Students’ faces brighten when Shantrell Sneed — “Coach Trell” to the kids — walks into a classroom at San Pablo’s Riverside Elementary School.
She organizes play during recess, promoting physical activity, conflict resolution, friendship and improved academic performance. These ultimately are elements of longer and healthier lives.
One of her games involves a spirited version of roshambo — the “rock, paper, scissors” hand game. As kids defeat rivals, they accumulate “cheerleaders,” and all shout out the final winner’s name.
One student asked if there was a prize.
“Yes, you get the entire class as your cheerleader as a prize,” Sneed said.
She works for Playworks, an Oakland nonprofit that has expanded its recess program from two Berkeley schools in 1996 to 248 schools nationwide, with plans to add hundreds more. Since 2005, the Robert Wood Johnson Foundation in New Jersey has supported it with $23 million in grants to promote health where it starts — where people live, work and play.
“We structured our program to look at factors outside the health care system that really affect health,” said Jane Lowe, team director with the Robert Wood Johnson Foundation’s Vulnerable Population Portfolio. “We called them social factors — housing, poverty, inadequate education, the neighborhoods that you live in.” The foundation spends $50 million a year on the portfolio.
The program targets neighborhoods devoid of basic resources.
like parks, gyms and grocery stores, and where poverty casts its pall. Their residents have far more chronic diseases and shorter lives than more affluent neighbors.
In the East Bay, residents in a West Oakland neighborhood with a high crime rate and a liquor store as its sole business can expect a life 16 years shorter on average than people living in a comfortable Walnut Creek suburb near numerous shops and a bike path.
Programs like Playworks are still few, relative to the need. But over the past decade, more large foundations, including the California Endowment, the Robert Wood Johnson Foundation and the W.K. Kellogg Foundation, have shifted toward projects that strive to preserve health and well-being.
Playworks is forging a path away from an intractable recess problem at many schools, particularly in low-income areas, Lowe said.
“Every school principal would say, ‘This is where bullying happens, this is where kids get hurt, where kids go back to the classroom and they’re upset at a fight with someone on the playground that interferes with learning,’ ” Lowe said.
Student behavior has improved dramatically since Playworks came to the San Pablo campus in September, said Riverside Principal Alicia Azcarraga. The students engage in far more physical activity when Playworks arrives, principals and teachers said in a survey, and they learn conflict-resolution skills that they also take home.
Last year at Riverside about five students a day were sent to the principal’s office for discipline problems; this year it’s down to a few each week, Azcarraga said.
“They’re really able to get into the academics as opposed to the conflicts that happened on the schoolyard,” she said. Researchers include education levels among the social determinants of longevity.
After decades of research, it’s proof-positive that programs promoting healthy development in early childhood and educational attainment pay off in improving health and longevity, said Dr. Anthony Iton, senior vice president for the California Endowment’s Building Healthy Communities effort.
Over the next decade, the Los Angeles-based foundation will lead the largest program of its kind to tackle the social factors underlying the ill health and shortened lives in poor neighborhoods. The organization will spend $1 billion by 2020 helping develop neighborhoods in 14 California communities — including Richmond and East Oakland — “where children are healthy, safe and ready to learn,” according to its website.
Compressed in a concern for improving the lives of hard-pressed youths is a huge economic benefit, Iton says. Care for chronic diseases consumes 75 percent of the nation’s $2.2 trillion in annual health care costs, which the nation can cannot economically sustain, he said.
He and others see an unrealized and relatively cheap chance in revitalized neighborhoods and schools to prevent heart disease, diabetes, hypertension and other killers that disproportionately affect poorer people.
“The solution to the chronic disease epidemic is not in more clinical medicine. That has been a failed solution that has driven up costs,” Iton said. “The solution is in how we engineer our environment — looking at how we design our communities, or workplaces, and in how we educate our young people.”
The endowment’s $1 billion — of which $80 million has been awarded — will support an array of programs. Ready access to coordinated health care, bolstering neighborhood safety, transforming the physical environment and promoting economic development form the overarching goals, Iton said.
Major goals include teaching people to advocate on their own behalf, Iton said.
“There’s been a failure of democratic systems in many of these places “…,” he said. “People are not being heard.”
The endowment funded advocacy training for residents in South Los Angeles who objected to the conversion of a former health care facility into high-end condominiums most residents could not afford.
After they spoke at meetings and organized campaigns, the developer agreed to create a community clinic, support small-business development in the complex, set aside one-third of the construction jobs for locals and another 10 percent for “at risk” residents, and 5 percent of the 900 apartments will be priced for low-income tenants. City planners last month approved the revised proposal.
“They’re ecstatic about it, and they see the potential power of pooling their efforts,” Iton said.
Health-care reform legislation also created the largest federal initiative yet to fund disease prevention, with an emphasis on low-income communities. It started with $750 million announced Feb. 9. It includes $145 million for grants awarded to groups with effective strategies for changing neighborhoods.
A 2009 analysis co-funded by the Trust for America’s Health, a Washington, D.C., nonprofit that works to prevent illness, reported that a $10 investment per person in key disease prevention pays for itself after the first year, provides 5-to-1 savings after five years, and continues to save into the future.
The health reform bill would put $16.5 billion into a prevention fund over 10 years, although the federal budget debate is heavily weighted against spending.
Local groups are also tackling health disparities. East Bay hospitals spend tens of millions of dollars each year on health and social support in neighborhoods with the lowest life expectancies and the most illness.
Some of these programs were spurred by a 1995 state law requiring nonprofit hospitals to create community benefits in exchange for favorable tax treatment. Some existed before the law, often developed by hospital staffs seeking to help people with limited access to health care.
Alta Bates Summit Medical Center, with campuses in Oakland and Berkeley, has about 20 programs to reduce neighborhood health disparities, said Debbie Pitts, Alta Bates manager of public affairs and community relations. They include simple but lifesaving measures like distributing refrigerator magnets describing heart attack and stroke symptoms and urging people experiencing them to call 911 for swift treatment.
The medical center also launched an asthma management center and a diabetes management program focused on low-income residents. These significantly reduced emergency-room visits and hospital admissions, Pitts said.
The hospital’s Ethnic Health Institute focuses on low-income neighborhoods for its education and screening program for chronic health conditions.
Alta Bates also sponsors Youth Bridge, which sets up social support and finds jobs for 100 youths annually who seem in danger of dropping out of high school.
Success stories — getting kids into college — abound, said hospital spokeswoman Carolyn Kemp. Many of the youths pursue careers in health care, she said.
Health leaders need to move beyond focusing only on the medical model, said Ethnic Health Institute Chairman Dr. Frank Staggers.
To make progress, he said, health leaders need to “pay more attention, which we have not done until recently, to the social aspects — where you live, what kind of education you have, what food stores are available to you, where you can walk — all of these things have a bearing on your health and your welfare.”
Contra Costa and Alameda County health leaders strongly agree. They have decided to step outside of their traditional roles to focus on what they call upstream factors that influence health. Increasingly, they look at ways to clean the air, improve housing, make streets safer, schools better and to improve access to fresh fruits and vegetables and to parks.
Hayward’s St. Rose Hospital opened a women’s clinic for low-income residents. It also launched a childhood obesity prevention program after 2007 data revealed alarming obesity levels among children in its area. In 2009, John Muir Health, with campuses in Walnut Creek and Concord, spent $33 million of its $40 million in community benefits on “the most vulnerable populations,” according to a hospital report.
Many other smaller-scale programs are under way in the East Bay. City Slicker Farms in Oakland has helped hundreds of residents in West Oakland learn to grow their own produce, and once a week it operates a produce stand there.
Those running such programs typically track results to make the case for more funding, and to replicate them on a wider scale.
That’s essential, said Iton, and the vast program he leads will rigorously evaluate results. But he said he’s also changed his view that good data alone will drive change, since statistics confirming the value of the many ways of promoting health and educational attainment have been available for decades.
Instead, Iton said it’s also critical to change social norms to favor health promotion, just as social norms have changed regarding smoking and gay rights.
“That’s what our work is about. It’s about pitching that new normal, the new narrative about what is health,” Iton said.
“Health is about what kind of investment our communities make in keeping people healthy.”