Discussion 4 Babies control and bring up their families as much as they are controlled by them; in fact the family brings up baby by being brought up by hi

Discussion 4 Babies control and bring up their families as much as they are controlled by them; in fact the family brings up baby by being brought up by hi

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Discussion 4 Babies control and bring up their families as much as they are controlled by them; in fact the family brings up baby by being brought up by him.

—Erik H. Erikson

A growing body of evidence is linking adult chronic disease to processes and experiences occurring decades before these diseases manifest themselves. In some cases, intrauterine influences may be linked to long-term health outcomes.

A major challenge in population health is determining how to influence early life to produce good health in later years. Some countries do a better job in reducing socioeconomic inequalities and other determinants of health or mitigating their impact on children’s health and development than others. The challenge for public health professionals is to promote a greater understanding of the circumstances of early life and to foster policies to benefit those whose health ultimately depends on family and society.

Medical care in middle age can mitigate the consequences but cannot redress or change the impact of those early factors. Additionally, medical care when you are already ill is expensive, sometimes providing too much care too late to make a difference. As demonstrated this week, medical care is less important for producing good health outcomes later in life.

For this Discussion, you examine how the use of concepts of the developmental origins of life and health can influence adult morbidity. Your Discussion also challenges you to propose ways to improve child health that will also provide a long-term benefit on population health.

To prepare for this Discussion, complete the readings and view the media in your Learning Resources. Look online and in the Walden University Library for additional scholarly resources regarding the developmental origins of health and disease and the impact of childhood policies and programs on lifelong health to support your discussion post and replies.

Post a brief reflection on how the commonly held sentiment “we are all born equal” may constrain how society thinks about early life. Comment on influences that this concept may overlook or mask. Then, explain two ways the use of concepts of the developmental origins of life and health can influence adult morbidity. Describe two challenges to addressing the upstream risk and protective determinants of health in current health policies and programs in the U.S. or in other countries. Also, explain why they are challenges. Finally, offer two suggestions for improving child health that can have a long-term benefit on population health for one chronic disease and explain why. Expand on your insights utilizing the Learning Resources. Neighborhood Adversity, Child Health, and the Role for
Community Development

Despite medical advances, childhood health and well-being have not
been broadly achieved due to rising chronic diseases and conditions
related to child poverty. Family and neighborhood living conditions can
have lasting consequences for health, with community adversity affect-
ing health outcomes in significant part through stress response and
increased allostatic load. Exposure to this “toxic stress” influences
gene expression and brain development with direct and indirect neg-
ative consequences for health. Ensuring healthy child development
requires improving conditions in distressed, high-poverty neighbor-
hoods by reducing children’s exposure to neighborhood stressors and
supporting good family and caregiver functioning. The community
development industry invests more than $200 billion annually in low-
income neighborhoods, with the goal of improving living conditions for
residents. The most impactful investments have transformed neighbor-
hoods by integrating across sectors to address both the built environ-
ment and the social and service environment. By addressing many
facets of the social determinants of health at once, these efforts suggest
substantial results for children, but health outcomes generally have not
been considered or evaluated. Increased partnership between the
health sector and community development can bring health outcomes
explicitly into focus for community development investments, help opti-
mize intervention strategies for health, and provide natural experiments
to build the evidence base for holistic interventions for disadvantaged
children. The problems and potential solutions are beyond the scope of
practicing pediatricians, but the community development sector stands
ready to engage in shared efforts to improve the health and develop-
ment of our most at-risk children. Pediatrics 2015;135:S48–S57

AUTHORS: Douglas P. Jutte, MD, MPH,a,b,c Jennifer L. Miller,
PhD,b,c and David J. Erickson, PhDd

aUC Berkeley-UCSF Joint Medical Program, University of
California, Berkeley, School of Public Health, Berkeley, California;
bBuild Healthy Places Network, San Francisco, California; cPublic
Health Institute, Oakland, California; and dFederal Reserve Bank
of San Francisco, San Francisco, California

allostatic load, community, community development, intervention,
neighborhood, public health, social determinants of health, toxic

All authors conceptualized and designed the article, drafted and
revised the manuscript, and approved the manuscript as

The views expressed here are the authors’ and do not represent
the Federal Reserve Bank.


Accepted for publication Dec 19, 2014

Address correspondence to Douglas P. Jutte, MD, MPH, Build
Healthy Places Network, 870 Market Street, Suite 1255, San
Francisco, CA 94102. E-mail:

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2015 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.

FUNDING: Drs Jutte and Miller were supported by funding from
the Robert Wood Johnson Foundation.

POTENTIAL CONFLICT OF INTEREST: The authors have indicated
they have no potential conflicts of interest to disclose.

S48 JUTTE et al
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On many fronts, pediatrics has been
successful in improving the health of
children. Medical advances and public
health measures have reduced the oc-
currence of acute life-threatening dis-
eases that were once the predominant
cause of childhood mortality and mor-
bidity. According to measures other than
acute illness, however, children are not
faring as well. Chronic and noncom-
municable diseases are on the rise,1 and
racial and socioeconomic disparities
continue to widen, not only in standard
measures of health but also across the
range of life circumstances that contrib-
ute to well-being such as education and
employment. More than 1 in 5 US children
live in poverty; among Latino and African-
American children, it is ∼1 in 3.2

These social disparities have the same
sort of impact on poor children as does
bullying of the weak by the strong. So-
cial inequality is the population equiv-
alent of the social hierarchies that exist
among schoolchildren on the play-
ground. Pediatricians are uniquely po-
sitioned to see the effects of these
growing threats to child development
and well-being. At the same time, we
pediatriciansmay feelpoorlyequipped,
address the biggest health challenges
our patients face.3

What can pediatricians do to address
the community-level social hierarchies
so prevalent in our society? We know
that the family and neighborhood living
conditions that our patients face can
have lifelong consequences for their
health. Recent advances from across
fields of science reveal that exposure to
adversity (particularly the sustained,
unmediated adversity producing “toxic
stress”) becomes biologically embed-
ded, influencing gene expression and
brain development. It has both direct
health consequences as well as indirect
health effects due to the resultant lower
educational attainment, lower economic
status, and poorer health behaviors.4–7

The effect of these latter factors is mul-
tiplied because they place children into
higher risk environments as they move
through adolescence and adulthood.
The result is significant differences in
life expectancy and health outcomes
throughout the life span and multigen-
erational disadvantage. Simply put, one’s
body is the sum record of the challenges
and opportunities faced throughout life.

Too many neighborhoods have too few
This fact is hurting the health of many
Americans, and children bear the brunt
because so many live in poverty. By un-
derstanding the developmental mecha-
nismsbywhichadversitygets“under the
skin,”8,9 we are better able to design
interventions to improve child develop-
mental and health outcomes. Pedia-
tricians witness the effects of these
disparities. We are in a unique position,
therefore, to advocate for change.

To address health disparities, we can-
not simply intervene with medical care,
even medical care in early childhood.10

We will also not be successful in ame-
liorating the effects of poverty by pro-
viding single-focus interventions, such
as pre-K education. Such interventions
are extremely important but do not—
in isolation—overcome the deeper
effects of sustained adversity.11 In-
stead, a critical strategy requires im-
provement in the overall neighborhood
conditions and life circumstances into
which children are born and spend
their early childhood years.12

The tools to improve neighborhood
conditions are beyond the means or
even public health practitioners. How-
has been building the expertise to allow
us to transform neighborhoods in ways
that will have a profound effect on
children’s health, both during childhood
and throughout life.

The community development industry
has a growing number of examples in

which disordered, high-poverty neigh-
borhoods have been transformed to
profoundly improve the trajectories and
life chances of the children living in
them.13 These efforts have brought
multiple elements together, often utiliz-
ing many funding streams and facilitat-
ing collaboration among partners from
different sectors of society. For example,
they unite affordable housing, better
education, functional transportation,
and reliable public safety. These suc-
cessful efforts are a great public policy
success story. It is a success story,
however, that is not well known.

health outcomes but, generally speak-
ing, improving health has only rarely
beenanexplicit goal ofthese projects. In
fact, in most cases, there has been no
research on health outcomes. These
efforts may represent solutions to the
biggest child developmental challenge
we face today: entrenched, multigener-
ational poverty and the impact of
growing up in high-poverty neighbor-
hoods. The present article proposes the
next steps for taking this approach to
scale and maps out the critical role that
outcomes more explicitly into focus in
these projects, to optimize intervention
strategies, and to use these natural
experiments to build the evidence base
for what works.


Neighborhood Matters to Health

Relationships with parents and care-
givers form an emotionally protective
environment for early childhood de-
velopment. Communities or neighbor-
hoods, similarly, are an influential
environment, positive or negative, for
adolescents,14 adults, and families.15,16

Neighborhood disadvantage, therefore,
harms young children in part through
its impact on family functioning.17–19


PEDIATRICS Volume 135, Supplement 2, March 2015 S49
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Research into the mechanisms and the
impact of neighborhood conditions on
health has now been underway for .2
decades.20 Key neighborhood factors
affecting individual and family well-
being include social integration, per-
ceived control, financial strain,21 social
capital, residential stability, and safety
or exposure to violence.20 Although
a handful of studies have suggested
caution regarding the nuance of these
links,22–24 a substantial body of re-
search now supports this connection:
neighborhood conditions have an im-
portant and independent impact on
long-term health outcomes.

Living in high-poverty, distressed neigh-
borhoods, such as those that undermine
social ties and threaten safety through
conflict, abuse, or violence, negatively
affects health status into middle and old
age.12,25 Indeed,studieshavedrawnlinks
between neighborhood disadvantage
and cardiovascular disease,26–28 can-
cer,28 obesity,20,26,27 depression,20,27,28

self-reported health status,21,27,29,30 and
risk behaviors such as smoking,26,27

risky or early sex,27,31 and alcohol use.27,28

Disparities in life expectancy of up to
25 years between neighborhoods just
a few miles apart have been highlighted
in citiessuch as Oakland, California, and
New Orleans, Louisiana.32,33 A child’s zip
code is more important than his or her
genetic code in determining future
health and life chances.34

Mediators of Neighborhood Impact

health outcomes to some degree by
affecting health behaviors26 and sig-
nificantly through the impact of toxic
stress and associated increases in
“allostatic load” (eg, stress and fear in
response to the perception of neigh-
borhood danger).29

Gustafsson et al studied the relationship
between neighborhood features and
allostatic load. They determined allostatic

including blood pressure, blood lipids
and glucose, and cortisol levels at ages
16, 21, 30, and 43 years, studying the
cumulative effects on subjects across
∼3 decades. Social and material adver-
sity were determined and cumulative
neighborhood adversity was calculated
with indicators including the percentage
of residents considered low-income, un-
employed, living in single-parent house-
holds, and with low occupational status
or low educational attainment. Cumula-
tive neighborhood disadvantage was sig-
nificantly related to higher allostatic load,
suggesting that biological dysregulation
(or wear-and-tear) accrued over the
life course as a result of neighborhood
disadvantage.35 These recent findings
are consistent with the few other stud-
ies available examining the long-term
impact of neighborhood exposure. For
example, Vartanian and Houser30 used
38 years of longitudinal data from the
PSID (Panel Study of Income Dynamics)
and a sibling fixed effects model to show
that living in more advantaged neigh-
borhoods as a child was associated with
improved self-report of health in adult-
hood. Remarkably, the relative affluence
of adult neighborhood residence had
little or no effect. This finding suggests
that intervention in residential condi-
tions during childhood represents a
critical period for effective impact. Using
NHANES data, Theall et al36 reached
similar conclusions. They, too, found that
teenagers living in higher risk neigh-
borhoods had abnormal biological mea-
sures that have been associated with
increased allostatic load.

One of the biggest challenges in studies
on the health impact of neighborhood
disadvantage has been to disentangle
and determine the effects of neighbor-
level adversity. Ross and Mirowsky29

found that neighborhood adversity
results in worse self-reported health,
even when controlling for individual
levels of poverty. Hurd et al14 found

similar outcomes with regard to adoles-
cent mental health. The research of
Theallet al36 and Schulz et al37 demon-
strated the impact of neighborhood pov-
erty on allostatic load in teenagers and
adults, respectively. Both accounted for
individual and/or family poverty and
found that neighborhood was an inde-
pendent predictor. Similarly, Gustafsson
et al35 linked cumulative neighborhood
disadvantage through adolescence to
higher allostatic load later in life, in-
dependent of individual social adversity
or current neighborhood of residence.
The longitudinal study of Johnson et al25

examined the long-term effects of
neighborhood exposure in young
adults (ages 20–30 years) followed up
for 38 years. After accounting for in-
dividual and family factors, living in
low-income neighborhoods early in
life was strongly associated with poor
adult health. Their findings suggest
that fully one-fourth of differences in
health in mid- to late-life can be at-
tributed to neighborhood differences
during young adulthood.

From Neighborhood Impact to
Neighborhood Intervention

Public health’s response to the role of
neighborhood on health often assumes
that the key mechanism of neighbor-
hood impact is lack of access to ser-
vices and resources. Examples include
work on obesity prevention that fo-
cuses on introducing grocery stores or
farmers’ markets in “food deserts” or
work to bring health services to commu-
nities lacking clinics. Although these op-
tions are important, access to healthier
food and medical services is not enough.
We must transform neighborhoods into
cohesive, stable, and appealing envi-
ronments for the well-being of families
and the healthy development of chil-
dren. It is good fortune that health has
a partner in the field of community de-
velopment, which has been doing pre-
cisely that since its establishment in the

S50 JUTTE et al
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The term “community development” de-
scribes a largely nonprofit sector of the
economy that provides interventions to
improve low-income communities and
the lives of the people who live in them.
The interventions are primarily invest-
ments allowing individuals and families
to build wealth and help communities
provide service-enriched affordable hous-
ing, clinics, schools, grocery stores, and
other facilities to make neighborhoods
more viable. In addition, community de-
velopment fosters small businesses as
a means of developing local entrepre-
neurs; more small businesses in low-
income neighborhoods provide local
jobs and can create a powerful, positive
ripple effect that improves the local econ-
omy for all.

The dollars invested are substantial.
The federal government has several in-
vestment tax credit and block grant pro-
grams that amount to nearly $16 billion
annually.38 Those subsidy dollars, along
with funds from state and local govern-
ments and foundations, provide the seed
capital that allows community develop-
ment to attract additional market-rate
capital from insurance companies, pen-
sion funds, and especially banks. Banks
are motivated by the anti-“redlining”
Community Reinvestment Act of 1977
requiring banks to demonstrate invest-
ment in low-income neighborhoods. To-
tal funds invested as a result of this act
are hard to measure, but according to
1 count from federal bank regulators,
it was more than $200 billion in 2009

The achievements of this community
development investment have been
substantial. Community developers
have built .3 million homes housing
some 10 million low-income individuals
and families since the late 1980s, using
the Low Income Housing Tax Credit. This
housing is a far cry from the common
image of government housing projects

as instant slums.40 Instead, as we de-
scribe later, community development
dollars have ledtohigh-quality housing in
vibrant communities. When high-quality
housing is coupled with integrated so-
cial services, it can serve as an anchor
investment in neighborhoods that have
experienced decades of disinvestment.
People begin to care about neighbor-
hoods they can be proud of, where they
feel connected and involved.

A Brief History of Community

Perhaps the earliest efforts at commu-
nity development occurred in the late
19th century when US cities grew ex-
plosively, with new arrivals from rural
areas or immigrants from other coun-
tries. These newcomers crowded into
cities looking for work. Competition for
jobs pushed wages down, and compe-
tition for shelter pushed rents up. As
a result, the new urban working poor
cities and many times: in Chicago in the
1880s, Rio de Janeiro in the 1960s, and
Shanghai in the 1990s. Erickson,38 in The
Housing Policy Revolution: Networks
and Neighborhoods, provides a history
of community development.

People living in these neighborhoods
spirit. Community development was born
in that liminal space between great need
and great opportunity. The settlement
houses of the late 19th and early 20th
centuries responded by providing com-
prehensive education, job training, and
skills. Immigrants took advantage of the
opportunities and built a better life for
themselves and their children.

Modern community development has
its roots in the War on Poverty initiative
begun under the Johnson administra-
tion in the 1960s. Federal programs
sought “maximum feasible participa-
tion” of low-income communitiesto help

themselves. Part of that process required
community organizations to create a
strategy for improving community con-
ditions, which were called community
action plans. Many of the plans morphed
into institutions, called community action
agencies, which evolved over time to be-
come community development corpo-
rations (CDCs). Senator Robert Kennedy
championed the first CDC, the Bedford
Stuyvesant Restoration Corporation in
New York, in the mid-1960s. Today, there
are .4600 CDCs across the country.41

CDCs are primarily real estate devel-
opers. They are joined in the community
development network by community de-
velopment financial institutions (CDFIs)
tailored financial transactions for com-
funds, many originating with the re-
tirement savings of Catholic religious
orders. Today, in the United States alone,
there are .800 CDFIs with more than
$30 billion under management, many of
them large and sophisticated. The Low
Income Investment Fund, for example,
has deployed more than $1.5 billion
benefitting 1.7 million low-income indi-
viduals.42 CDCs and CDFIs also work with
banks, for-profit real estate developers,
state and local governments, and other
nonprofits in true public–private part-
nerships to improve neighborhoods.

Health and Community

not consider health to be among their
responsibilities. More recently, com-
munity developers and public health
visionaries who recognize that zip code
has more influence over health than
one’s genetic code have realized that
a partnership between industries con-
cernedwithhealthand thoseconcerned
with neighborhood development could
be fruitful. Indeed, Risa Lavizzo-Mourey,
president of the Robert Wood Johnson
Foundation, the nation’s largest health


PEDIATRICS Volume 135, Supplement 2, March 2015 S51
by guest on August 31, from

foundation, wrote recently that “we
are likely to look back at this time
and wonder why community develop-
ment and health were ever separate

Examples of Community
Development’s Impact on Children
and Families

The community development sector
for addressing what the medical and
public health fields consider the social
determinants of health.43 The key ques-
tion is whether neighborhoods can ac-
tually be improved enough and in the
right ways to make a difference in
children’s lives. Can they be transformed
to provide families the environments
they need to support healthy child de-
velopment and end the cycle of poverty?

Over the past several years, the Federal
Robert Wood Johnson Foundation, has
led a series of meetings around the
United States to explore how commu-
nity development and the health sector
can partner to create meaningful changes
in disadvantaged neighborhoods, and
to do so at scale.10 Although rigorous
evaluation data on health outcomes
have not yet been gathered, there are
a number of neighborhood transfor-
mation projects with results that are
powerfully suggestive.10,40 The most
successful projects tackle neighborhood
distress and dysfunction on numerous
fronts simultaneously, addressing mul-
tiple social determinants of health (al-
though those in community development
would generally not have used that
term). By addressing both place and
people (ie, physical infrastructure and
human capital/community processes),
these projects achieve results that are
more than just the additive benefit of
separate component parts. Each project
is also tailored to its community, in-
assets of each neighborhood. There are

commonalities across these projects,
however, that could be replicated to
“routinize the extraordinary.”40 A key
common feature is that each project has
had a “community quarterback,” usually
a single organization often led by a dy-
namic individual, that holds the vision
for the project, convenes stakeholders
and potential partners, coordinates
partners’ activities across sectors and
funding streams, provides staffing, and
tracks results.44 Recognizing the impor-
tance of community quarterbacks in
catalyzing and coordinating transfor-
mational change, the Citi Foundation
through its Partners in Progress pro-
gram recently awarded more than $3.25
million to 13 organizations across the
United States to play such a role.45

The present article describes 3 such
projects that have dramatically improved
neighborhoods: East Lake in Atlanta,
transformed by what subsequently be-
came Purpose Built Communities; the
Magnolia Community Initiative in Los
Angeles, a multisector network in part-
nership with residents; and Neighborhood
CentersInc,responsiblefor transforming
several neighborhoods in the greater
Houston area.

Purpose-Built Communities/

In the early 1990s, the East Lake neigh-
borhood of Atlanta grappled with ex-
treme poverty, high crime rates and
violent crime, poor educational attain-
ment, and high unemployment. The
neighborhood was called “Little Vietnam,”
not because it was home to Vietnamese
immigrants, but because it was like a
war zone.46,47 Prompted by a study link-
ing neighborhood to the likelihood of
resident incarceration in the New York
state prison system, Atlanta philanthro-
pist Tom Cousins devoted the resources
of his family foundation to transforming
East Lake.48 Using both community de-
velopment and private funding, the East
Lake Foundation built mixed-income hous-
ing in place of the existing substandard

public housing, built a charter school,
and brought in shops and the YMCA.47

The effort of this public–private part-
nership took ∼10 years, with a lead or-
ganization dedicated solely to ensuring
that all elements were properly se-
quenced and coordinated (ie, a commu-
nity quarterback), but the results are
impressive. There was a 73% reduction
in crime and a 90% reduction in violent
crime. The estimated economic benefit
of reduced crime (including reduced
costs to victims and savings from esti-
matedreducedlifetimecriminality ofthe
student body) was $10 to $14 million in
2007 dollars.49 The employment rate
rose from 13% to 70%. Although some of
the original residents did not return to
the reconstructed East Lake neighbor-
hood, most did. The neighborhood also
attracted many new middle-income neigh-
bors. The new Drew Charter School is
now 1 of the top-performing schools in
low-income children (80% of the students
receive free and reduced-cost lunch). In-
creased lifetime earnings as a result of
higher educational attainment were pro-
jected to be $14 million (in 2007 dollars)
per graduating class of 85 students or
nearly $165 000 per child over the course
of his or her life.

The project was successful because it
used a coherent and integrated strat-
egy.50,51 As the Robert Wood Johnson
Commission to Build a Healthy America
noted, “Instead of attacking poverty,
urban blight, and failing schools piece-
meal, a group of community activists
and philanthropists in Atlanta took on
all of these issues at once.”52 Inter-
estingly, in the early stages of this effort,
neither health nor health care was
identifiedas key components, although a
health-related focus has been incorpo-
rated more recently. The approach used
in the East Lake neighborhood has
become the basis for multiple efforts
across the country, including New Orleans,
Indianapolis, and Omaha.

S52 JUTTE et al
by guest on August 31, from

Magnolia Community Initiative

The Magnolia Community Initiative fo-
cuses on a 5-square-mile area, com-
prising 4 zip codes and 500 square
blocks south of downtown Los Angeles;
this neighborhood is home to 35 000
children. The Magnolia Community Ini-
tiative was launched with the goal of
reducing child abuse and neglect. In-
stead of focusing on identifying in-
dividual at-risk children and providing
individual services, the initiative took
a population-based approach, seeking
to improve conditions within the neigh-
borhood so as to provide robust
improvements in conditions for all
children. The initiative supports resi-
dents within neighborhoods to take
personal actions that improve the well-
being of their own family and their
neighbors. Moreover, the network of
organizations that comprise the initia-
tive set aspirational goals for itself: that
the childrenliving inthe catchment area
“will break all records of success in
theireducation, healthand the qualityof
nurturing care they receive from their
families and communities.” Four goals
that are recognized contributors to
lifetime outcomes for children were
identified: “educational success, good
health, economic stability and safe and
nurturing parenting.”53

The initiative established the Magnolia
Place Family Center, a community hub
offering colocated services related to
all 4 of the core goals and bringing
together agencies and service pro-
viders offering medical care, parenting
classes, legal services, access to af-
fordable financial services at a bank,
and mental health services. The state-
of-the-art center, opened in 2008, also
offers spaces for family activities and
parent/child activities. More than 70
that comprise the network operate at
the center and throughout the larger
community.54 An explicit feature of the
multisector partnership is that new

partners (organizations or individuals)
are asked to bring to the community
the contributions that enable them to
fulfill their goals. The initiative does not
incentivize or compensate partners;
instead, they participate in the initia-
tive as part of fulfilling their own mis-
sions. They focus on working together
as a system using linkage, empathy,
and holistic elicitation of client and
resident assets and needs to support
achieving the 4 core goals. The network
utilizes the expertise in diverse service
sectors on how to mitigate toxic stress
and optimize well-being. Progress is
rigorously tracked by using a commu-
nity dashboard (Fig 1) that follows
outcomes on a population basis.55

Neighborhood Centers Inc.

The focus for Neighborhood Centers
Inc (NCI), based in Houston, Texas, is
smoothing the way for immigrants and
other newcomers to succeed, thrive, and
contribute as they integrate into life in
Houston and other Texas communities.56

Using an asset-based approach,57 the
goal of NCI, which operates 74 centers in
60 Texas counties, is to change lives. They
start not from what is “broken” in com-
munities, says CEO Angela Blanchard, but
from what is working.58 This method
involves facilitating residents and social
service partners in the community …

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