Hope — and Healing — Go Into Massive Redevelopment Effort
The causes of poor health are rooted in neighborhood. Partners in San Francisco’s HOPE SF effort are learning the solutions are too.
by Natalie Orenstein and Barbara Ray
When patients arrive in the lobby of the new Sunnydale Health and Wellness Center, in San Francisco’s Visitacion Valley neighborhood, the first thing they see is a bustling front desk helmed by helpful staff.
And while that doesn’t sound unusual, the front desk staff are not just any friendly employees. They, like the patients, are tenants of the Sunnydale public housing complex. The employees are “peer health leaders” — residents who are trained to work as intermediaries between service providers and other public housing residents, and in some cases as health advisors to their neighbors.
But these peer employees represent something even more critical than their important desk jobs: They are key to overcoming one of health care’s longtime challenges in low-income, and particularly public-housing, neighborhoods — lack of trust.
The health center and the peer health leaders are part of a $3 billion, 20-year effort to redevelop some of San Francisco’s oldest public housing complexes and the neighborhoods that surround them. The effort, called HOPE SF, is about much more than rebuilding dilapidated buildings.
When the city and its more than 30 public and private partners launched the project 10 years ago, they knew health issues affected the public housing tenants in all aspects of their lives — so health had to be at the forefront of their fight against the harms of concentrated poverty.
Putting health upfront, says Theo Miller, who directs the project for the city of San Francisco, “is a monumental shift for public housing and for the city.”
Why Health in Housing Redevelopment?
The Hope SF reforms are taking place during a time of growing awareness that one’s health is a product of one’s community and environment. Genetics and luck play significant roles, but the “social determinants of health” are what contribute to residents in one neighborhood living years longer than those living just a couple subway stops or exit ramps apart.
Low-income families are more likely to live in neighborhoods with environmental hazards, substandard housing, cut off from jobs and opportunity, without full-service grocery stores, and other conditions that tax health. PolicyLink has called this health–housing connection the “modern-day segregation.”
Bayview-Hunters Point is a case in point. Once home to a naval shipyard, the southeastern-most neighborhood in San Francisco became the city’s industrial hub for much of the 20th century. Power plants, a sewage treatment center, and dozens of brownfields created numerous lingering health hazards for residents. Disinvestment, coupled with federal housing policy and major shifts in the global economy, concentrated disadvantage and poverty in the isolated area — while the rest of the city has quickly grown wealthy. Although the black population has declined dramatically in San Francisco, African-Americans are still a plurality in Bayview-Hunters Point, where opportunities are scarce and where residents feel cut off from the economic boom.
Underscoring the concentration of poverty in San Francisco, a 2005 study by the city’s Human Services Agency found that the majority of low-income children in San Francisco involved in public systems like child welfare or juvenile justice live in a tight circle around just a handful of public housing developments.
The undertow of poverty and this erosion of trust have contributed to climbing rates of diabetes, heart disease, asthma, and other illnesses. “The kinds of disparities in these communities are pretty staggering,” said Ellie Rossiter, initiative officer and partnership director for HOPE SF at the San Francisco Foundation, the leading philanthropic partner in the project. Among tenants of the four HOPE SF housing developments in and near Bayview-Hunters Point, for example, the diabetes rate is several times higher than in the city overall.
“The kinds of disparities in these communities are pretty staggering.”
Early on, the leaders of HOPE SF realized they had both obligations and opportunities when it came to the health of the residents.
“We’re the nation’s first public housing transformation and reparations initiative to transform a low-income community without mass displacement,” said Miller. “I say reparations deliberately because we as a city have to repair what we’ve broken. We need to repair broken trust and repair a system.”
But if the causes of poor health were rooted in neighborhood and community, they soon discovered, so too were the solutions.
The Nurse Next Door
HOPE SF — led by the Mayor’s Office of Housing along with city agencies and private and academic partners — is turning the four San Francisco public housing complexes within a small southeastern swath of San Francisco into mixed-income developments. Each development — Alice Griffith, Hunters View, Potrero Terrace & Annex, and Sunnydale — is paired with a different developer, whose work to rebuild is supported with $100 million in city subsidies for construction. While current public housing residents will be able to remain in the development, an equal number of units will sell for market rates and another third will be subsidized to be affordable for other non-public-housing residents. The city subsidies will allow builders to still earn a profit while replacing dilapidated buildings and adding new, much-needed affordable housing. Having more economically diverse neighborhoods, policymakers believe, is healthier for the residents of the neighborhood — as well as for the city as a whole. When it’s all said and done, the population will be triple the size it is now.
Because of exploding demand for housing in the city, market-rate developers have been laying claim to every free square foot of land — which makes the HOPE SF development even more critical for its current residents.
Current tenants have the right to return when the new buildings are complete, and they are promised temporary on-site housing during construction, an unusual protection. In Chicago, for example, where similar transformations are underway, the city has lost 14,000 public housing units in the push for mixed-income communities, and only 8 percent of original public housing residents are living in the new mixed-income developments. (Another one-third had moved back to public housing and 40 percent used vouchers to move elsewhere.)
Many of the San Francisco tenants or their families have lived in the four complexes for decades. HOPE SF is the most ambitious improvement project they have seen, though it’s hardly the first. Over the years, services have come and gone, and researchers who come to take surveys are often never heard from again.
“We’ve seen people come in and out of this community, promising things to residents and not following through.”
“For many years, we’ve seen people come in and out of this community, promising things to residents and not following through,” said Iulio, a tenant in a new unit at Hunters View, the site furthest along in the redevelopment process.
This broken trust has shaped how the residents interact with the city, with each other — and with the medical system.
For example, many of the public housing tenants have historically used the emergency room as a primary care provider. This had long puzzled the city, given the proximity of public clinics to each of the housing developments.
“There are robust services in San Francisco,” said Ken Epstein, the San Francisco Department of Public Health’s lead on HOPE SF. “But there hasn’t been that level of utilization because we have traditionally failed to engage the community and build trust.”
To try to rebuild that trust, the San Francisco Foundation tested out an innovative alternative in 2014. After cleaning up a vacant unit at Sunnydale, the largest HOPE SF complex, Rossiter and her colleagues opened a pilot wellness center, outfitting it with a registered nurse and peer health workers.
“Usage was unbelievable,” Rossiter said, recalling the nearly 300 visits to the nursing clinic and the nearly 600 visits for mental health care during the first six months the center was open. Evaluators documented over 1,700 interactions between residents and peer health leaders throughout that period, including 315 drop-in visits.
“There are robust services in San Francisco, but there hasn’t been that level of utilization because we have traditionally failed to engage the community and build trust.”
The success of the pilot gave rise to the new full-scale center at Sunnydale. Eventually each development will have its own health facility.
The center is not meant to be a stand-in for primary care, but rather a conduit to it and a place for basic preventive care and counseling. Registered nurses and behavioral health clinicians offer chronic disease management support, health education, individual and group therapy, medical referrals, nutrition and parenting classes, and other services. The center accepts anyone who walks in.
And the magnet that attracts residents to the new center, the staff said, is the crew of peer health leaders.
The peer program is a product of a San Francisco State University evaluation, which found that the model resonated with the HOPE SF population. Some residents say it makes a difference to work with someone who shares their background and is less likely to be condescending or disrespectful.
“It has been helpful to have residents on the team,” said Rose Marie Sims, a lifelong Hunters View resident who has a job connecting tenants to social services. “Other organizations came in and it didn’t work. The reason being, they didn’t trust them.”
‘They Made Sure We Were Well Ourselves’
The peer health program also makes a difference for the peer leaders themselves. A few years ago, Iulio — called PJ — heard that the Bayview YMCA, which provides social services at Hunters View, was looking for applicants for a peer health program. He applied because he wanted to help boost health in his community — the health of the other residents as well as his own.
Iulio, 31, who has lived at Hunters View on and off for 18 years, is diabetic. When he started training to become a peer leader, he had a hemoglobin A1c, a measurement of blood sugar levels, of 15 percent. A “manageable” level is 7 percent. He got treatment as well.
“They [program organizers] made sure we were well ourselves and taken care of, before we were offering help to other people,” Iulio said. “I was learning the little things I could do to take care of myself.”
The peers attended trainings on the chronic conditions common in their neighborhood. They learned how to use, and help others use, nontoxic pest control tools to reduce asthma flare-ups. Eventually they hosted workshops on heart diseases and diabetes for all residents, and workshops on sexual health and safety for teenagers.
“With residents here, they want to see that you care, they want to see consistency,” Iulio said.
After Iulio’s stint as a peer leader, he was hired as a health and wellness ambassador for the Hunters View community. In this role he meets with prospective service providers, and helps determine whether they would be a good fit with the community. He said his A1c is now below 7 percent.
Iulio’s success has not yet been shared by all tenants, however. The peer leader project, like HOPE SF at large, has not been without bumps in the road — as is the case any time outsiders come into someone else’s community wanting to make change. The program has not yet encouraged every resident to participate in the medical system. Some are still distrustful of doctors and others continue to struggle with addiction.
The road to redevelopment has not been a completely smooth one either. The four sites were whittled down from an initial eight, and the HOPE SF partners had to take unexpected steps to ensure current residents could transfer into the new units, like helping them make up for past unpaid rent so they could meet the developers’ requirements. The HOPE SF partners know there is still progress to be made, and have worked to carve out new ways of reaching residents where they are.
Building Community Amid Trauma
BRIDGE Housing Corporation, the nonprofit developer at Potrero Terrace & Annex in the Potrero Hill neighborhood, knew that redevelopment required active participation and leadership from the residents. But they didn’t realize just how complex “community-building” would be within the HOPE SF communities.
They faced several challenges right from the start. The developer organized tenant meetings, but attendance was sparse. In some cases, residents felt there was no use attending, having heard promises from reformers in the past that were not kept. At the hillside development, gang activity also deterred many residents from attending meetings.
BRIDGE recognized that it had to do things differently to be successful. The developers, along with San Francisco State University public health professor and researcher Jessica Wolin, started by creating the Trauma Informed Community Building model.
This approach, called TICB for short, recognizes that in low-income communities hardship can prevent social cohesion, and that without attention, community-building efforts can even exacerbate trauma by breaking trust even further. The TICB model encourages practitioners to set realistic expectations, to express acceptance of all community members, to provide incentives for participation, to reflect residents’ voices to other stakeholders, to grow incrementally, and to avoid over-promising.
At Potrero, BRIDGE distributes a calendar of activities at the start of each month. Residents receive financial rewards for participating regularly — be it in the garden, the family reading group, the sober living group, or the walking club. The developers explicitly ignore certain traditional tenets of community development, choosing, for example, to send multiple invitations to the same event, which is usually discouraged in traditional organizing models.
“This is about repairing and building relationships between folks who really don’t trust each other,” Miller said. “This has been persistent, institutional, racialized trauma the communities have experienced. To attack something that deep and insidious, you have to get to the heart and mind of people and build trusting relationships. That takes a lot of meetings.”
Not Business as Usual at City Hall
This new approach to community-building and health is not the only unique aspect of HOPE SF. The city is not going at this alone. In fact, the scale and depth of the project’s cross-sector commitment is what makes HOPE SF stand out, according to Miller.
The project has more than two dozen public and private organizations taking part in the process. Miller’s team at City Hall reports directly to the mayor, which means decisions are made quickly and obstacles are eliminated more rapidly when they pop up.
The heads of major city departments, including public health and human services, are also important members of the team. The San Francisco Foundation is taking the lead in spearheading philanthropic and private-sector support. Community development experts and nonprofits make sure the voice of the community is heard.
Miller’s role, he says, is to provide the foundation that allows everyone working together to achieve the project’s ultimate aims. “This entity is the backbone of the collective impact initiative,” he said. “We facilitate, inspire, hold people accountable, get resources, and create the political will to take action.” Without that community quarterback, the odds of moving this massive effort toward an end goal would be slim.
“That’s tough to relinquish power, but the real juice in this work comes from community, authentically.”
Ultimately, said Miller, “you have to collaborate and lead like a shepherd leads: Let the folks who are the ‘objects’ become the subjects, the leaders. That’s tough to relinquish power, but the real juice in this work comes from community, authentically.”
It will be years before San Franciscans know whether this approach to building community, and community health, truly works. Other cities have had similar high hopes only to see them falter in the face of sinking markets or entrenched political bias. In San Francisco, higher-income families have not yet moved into the HOPE SF complexes, which in other cities has also led to tensions.
In many respects, the residents are right to be wary. The history of public housing renovations is a history of disappointment. And yet, say experts who have followed other efforts, this new approach is promising.
Though challenges remain, Mark Joseph, director of the National Initiative on Mixed-Income Communities based at Case Western Reserve University, and his colleagues, who study mixed income housing, are encouraged. “HOPE SF’s careful design has infused it with an array of promising principles and strategies, and the initiative appears to be built for the long haul,” they wrote.
It better be, said Miller: “We have a high-pressure opportunity to do right by 5,000 individuals and 2,200 households who have been discarded by our city and our health system and our economy.”
Finding Health on Top of the Hill
It’s an unusually crisp late summer day at Potrero Terrace & Annex. The grey-blue of the sky meets the grey-blue of the bay. As they do most weekday mornings, a group of tenants has gathered for the walking club, only this time in puffy coats and earmuffs.
They walk around the complex in a pack, picking their way carefully down dirt slopes in places without pavement. “You’re entering no-man’s land,” announces Uzuri Pease-Greene, a Potrero resident who works for BRIDGE. No buses come to this side of the development, and there are large areas that are not wheelchair-accessible.
On today’s walk, a resident named Bobbi keeps time and leads the group. She always does, she jokes, because she wants to get done with it first. Bobbi has been living at Potrero for 46 years, so she knows the complex intimately but rarely leaves her apartment because she is wary of “drama.”
“I like peace,” she says. But walking feels therapeutic, so she doesn’t miss a club gathering.
Other club members are newer to the neighborhood. Janice moved to Potrero from the less isolated Richmond District seven years ago. At first, she was nervous; she hated hearing the police come every night. Over time, she began to feel more comfortable in the neighborhood and discovered that people are friendly.
Still, “I’d never walk by myself here,” she says. The walking club has helped her integrate into the community and make friends she would not have otherwise. They are always teasing each other.
“You’re skinny.” says Janice’s friend.
“It’s because I walk.” she brags.
In the middle of the pack is Pamela Winchester, who has lived at Potrero for 20 years. She started walking to improve her health, and to get in shape so she could play with her two grandkids at the park.
Since she started participating in the club and other activities, like the Zumba class, Winchester has lost 28 pounds. She is relieved that her cholesterol and blood pressure are down.
“Ooh, these hills, though,” she says as the group climbs a gnarly one. “They keep me moving, keeping me living.”
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