have you or someone you know delayed medical treatment for one of the following reasons? Lack of health insurance. Cost of visit or services. Lack of time to visit the doctor. Access to transportation. Or never delayed medical treatment.

All right, let’s go ahead and see what the results are for this. So we have 37% here that picked cost of visit or services. 28%, lack of health insurance. 18%, lack of time to visit the doctor. Access to transportation was actually really low at 3%. And then finally, never delayed medical treatment was at 14%. So we had a pretty high number here on the cost of visit or services. So it’ll be nice to have our panelists speak to this and talk about it some more.

So I would now like to turn the presentation over to my St. Louis Fed colleague, Nishesh Chalise. Nishesh, the floor is yours.

Nishesh Chalise

Thank you, Matuschka, and thank you everyone for joining this important conversation. Last March, when the pandemic was beginning to take its toll in the US, the Federal Reserve System came together to implement a national COVID-19 impact survey. The survey was designed to track the pandemic’s impact on low to moderate income communities or LMI communities. In each of the four iterations of the survey in 2020, it was clear that the pandemic was causing a significant disruption on LMI communities with employment loss and impacting businesses. Even in October, organizations were reporting that the impacts were getting worse. Not only the communities, but the organizations serving them also faced significant challenges with higher demands and constrained resources.

Although, everyone was affected by the pandemic, there were disparities. Based on various data including number of cases, hospitalization rates, and mortality rates, we now know that the pandemic proportionately impacted African-American, indigenous and Latino communities that have been historically marginalized. Even in our survey, organizations serving Black and Latino communities reported relatively higher disruption and difficulty in recovery. The intertwined nature of this public health and economic crisis has made us look deeper into the connections between health and economic equity. How are the barriers towards health and wellbeing tangled with economic prosperity? If the challenges are tangled, are there solutions or leverage points that can help us achieve positive outcomes for both? These are complicated questions and I’m excited to listen and learn from our esteemed panelists.

To get things going, I would like to ask Dr. Purnell to take us off.

Jason Purnell

Thank you very much, Nishesh. I appreciate the opportunity to join you this afternoon. If we can advance to the next slide.

So a very simple statement that I first heard roughly 15 years ago in Rochester, New York has stuck with me all these years because it speaks so eloquently and succinctly to one of the critical ways in which health outcomes are determined. I quoted this statement, “If you want to lower my blood pressure, help me pay my electricity bill”, in an essay that appeared a few years ago in a book called What It’s Worth, in which I argue that financial health is public health, that people’s economic conditions from the various very earliest years of life influence their health and wellbeing throughout the life course. And despite our wealth as a nation, our health outcomes lag those of our wealthy peers. In fact, to follow up on the polling question, we spend about 18% of GDP on healthcare and lag other wealthy OECD nations on a number of indicators. Our health outcomes are poor to middling when you compare us to the other wealthy nations of the world. And that’s in part because we are much less likely to attend to the most basic needs of our communities and our families and individuals within them.

So on the next slide, I’d like to provide an overview of what we mean when we say the social determinants of health and public health. We are talking about a range of factors that as the Kaiser Family Foundation has laid out, help us to explain the kinds of health outcomes we have in terms of mortality or death, morbidity or disease, life expectancy, disability. We know that healthcare and access to healthcare, again, relevant to the poll is extremely important. In fact, it’s necessary for people to have healthcare coverage, access to providers, culturally competent and quality care. But healthcare alone only accounts for about 10% to 20% of health outcomes.

We also know that factors like economic stability, neighborhood and physical environment, education, food access and community and social context have an outsized impact on health outcomes. And I would add, I would actually edit this graphic to include wealth under economic stability, and I’ll talk more about that focus on wealth. But I also want to ground us in a definition of health equity and what we mean when we say health equity, borrowed from the Robert Wood Johnson Foundation, which says that health equity means that everyone has a fair and just opportunity to be as healthy as possible, which I think we can all agree to. But what I like about this definition is that it goes on to say that getting the health equity requires us to remove obstacles to health such as poverty and discrimination and the consequences of both of those which are powerlessness and lack of access to good jobs with fair pay, quality education and housing and safe environments in healthcare. And it turns out that more wealth, more economic resources helps to buy many of those things in terms of improving the likelihood that people will live in good health.

On the next slide, we have just a few of the associations between wealth and health. We know that those with more wealth have lower death rates, lower rates of chronic diseases, improved mental health, a better ability to function in daily life and lower rates of smoking, obesity and excessive alcohol use and other deleterious health behaviors. In fact, when you graph increasing levels of wealth against some of these health behaviors and health outcomes, you have what we call a socioeconomic gradient in health, which is a fairly consistent stepwise function where rather more wealth is associated with lower rates of negative outcomes in terms of health.

On the next slide, we can see that these associations begin very early in life. In fact, a child’s starting point in life is a fairly strong and consistent predictor of their later health outcomes. But even before they reach adulthood, children from wealthier families have lower obesity rates, fewer markers of asthma, and actually show better social and emotional development very early in the life course. So again, this is a consistent set of associations that we see between economic resources and in particular wealth. And there are specific ways in which we think this connection between health and wealth takes place.

So if we look on the next slide, some of the hypothesized ways in which the health and wealth connection can be explained, one of the stronger hypotheses is through the stress pathway. So wealth actually helps to buffer stress, particularly the stress associated with having limited financial means. And we know from decades of research, the weathering effect that stress has on the body on its multiple systems, including hormonal pathways, immune system response, and negative psychological functioning.

So the stress pathway operates in such a way that if you’ve got a store of wealth, you’re better able to weather economic storms and crises, not unlike the COVID pandemic that we’ve been experiencing for over a year now across the world. Another explanation has to do with education. Wealth allows one to buy high quality education for the next generation, which creates a virtuous cycle where better education also allows subsequent generations to accumulate more wealth. We also know that people with higher levels of education are more likely to access and to act upon the latest health information which translates into better health behaviors.

Another hypothesized pathway has to do with future orientation. Wealth gives people an orientation towards the future. It allows them to envision a world beyond tomorrow that’s worth saving for. We know from research on child development accounts that families who are provided these investments in a child’s future at birth report greater hope and a greater sense of future orientation in terms of that child’s ultimate educational outcomes. There’s also research suggesting that perhaps an underlying future orientation is implicated in both financial and health behaviors so that people with more future orientation are more likely to plan for their future health and wealth. But we have to attend to the ways in which systemic racism also patterns this connection between health and wealth. And that is the subject of this latest brief from the Asset Funders Network on Wealth and Health Equity that notes the ways in which racial wealth disparities help to explain racial health disparities.

And a nice succinct description of this connection from that brief says that wealth enables people to afford health promoting goods and resources, spend more time on health promoting activities and feel less anxious, and all of this has a direct impact on health. And all of that is shaped by a legacy of systemic racism in the United States, which has precluded populations from participating in wealth accumulation.

On the next slide, we can see the toll that stress has taken during the COVID pandemic. This is taken from the Stress in America survey of the American Psychological Association, which shows that nearly 8 in 10 people in the United States say that the pandemic has been a significant source of stress in their lives, and that shouldn’t be surprising to anyone. Nearly 7 in 10 saying that they’ve experienced increased stress over the course of the pandemic.

Again, not a surprise, but what we know is that in terms of the financial strain that’s been experienced, people with household income under $50,000 are more likely to report those financial impacts of the pandemic, with 21% or double the rate, saying that they’ve been laid off during the course of the pandemic. Nearly three quarters saying that money is a significant source of stress and almost 60% saying that the cost of housing has been a significant source of stress. So we know that even though we have all experienced the stress of the pandemic, the burden has not been evenly borne, not just in terms of health outcomes, but in terms of the financial impact.

On the next slide, I want to close by talking specifically about the role of healthcare. This graphic is borrowed from a blog post in Health Affairs by Castruchi Araba in 2019, which is showing that, as I mentioned, only 10% to 20% of health outcomes are accounted for biomedical care, and alone healthcare is not going to change population health and the kinds of disparities that we see at the population level. More and more at the midstream of this graphic, we’re seeing health systems beginning to address individual patient’s social needs, and that includes things like housing and transportation and food access.

And that’s an important addition to the downstream medical interventions that we see traditionally in clinical settings. But in order to have sustained and meaningful impact on population health, we know that we need to move further upstream, and that means attending to the laws and policies and regulations and investments that actually change conditions in community. And that is a great deal of what I’m focused on in my role as Vice President of Community Health Improvement for BJC Healthcare.

So I’m going to stop there and now turn it over to Bobby Milstein with ReThink Health.

Bobby Milstein

Thank you Jason. I’m going to pick up so many of the threads that you and Nishesh have begun to develop in this conversation. The problems that we face, the challenges and aspirations that we strive to achieve are really too numerous to ever deal with them one at a time. And we’re discovering more and more that they’re actually not truly separate but deeply interconnected. And so the question starts to become how can we start to act or think and act in ways that are really representing the full interconnectivity of the world in which we find ourselves? And that leads to a practice of multi-solving where it is possible to think about health and wealth and wellbeing and other dimensions of this work as different facets and co-benefits of the kinds of activities that we engage in.

We go to the next slide. It sort of captures the essence of what multi-solving is. We can build more operational definitions in a second, but for a lot of us trained to identify problems and identify specific interventions, the idea, the very prospect of multi-solving requires a daring effort to imagine that it is possible that our problems might be easier to solve together than one by one. What I love about that quote from our colleague Beth Sowen is the double entendre of together. We have many problems, but we are also plural people with many talents and in immense capacities. And so the together here represents both the ideas and issues that we need to engage with and also the larger and larger we that can participate in shaping a common world. One of the questions that we had at ReThink Health and we do a lot of policy analysis and looking for the empirical foundations of the system in which we live and where the leverage points are.

There’s a lot we can say about how to do science with a focus on multiple issues at once. But I’ll just sort of cut to the chase on a recent paper published January of last year where, this was in the middle bank, quarterly, where we were curious about the extent to which a long list like a dozen interventions could in some ways contribute to improvements in health and quality of life and reductions of premature death and lowering of healthcare costs and other social service expenditures. And to skip over a lot of the complexity of that study, one of the major findings is that efforts to reduce poverty and also to expand social inclusion are uniquely positioned in the network of phenomenon that we face. They have stronger, more diverse, quicker impacts on health and wellbeing than a dozen other interventions you can dream up. And one of the reasons is that they sit at the center of a tangled set of threats and are often treated separately.

So we don’t necessarily appreciate both the vicious cycles that conform or also the virtuous cycles that can take hold when our analytic methods and our strategic investment frames are not really taking into account the fact that these separate threats are in fact actually connected. I’ll just give you a little glimpse into how we did this study.

On the left side of the next slide, we laid out a number of vital conditions that all people pretty much depend on all the time to reach their full potential for health and wealth and wellbeing. And then we used the county health ranking database to array out and profile a number of very common and some of the most serious threats that undermine those vital conditions.

And on the next slide, we sort of built that place-based wide angle view of the conditions that people and places find themselves in. And looked across a peer cohort of 39 large urban counties. This is about 58 million Americans live in these places. And we did sort of complicated regressions where each of these outcomes took its turn as both the dependent and the independent variables. And the drawing on this thing shows just how intimately and centrally connected poverty and inadequate social support are in this sort of set of tangled threats.

And on the next slide, it just sort of summarizes the question of if we could make progress, even just 25% progress, in each of these areas, how much would it contribute to expanding the years of life and expanding the health and wellbeing of our experience of life and also lowering costs of an array of urgent services. And the picture tells the entire story that in every one of these pure counties, it is poverty and social support that ranked number one and number two often in combination to deliver the vast majority of the potential gain that can happen. Almost 1.7 million more years of life, or almost 2.7 more people with better health or nearly $270 billion of annual lower spending in just those 39 counties.

So one of the punchlines on the next slide, there are just practical implications from this way of looking at the world that health is in some ways powerfully moved by both economic and social inclusion. They work better together and it’s when people experience both the dignity and value of their work to create a more thriving commonwealth, to create those conditions that Jason was talking about is a major sort of multi-solving move. And we could learn to be designing initiatives that are built to leverage those co-benefits. Just think about the possibilities of a really strong, deeply rooted civic effort to create a more equitable economy that is more just and regenerative and multiracial, things that our economy in the US has really never been built to do but are still within reach.

On the next slide, and really in just the last couple comments I’ll make is, there are an increasing number of resources for people who want to work in this sort of place, space, interconnected, multi-solving way of practice. In the late spring of last year, more than a hundred people and organizations came together to write the springboard for Thriving Together. It’s a document that sort of describes how we can convert the loss that is underway not just in this crisis, but in a series of intergenerational shock that we’ve been enduring over time. And how do we convert that loss into renewal.

That renewal, it in some ways begins with an understanding of who is that we. And in this diagram, we sort of put belonging civic muscle as the, it is both a vital condition. We all need to feel like we belong, we have to feel like there are things that we can bring and help shape a common world. Those are necessary for people’s sense of dignity and purpose in the world and quite directly affecting our health and wellbeing. But it’s also a practical necessity if we want to create a more thriving sort of environment and have better access to the conditions that we need for basic needs for health and safety, clean air and clean water and routine healthcare and freedom from addiction and trauma and violence, also humane housing and meaningful work and wealth, lifelong learning, reliable transportation.

All of these things begin and run through our capacity to build a wider and wider sense of belonging and the civic muscle. It can only come when we work together across our differences. And so the springboard speaks about various ways of taking action in the moment. The whole array of pivotal moves that can be taken in various walks of life and sectors, but it also braids those actions together into three areas of long term cultural and institutional renewal around the prospects who are renewing our civic life, our economic life, our social, emotional and spiritual lives. Those are some of the most powerful ways that we can become multi-solvers and ask questions that’ll really change the legacies that we’ve inherited into ones that we’re really proud to pass on to future generation.

In the next slide, just a couple other resources to say that just a few months ago, the US Surgeon General published a remarkable report, unlike reports of Surgeon Generals in the past, that talks specifically to businesses and how they can leverage this interdependency between community health and economic prosperity. Both are necessary for each other to happen. And that report is organized around these vital conditions, speaks about the roles for businesses to become better stewards, interdependent with others in their communities, to be able to create conditions that not degenerate health and wealth over time. And the Build Healthy Places Network, we’ll hear from Ruth Thomas-Squance in a second, published also a remarkable companion document, a policy scan also organized around the same vital conditions to think about how we can make healthy neighborhood investments.

My last slide is really a resource given to all of us at the moment to begin to think about what can we do as in pursuit of greater health, wealth, wellbeing, equity, and racial justice. Those are hard multi-solving challenges, but we have an array of actions that are possible before us. And when the wellbeing of The Nation Network has assembled a policy library hosted by the community commons with more than a hundred actions that people can take in different walks of life to be able to advance a wellbeing economy that is more equitable, there’s also a Delphi survey that all of you can participate in. If you click on the link for the Delphi survey, you could add your voice to this about what are of these many actions that we can take, which ones do you think are most important, most feasible, most easy to implement? So these curated policy libraries can actually help us come together across difference and really remake the conditions that we all need to thrive together.

So I will stop there and turn to Ruth Thomas-Squance from the Build Healthy Places Network to continue the discussion.

Ruth Thomas-Squance

Thanks so much, Bobby, for that. Hi everyone, it’s good to speak with you today. Yeah, my name is Ruth Thomas-Squance and building off that discussion of interconnectedness, the Build Healthy Places Network really as it works as a national center at the intersection of community development and health. And our mission is to transform the way organizations work across the health community development and finance sectors to collectively advance equity, reduce poverty, and improve health in neighborhoods. And we do this through engagement, education and synthesis. And the intention is to drive investments through equity focused cross sector partnerships that address the social determinants of health that were mentioned earlier.

So next slide. In addition to this, the cross sector perspectives, we also as an organization determine that race equity, diversity and inclusion already lens for sure is really central priority to our work. We recognize racial equity as a key driver of health and wellbeing and it’s certainly something we’ve seen born out in the particular patterns of COVID-19’s impact on black, indigenous and other people of color. And in doing so, we join many other key health and public health organizations that now acknowledge racism as a public health crisis. And in response, we intentionally embed this ready lens in our work.

So I’m going to circle back on the next slide to something that was laid out nicely by Jason about the social determinants of health. And this slide just makes the distinction of what in public health is called the level of intervention. And if you take through the first arrow, it shows that really the majority of spending on healthcare that we heard about earlier, the astronomical spending on healthcare is really focused on the lower two levels of this image. It’s the clinical care, the medical care interventions, and then some of the interventions that just mentioned that where health institutions and screening patients and connecting them to external services as a means of addressing social needs.

And it’s all the incredibly important work. And what I’m going to talk about today with the next arrow is really bringing where BHPN works to take this shift up one level to interventions that are improving community conditions. And these are the social determinants or to use the terminology that Bobby mentioned from the Thriving Together springboard, they’re the vital conditions that are working to influence an individual’s health outside of that clinical delivery walls.

So this connects to the project that I’m going to talk about today, which is the Community Economic Development Playbook that Build Healthy Places Network released this month in collaboration with NASIDA. And the Playbook is really an action-oriented guide and it’s designed for community economic development organizations that are looking to pursue partnerships with healthcare systems. And it provides guidance on how to partner to create career pathways for people living in low income communities and particularly communities of Black, indigenous and people of color.

And the work builds off a previous playbook that we produced in 2018, that was Healthcare Playbook for Community Development. And the Playbook really creates pathways and case studies that help enterprise embarking on these partnerships and how to leverage these assets that this cross-sector work can bring to achieving racial justice and ultimately impacting community help.

So in the next slide you can see that as we created this playbook, we interviewed 36 stakeholders from multiple sectors and drew together some themes around strategic approaches that partnerships can take to advance economic inclusion. And the first one was developing training and career pathways that led to economic mobility and the second, fostering an environment for local entrepreneur’s success, leveraging assets from health institutions, creating access to healthy food and advancing food sovereignty. And food sovereignty, as opposed to food access, if you’re not familiar, is where you take into account how the food is made, where it’s made, the ecological sustainability and those kind of factors. And finally leveraging capital to develop local health facilities.

And all these impact, the sort of vital conditions that Bobby mentioned that are needed for foundation of physical and mental health. So you’re impacting the basic needs for health and safety and healthy food and food sovereignty and that vital condition of meaningful work and wealth that contributes to self sense of inclusion and wellbeing.

So in the next slide, I’ll begin with a few case studies that we have featured in the Playbook and the first one’s in Los Angeles. And it’s the partnership between LISC and Kaiser Permanente. And the goal of the strategy was really for supporting local entrepreneurs to remove barriers to prevent people of color from starting successful business. And Crenshaw is one of the largest black communities west of the Mississippi River. And this is a three initiative led by LISC and CDFI to connect residents and businesses in South LA to regional economy and to foster connections among stakeholders and really trying to create ladders of opportunity, economic opportunity for residents.

And they were given a financial boost by partnering with Kaiser Permanente, which is the large integrated non-profit healthcare system. And they partnered to deploy grant and loan resources as a means for them to improve health wellness outcomes in the south LA neighborhoods that they serve. And this destination crunches a corridor of art and culture and it’s to facilitate economic security and entrepreneurship. They work together to strengthen an operation small business and created a COVID-19 recovery grant fund for small businesses and they’re developing a creative economic development council. And the hope is that the long term will position local stakeholders to benefit from events such as the upcoming Olympics and create a financial stability while also maintaining a cultural identity and vibrance to the area.

The example on the next slide comes from Washington DC where some others might eat or some partnered with United Care, and they really focused on a strategy of training and career pathways to support economic mobility in historically marginalized communities in Washington DC STEM ward.

So again, in this situation there was a situation where the black community was experiencing 88% of homelessness while only being represented in 48% of the general population. And STEM works with those experiencing homelessness and they developed the Conway Center together with the United Healthcare System, which combined affordable housing with training for living wage jobs, healthcare services, all under one roof, and included a federally qualified healthcare center that itself created jobs and as well as 128 affordable homes combined with the kind of supportive services that are really essential for successful healing. The trauma of experiencing homelessness, particularly long-term homelessness and 20 homes are at substance abuse treatment programs. And the employment center offers tuition-free adult workforce training and preparing adults for careers allied to health and in the building traits and trying to really create a gateway to sustainable pathways out of homelessness and poverty.

And in the next slide we move to LISC ProMedica operating in Toledo, Ohio. And ProMedica is a large healthcare system that’s made a commitment to improve social determinants of health in the neighborhoods they serve. And they partnered with LISC again in this case to commit $45 million to the effort to scale up economic opportunities and improve health outcomes in the region over a 10 year period. And this particular part of the project, they launched Market on the Green and the Ebeid Center in downtown Toledo. And this is a full service grocery store that is owned by the ProMedica Healthcare System and it operates in a designated food desert. So also in addition above the market, there is a teaching kitchen, computer lab and job training site and some of those in the job training get work experience at the Market on the Green. And the center also houses the first financial opportunity center to be run by a health system.

And LISC bridges to career opportunities model connects clients to middle skills jobs that have career pathways. And they’ve had a great success, they’ve had almost 70% completion since they’ve started. And ProMedica really tries to provide graduates with job placements, specifically from the state nurse training to local healthcare employers including their own system. And just one point, I think, related to what was being said before about that interconnectedness of these conditions is that one challenge they had during the pandemic was the job placement was that qualified parents were hard to place when schools were closed and that there was a lack of appropriate childcare. So you can see that as Bobby referred to how these challenges don’t exist in isolation but connected. And so our solutions really have to be rounded and holistic in response.

And this next example, community development for all people and Nationwide Children’s Hospital worked together in Columbus, Ohio and they focused on revitalizing an area that was very near, within a mile of the hospital campus, but had very high rates of poverty and poor health, and historically marginalized communities. And the approach they took again was that they collaborated with the hospital so that the training best aligned with the employment opportunities, because as in many cases, the hospital is one of the largest employers in the area.

And what I like about this, the hospital also contributed their development team provided training and soft skills, culture, linguistic training and greening trust and relationships, which is often a piece that’s overlooked. And again, referring to the interconnectedness, community development for all people, I run a free store that provides free food and is one of the largest distributors of fresh food and veg. And this really became a community focal point and a means to build relationships and information conduit for recruiting to the actual job training. So they got a lot of interest and in the first year, the hospital increased their hiring from the residents of the healthy families community by 15%. And one thing that stuck with me really from speaking to them was that six months into the pandemic, over 93% of the participants they had hired had retained positions during the stay at home orders. And that’s the kind of change that really sort of bugs the trend of the statistics we saw happening in most neighborhoods of this demographic really across the country.

So in summary, some future opportunities that we identified. I haven’t spoken today so much about innovation districts but really that they’re a possible framework for hospitals to have equitable economic impact. Certainly, we think that we will see healthcare providers building community wealth and through these anchor institution roles that they play. Public health as you come out with the pandemic is definitely shifting priorities to look at these inequities that really existed but got laid there by the impact and increased investments in public health should help support those efforts.

And I’m going to finish by just sharing this little quote that has really captured my attention over the past 12 months and that comes from Admiral James Stockdale, the US Naval Officer who was captured during Vietnam for seven years and speaks to the crisis leadership. And it’s that, “We must never confuse faith. We will prevail in the end, which we can never afford to lose with the discipline to confront the most brutal facts of our current reality, whatever they might be.”

And COVID has been both a brutal reality of an experience for many but has really unveiled the many brutal realities that preexisted the pandemic. So for so many communities of color across the country. So I think we can confront the harshness of that while holding the fate that we can, through intentional and through thoughtful new ways of working together, these sort cross-sector kind of innovations that we have all spoken about, that we can create anti-racist systems and bring changes that will support all Americans to achieve their best health and wellbeing that really will be to the benefit of us all. And you can find more information on a website about the playbooks and the materials that I spoke about today.

And thank you so much for your attention and I hand it over to you, Nishesh.

Nishesh Chalise

Thank you, Ruth. Thank you everyone. That was amazing. I really appreciate your deep knowledge and your passion in all the work that you do. I would like to call back Jason and Bobby so that we can continue this conversation. All of you touched a little bit on COVID-19 and so maybe we can start the conversation there. And this is an open question for all of you and so feel free to jump in. How has COVID-19 shaped or reshaped some of the thinking about the way you approach your work in your particular organization that you’re currently working at?

Jason Purnell

I think, for me, one of the primary learnings from the pandemic is that systems on autopilot do not produce equitable outcomes. So unless we interrupt those systems and make equity central to what happens, we’re not going to get to equitable outcomes. And I’ll give you a very simple example. When vaccination was finally available, many of the health systems put the link on a website even though the people eligible were older adults, many of whom we knew during the pandemic didn’t have access or facility with digital tools. But that was what we thought of, that was the first thing we thought of, rather than asking the question from the outset, how will the most vulnerable people access this resource? So that’s just one example of the ways in which the pandemic has shown that unless we make equity central to how we do things and institutionalized that, we will not get equitable outcomes.

Bobby Milstein

I can pick up on that thread, it sort of echoes to the point that Ruth ended with as well, that when systems collapse, that is a time when people rise. And in many ways, there’s a reservoir of resilience in communities across the country to work differently and better across difference. But that resilience is being tested. I mean, many people have to find that resilience every day because the world wasn’t really built for them to thrive. And how can we, at a larger structural level, begin to let go of some of the legacies that have created systems that are not resilient, that don’t put people and places at the center of their thinking and construct conditions where the intention is for all people to thrive together.

That has never been really a design principle of the ways of life in America, but it can still be, and this is really a time for this generation to find the resilience as other generations have in the past to take a meaningful stride toward wellbeing and justice at a time when maybe our commitment to thrive together as being tested. And so we’ve really tried to hold both of those characteristics together because in between the two is really where we find who’s willing to step in to do this work differently together.

Ruth Thomas-Squance

Yeah. Those are all really great points and I think, for us, it’s really shown the idea that social determinants of health are real, but these external factors that were all tried by what was essentially a health threat, they were all tried and tested, stress tested, I should add. And I think that it really shows that our systems, we may think of them administratively as being individual, but they really don’t work in isolation. So that when we have a pandemic, we close schools and then we have schools struggling to figure out how they’re going to do meal deliveries to hundreds, thousands of children per day.

So then we have to acknowledge that our school system is also a nutrition delivery system. And so decisions that we make on one system really are going to impact the system. So even though we may administratively be thinking of them separately, how the individual experiences them is clearly not that way. And I think it comes back to what Bobby was mentioning about in terms of moving people forward to health, it’s that multi-solver approach that we are looking at that holistic impact of what systems are impacting people’s health.

Nishesh Chalise

Thank you. And just to connect to the social determinants piece that you mentioned, I think we’ve realized how important that framing is. Based on your experience, again, this is open for everyone but Jason and Ruth, you specifically mentioned this in your presentation. Based on your experience, what do you think are some of the key ingredients to make that community level intervention work, to have the outcomes that are intentioned at that level of intervention?

Ruth Thomas-Squance

I think, my response to that would be that community, we really want to promote community grounded or rooted solutions. There are different ways of looking at that and I think one of the ways to do that is to engage community early in the process of your planning and to do it consistently and to do it in a meaningful way. So I think, at the network, we’re looking and that’s something we’re very interested in coming out of this is how to make meaningful community engagement. It’s definitely the ability to tick a box and just say you held one meeting, but how you integrate that into the process I think is really going to impact the kind of sustainability your solution will have and the kind of impact and outcomes your solution will have. I think it’s retained better, it’s participated better when it comes from a community grounded participation.

Jason Purnell

I would definitely agree with that wholeheartedly. I just used this analogy earlier today that we can’t have made the batter to the cake and then be ready to put it in the oven and then ask the community what flavor would you like before we’ve even asked would you like cake? And that’s very often how we do our interventions. We come up with brilliant ideas in our offices and then wonder why the community isn’t accepting or uptaking our ideas because we didn’t ask the end user. But I would add definitely to what Ruth said, that we’ve also got to make meaningful investments and those investments have to move further upstream. We’ve got to deploy the assets and resources of multiple sectors and then we’ve got to create sustainable policies that begin to support the kinds of community context that we know produce better health and wellbeing.

Nishesh Chalise

I really appreciate that you mentioned the community engagement piece that was supposed to make my second question so I’ll maybe ask it as a follow up. Yeah, I agree that most of the times research happens very far away from people who are experiencing the problem, solutions get designed far away from people that are experiencing the problem and we do say let’s engage community, but there’s a spectrum there about how we can go about engaging the communities. Again, this is an open question. In your experience, what have you seen that you are like, “Aha, this is the way to do it. They did it right.” Or you can also say, “I’ve not seen that happen”, but I don’t know, any nuggets of wisdom to share?

Bobby Milstein

Well, I will say that throughout the springboard for Thriving Together, there are case examples in every one of those, the chapters around the vital conditions and also in all three of those areas of renewal around economic life, civic life, social, emotional, cultural life. So there are really no shortage of examples. There are lots of instances where people are doing really impressive things across boundaries with an aspiration to really change course, not just make incremental improvement around the edges of a system that was never really designed for all people to thrive. A little mix of what I’ve seen in common in a lot of those examples is the creative tension between a north star, goal, an expectation that all people in places can thrive together. Also, a commitment to back that expectation up with measurement, not just measuring every disease and body part issue, but really asking the question of who is thriving and who’s struggling and who’s suffering.

To really look at people’s life experience and treat that experience as legitimate and important alongside content expertise and learn with them. So marrying that north star with a commitment to measurement and the levels of measurement that are necessary to roll this up into patterns and intergenerational patterns of thriving and struggling and suffering. And then being able to work across boundaries in all the ways you’ve heard so often today that the things that really make systemic change are rarely going to be limited to any single administrative boundary. And those are the things that move those measures, those are the things that really bring us ever closer to that North star.

Nishesh Chalise

Well, Bobby, since we are talking, maybe I wanted to ask a question about multi-solving specifically. The resource that you shared about Equitable Economic Policy Library. That was great. I bet the folks and our audience will really appreciate that resource. From your point of view, who is best positioned to lead these kind of multi-solving endeavors?

Bobby Milstein

Yeah, that’s a good question. In some ways, we’ve talked a lot about what needs to be done and I really appreciate the question about exactly who can start to do this work that we’re describing. And I guess, I’ll say just for myself, I went through a school of public health. I was never trained in most of the things we talked about today. A lot of organizations are not built and to learn this kind of work on the job. And at the same time, we did a poll through the, a tracking poll with change makers through the pandemic and one of the questions was about becoming multi-solvers and about half of the respondents said that it sounded like a familiar word for the way that they already think and the other half said it sounded like something pretty interesting they’d like to learn more about. And either way, I think that the idea is that we can all play roles that are a little different than the ways that our org charts define them.

We’ve got organizations that are defined often by disease and body part and population sector, but the thinking and acting like multi-solvers or being able to see ourselves embedded in a system that we don’t fully understand but still see our work as stewards of that system, as shared and to build the shared stewardship that is necessary to steer systems in new directions. That’s a skill that a lot of people can cultivate. It’s different than being a leader on behalf of an issue or an institution, but being a steward along with others to create conditions where all people can thrive is a way of working that is often unseen and uncelebrated, but it is there if you start to look for it. And then we can build that capacity together.

So I would say, who is anybody who sees themselves as a steward of the systems that shape our lives and our livelihoods together. There are ways of stepping into that work and getting ever deeper and more interconnected. But just that mindset shift of I’m not leading on behalf of one issue or one institution or even myself, but I’m leading on behalf of a system, an intergenerational system in many ways that we’re going to leave better off today than it would left to us.

Nishesh Chalise

That’s great. Thank you. Yeah, really appreciate that response. I could keep going on and on. I have a bunch of questions, but I know our audience members are also very interested in asking some questions. They’ve already asked some questions, so I would like to ask Matuschka to share some of those questions to the panelists.

Matuschka Lindo Briggs

Yes, thanks Nishesh. So before we get started, as a reminder, we are taking questions from our participants today. So please, all you need to do is you can look down at the bottom left hand of your screen, you’ll see a ‘Ask a question’ button there on the left hand side. Just hit that button. You can also email us at communities@stls.frb.org.

So our first question that came in is a general question for all of you to answer. “What are three top things to improve health and economic equity for all?” Bobby, we can start with you.

Bobby Milstein

Yeah, it’s a good question and I think I would point again to that Delphi survey because I could say, euphemistically… That’s not the right word, thematically, that it’s not a single silver bullet policy that is the thing that we should be all focusing on doing. I think it’s the idea that we can together create a very different economy and a very different society in which it is possible for all people to thrive. I would say that is the chief animating force to expect that we can get something different and then work persistently toward it.

That’s the sort of driving capacity that we speak about in the springboard and that the Surgeon General talks about. And also we see another document. So if you want one thing, it’s that capacity to work together across difference and use our sense of belonging civic muscle to reshape our economy and renew these other dimensions of our lives together. But the Delphi survey in some ways is the next step is there’s no shortage of worthy policy and program change available. A lot of it is evidence based. A lot of it is delivering benefits already to some people in some places, they just haven’t been enacted elsewhere or made more widespread of norms. And so the question of what feels important and feasible in your community is really a question that we should all ask ourselves and go through a process of discernment together.

That is the reason for doing the Delphi rather than have an expert say, “Hey, this is the most important thing in the world.”

Matuschka Lindo Briggs

Anyone else?

Ruth Thomas-Squance

I think I would say, yeah, my wishlist. I think one of the things we’ve said that we recognize not alone is that racial equity is really a key driver of health and wellbeing. And I think that it goes along with the economic equity, but that idea of looking at our systems, and this is a challenge I think that we have seen across the sectors that we work with, certainly community development, public health and health care, looking at their systems to see and identify where systemic racism is impacting some of the outcomes that we see.

And I think that it’s an opportunity that has come from seeing just the COVID-19 pandemic play out along predictable lines that we can look at where we have implicit biases in our system that are recreating the same results for people. And I think some of the keys to changing that I think are also to have those analytic approaches within their system, but also think about as what Bobby was suggesting, to work differently, to work across sectors to be able to make, to really move the needle on health outcomes that are sort of persistent.

These are very persistent issues and I think that the way that we change them is because we can’t do them doing the same things that we’ve always done or doing more of what we’ve always done, but doing it slightly differently and doing it with new partners I think is a very powerful way of moving forward. And that’s what we would like to see. Definitely, with community development being very natural partner to address many of the social determinants of health that healthcare are really struggling with.

Matuschka Lindo Briggs

Go ahead.

Jason Purnell

I would say specific to healthcare, which is where I sit and think quite a bit about, the way we’ve framed community health improvement and the work that needs to happen is very much along the lines of what Ruth mentioned in terms of playing that role as an anchor institution, which means looking at the ways we do hiring, local inclusive hiring, local inclusive purchasing and supporting minority owned and other diverse businesses in the local context. And looking at where we do investment, not just with CFIs but banks and other institutions, investing in community and economic development as healthcare institutions.

And also back to our earlier conversation, showing up in different ways in which we partner and collaborate with others. To Bobby’s point, not just that our systems aren’t designed to deliver on equity, they’re also not designed to coordinate with each other and to be in conversation with each other in ways that amplify the impact when we’re working together. And that has to be informed by the lived experiences of the most impacted community members. And then our third pillar is really around policy and that evidence based policy at the local, state and federal level that includes and expands the agenda to address the social determinants of health.

So those would be the top three from my standpoint. And again, it’s not a silver bullet, but it’s a way we show up in a way that we do things.

Matuschka Lindo Briggs

Jason or Ruth, we have a question here that says, “Can you provide a few examples of interventions?”

Jason Purnell

I mean, Ruth provided several of them where there is targeted investment in a particular neighborhood or a particular geography that is supposed to be mutually reinforcing. So you’re not just dealing with the single issue of improving health outcomes, but for instance, you are supporting businesses within the food environment that also has an impact on the downstream health outcomes for people and community. So I think about things like the grocery store was mentioned, but through our membership in the Healthcare Anchor Network, we were able to visit Cleveland a couple of years ago and see the Evergreen Cooperative where the employees there are part owners of these businesses, which include an apoptotic greenhouse and a laundry that does 17 million pounds of the Cleveland Clinic’s laundry every year. So you’re not just creating a job, you’re creating some wealth potential, some ownership potential at the same time that you’re investing in communities. We’re still pretty early in our journey, but we’re certainly learning from health systems around the country who are testing out these approaches.

Ruth Thomas-Squance

I agree. Just from the examples and I definitely encourage people to visit our website where part of what we do at the Build Healthy Places Network is really showing some of the many examples and the economic playbook has the larger scale examples, but it’s also important to remember that some of these things will start on a smaller scale and sometimes they can be a healthcare system just offering a cool localization of services with residents in a community development, affordable housing. And I think it’s just, because at the end of the day, it comes from relationship building. So you do have to get to know each other as these institutions and part of what we work at the Build Healthy Places Network is part because we’re not rubbing shoulders at the same conferences, we’re not necessarily having those conversations to build the kind of results that you want to see where you can know who to call or who to approach in terms of developing across the whole country. But certainly there are plenty of examples.

Bobby Milstein

I will also say that there are lots of business oriented examples throughout the Surgeon Generals report, as well as examples that show how businesses can team up with community development financial institutions as well. And the Build Healthy Places Network policy scan talks about policy that can matter for healthy community investment, but also who implemented them and how in other places. So there’s plenty of examples there. In the Delphi, we housed the Equitable Economies Win Network Delphi study on the Community Commons precisely because it’s a free common asset across the country is who raised on Detra is to have examples and to share those examples across the country. So the Community Commons is an amazing source of resources showing who’s doing what where.

Matuschka Lindo Briggs

The next question I have is a little bit lengthy, but I think it’s a one that Bobby, you could probably answer. “So with the influx of ARP funding, most likely being distributed through existing mechanisms like CDBG grants and driven by state leadership, what are ideal multi-solving solutions that we should advocate for our leadership to support? It seems like politics may get in the way of big fundamental shifts.”

Bobby Milstein

Yeah, it’s a great question. And the influx of capital in some ways can be both benefit and cursed, right? Because the money can sometimes be the trigger for imagining a very different future and how to get there and how to work together around it. And it can also be a way of channeling resources into the existing structures and systems that have really never changed before. And I had a conversation today with multiple organizations from a 19 municipality region in Wisconsin, who were really thinking about exactly this question. How in a moment of unprecedented assets could they begin to think about mutual local accountability and a strategy that allows them to not just parse out these assets, but how can they use it as a transformational catalyst that isn’t going to get them dependent on program services that are going to dry up when those resources are gone? It really is a chance for a structural change. And so that conversation about what counts as a legacy improvement, a structural change in the region is a pretty good way of starting that conversation.

Matuschka Lindo Briggs

Thank you. The next question anybody can answer. “What is the role of community led, not just engaged initiatives? If we’re talking about inclusion and belonging, generally prioritize the leadership of those most impacted communities?”

Jason Purnell

Yes. I mean, I think that’s the spirit of what we were saying earlier. It isn’t just about engagement, it is about, actually Bobby and I sit on the national round table for population health improvement through the national academies and just had an entire session on this, in terms of community led efforts. It’s essential. But what I like about the graphic that Bobby showed is that civic muscle is very often lacking in regions. And part of that civic muscle is the connection between the grassroots and the grass tops and what I call the connective tissue, where community led efforts can be amplified by the resources that are controlled at the grass tops level. And we have to find better conduits. We have to find better bidirectional communication and common tables around which community led efforts and leaders can sit with those who are controlling larger pools of resources so that these efforts can be amplified and brought to scale in meaningful ways.

Matuschka Lindo Briggs

Okay, next question here. We’re getting close to time here. I’m going to try to get one or two more questions then. “How can we change funding designed to address discreet issues into funding that recognizes the interconnectedness or tangled threats so that service providers have the flexibility needed to successfully address complex situations?”

Ruth Thomas-Squance

That’s a great question, and I do think that that is really key to supporting the kind of vision of work that, for example, Bobby’s talking around that flexibility in funding. And I think it’s to move conceptually away from that single issue funding to think more holistically about how you’re impacting all of those vital conditions, to encourage communities to thrive. And I think it’s a conceptual shift and again, we’re talking about changing just the way that people work. And I think it’s maybe the way that funding is given out and also a challenge to philanthropy to think about its role in terms of addressing a more holistic approach and a flexible approach, incorporating all the great things that we’ve talked about of community vision, community lived experience into that framework. But I think it’s a great point and it’s really important.

Bobby Milstein

Yeah. I’ll just add one thing that I’ve learned by watching a interagency group across the federal government, think about what is their role in long term community resilience building. And funding is a piece of that. But I mean, there is no greater siloed bureaucracy than the US federal government. And they have begun to map a lot of their interagency responsibilities, authorities, funding avenues, and a half dozen other ways in which they influence the world, all mapped around vital conditions. And they’re discovering that it might say housing and urban development, but they do a lot to help build leadership capacity or they’re connected to issues around transportation.

And so the titles of bureaucracy sometimes don’t necessarily show the ways in which they can work as multi-solvers and across boundaries. And so funding, we got to look underneath funding and say, “What’s the functional purpose of those dollars?” And many of those dollars can be multi-solving dollars. It’s possible to simultaneously, as Ruth said, work on food and housing and transportation because they’re so intimately connected. We don’t normally think about the money that way, but our federal partners are beginning to talk about that and so must we all across the country.

Jason Purnell

The only thing I would add to that is we have to fund collaboratively and we have to fund the process of collaboration. And that’s very often not flashy or sexy to fund, but collaboration is work and it has to be someone’s work to actually manage collaboration. And we also have to fund organizations if we want collaboration to happen in collaborative ways so that the funding doesn’t just flow to a single organization when you want a collaborative outcome. So there’s got to be some creativity both in terms of how the funding flows, but also to fund the vital function of collaboration.

Bobby Milstein

Yeah. Well said.

Matuschka Lindo Briggs

I’m going to ask one last question here. I can have a few of you comment or all of you, but we’re going to end on this question. “Economically distressed rural communities are severely lacking in key social determinants of health, such as housing, childcare, clean water, transportation, broadband. Can anybody comment on the opportunities for building rural infrastructure as a means of building equity?”

Ruth Thomas-Squance

Absolutely. I think this is something that we are really interested in at the network that we’ve been looking at, is how we can best show up and support these kind of cross sector partnerships for health in rural environments. And I think it’s sort of really fascinating to look at ways that there are unique challenges, but also unique assets in these environments that really have to do around the interconnectedness, that preexist there really, that there is a much less siloed operational model there. And that how can we leverage how community development operating in rural areas to support rural healthcare systems that struggle for many, many reasons due to in payment models, et cetera, and under populations that they serve being older with more chronic disease.

So there’s definitely a real opportunity, I think, here to, while we’re talking about changing the thing, the way things and ways sectors work together is to really build some of that cross-sector work in rural communities. And that is something that we’re actively working on, and we definitely love to hear about more partners to do that. And I think also, I was just going to say that also bringing a difference in how we assume an urban model of scale and reproducibility that doesn’t really apply or work in rural to see success, but it also fosters an opportunity to have big impacts with less investment because that scale actually works in a positive way as well. But yeah, it’s a really interesting question.

Matuschka Lindo Briggs

Okay, I think we’re going to have to end on that note. I’d like to thank all of our speakers today for sharing their time and stories with us, as well as all the participants that joined today for our discussion on exploring the Intersection of Health and Economic Equity. A few reminders. We will have a recording available with an audio file on the Connecting Communities website, and you can find a variety of additional resources available on the Fed Communities website. We also welcome ideas for future recordings. We just shared a survey link if you joined us in the webinar, and this same link will be distributed via email in a few minutes. We’d appreciate your feedback about today’s session.

Join us next month on June 3rd for our next Connecting Communities titled, Findings on Economic Wellbeing in 2020 from the Survey of Household Economics and Decision Making. Thank you for joining us. This concludes today’s Connecting Communities webinar. Enjoy the rest of your day.

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