The usual solutions are to put supermarkets in the inner city, or to have farmers markets in the inner city or urban gardens in abandoned lots.  While all of these solutions are excellent long-term answers, all have problems or limitations.

Supermarket chains are increasingly reluctant to begin an effort to put a supermarket in an underserved low-income, inner city area.  There is an old saying that “No good deed goes unpunished” and that certainly applies to supermarket chains that try to do the right thing.  Almost always, labor unions and community coalitions try to force the chain to make various kinds of concessions as a condition of withdrawing objections, and small businesses who perceive they are threatened by the supermarket fight to the death to keep it out.  Last September 29, The New York Times published a story about a supermarket chain that tried to open a store in the Bronx, and was stalled by several different special interest groups.

The farmers markets and urban gardens are good solutions for growing foods during the growing season, but they do not provide a complete solution for population food needs during colder weather.

What works all year around is a delivery service that regularly trucks food that is ordered online from the supermarket to convenient locations in the inner city that only need storage space and security from break-ins and thefts.  Churches, schools, community centers, and industrial warehouses located in inner cities all can serve this purpose. The Baltimore City Health Department is actually pioneering this idea in a program it calls the “Virtual Supermarket Project.”

When I have spoken with people who have attempted to solve the food desert problem with delivery services, they always say that the “economics of the proposed service do not work for the delivery service.”  That strikes me as a phony argument.  Certainly, if a delivery service tries to copy a door-to-door service it provides in a wealthier area, the economic argument would make sense.  However, delivery to a location that clusters or groups multiple orders, but is convenient for local residents makes a whole lot more sense.

This whole discussion reminds me of the economics of mail delivery, which, by the way, is a way of delivering fresh fruit over long distance from gourmet services like Harry and David.  Postal services that have more freedom to change their delivery model, such as the Emirates Post, deliver to clusters, and charge extra for door-to-door delivery.  When I was at Pitney Bowes, the major corporate customers we served through our mail delivery services increasingly wanted delivery to clustered mailboxes rather than to individual desktops or mail cubicles.

In some European countries in which postal unions are large and powerful, the delivery obligations are far greater than what we have here in the United States.  For example, in the UK, on some routes, letter carriers have to walk up several flights in apartment buildings and deliver mail through slots on the doors of individual apartments.  This preserves postal jobs, but it makes delivery service extremely expensive.

The reason I prefer delivery services as a near-term or even a medium-term solution is that the construction of a supermarket, even when the supermarket owner can run through the gauntlet of community special interest groups, locks residents into the choices that supermarket offers.  Delivery services give the residents an ability to buy from any grocery store or supermarket within a reasonable radius of the community, which creates more competition.  When a supermarket comes into a community, it adds a single competitor, often one that displaces some or all of the small food stores already in place.  A delivery service keeps local competitors in place, and adds competition from the outside.  Moreover, over time, it can even incorporate long-distance online purchases of non-perishable items to put even more competitive pressure on the local bodegas or convenience stores that fail to offer adequately healthy food.  Having access to delivery services makes everyone more willing to be competitive in their pricing and their services for poorer communities.

The theory behind this strategy is that smoking, not ingestion of harmful ingredients, is the health risk both to the user and to bystanders.  Clearly, when someone orally ingests nicotine, there is no second-hand smoke problem for others, and, for the user, there is no problem with small particulate matter in the lungs.  The remaining hazard is the chemical alteration of the body from the ingestion of nicotine and other substances.  Smokeless ingestion systems are less harmful than traditional cigarettes, but some degree of harm remains.

Even more interesting, Altria recently acquired a company that markets smoking cessation products, which positions it to offset the decline of sales of cigarettes.

This article poses two big strategic questions in the battle to improve health:

• Can we enlist those who have produced unhealthy products and services to transition to healthy or, at a minimum, less unhealthy offerings?
• Should we support the marketing of transitional products that retain addictive behaviors which are still harmful, but are less harmful than what they replace?

Do We Enlist the Offending Companies and Industries in Developing Healthier Alternatives?

My answer to the first question is that I am convinced that food, beverage, tobacco, alcohol, and drug companies have to be enlisted in finding solutions.  They create jobs, economic return to a wide range of shareholders, including public and private pension funds, and community value, and we should attempt to redirect, rather than destroy, them.  The challenge is how to break through the inertia they undoubtedly experience when their own industries and probably their own organizations have deeply-imbedded cultures that would prefer that nothing change.  It is not easy, and, in any industry, only a handful of players will be bold enough to move beyond a successful business model when it is still producing big profits.

Some companies are making the transition already. Pepsico is making a strong commitment to reducing the marketing of its most sugary beverages and to reducing the sugar and sodium content in all of its products.  Campbell’s Soup recently reduced sodium content in its soups. Wegman’s, a retail grocer in Rochester, New York, took the bold step of discontinuing the sale of cigarettes in its stores, a decision that must have cost it short-term profits.

However, many companies do not know how to make this transition, or fail when attempting to do so.  How does a pharmacy or retail grocer which makes a lot of money slotting and selling cigarettes replace the profits from those cigarettes?  Almost certainly, there is no comparably profitable retail item in the near term.  As someone who attempted to wean Pitney Bowes from being too dependent on postage meter revenues and profits, I can state categorically that the first step in moving toward change is to accept the fact that the future requires a higher volume of sales to replace what’s lost and a diversification into adjacent market spaces.  Companies that try for too long to hold on to an unsustainable business model or product line decline very rapidly when change comes.

I also believe that government can play a constructive role in setting standards and timetables for change.  Even in the most change-resistant organizations and industries, there are those who want to change and who know how to make it happen.  Government standards and timetables give them air cover to win the debate against change-resistant leaders in their organization or marketplace.  To some degree, governments have to recognize that there is a delicate balance between forcing change too fast and accommodating the most reluctant industry players.  Governments should find the center of gravity for an industry and peg their change decisions at that center or at an even more aggressive point, not at the slowest and most change-resistant point in a marketplace.

Governments also have to come down hard on industry players that want to take the easy way out by marketing that they have healthy alternatives when they really do not.  Those kinds of players hurt everyone else.  Governments also have to recognize that any mandated change will produce winners and losers.  They cannot worry about insulating losers from the consequences of their bad decisions.

Supporting transitional products and services that are harmless, but less so.

My moral position is that tobacco is different from foods, beverages and alcohol.  There is no demonstrable affirmative benefit from tobacco products, whereas there are positive benefits from food, beverages, and alcohol as long as they are consumed in moderation.  Moreover, tobacco is an addictive product and I am opposed to marketing even less harmful versions of addictive products, for two reasons:

• When there are reduced quantities of the harmful, addictive substance in a product, there is a great temptation to cause people to consume more of it and end up with the same quantity of harmful substance ingested.  Thus, for example, if a cigarette company reduced the nicotine content in a cigarette by 50%, it might be tempted to get people to consume twice as many cigarettes.  The tobacco company would love this result because it can make more money, but this is bad for the customer.
• It is too tempting for a marketer of a less harmful, but nevertheless harmful, product to be satisfied with reducing harm rather than eliminating it.  Inertia is a powerful force when companies make a high profit margin on even less harmful products.

Relative to food, beverages, and alcohol, the challenge is to get people to consume in moderation.  To the marketer, the goal should be to maximize profits and reduce consumption at the same time.  The best example of how to do this is in the coffee category.  Starbucks found a formula to get people pay well over $2 for a cup of coffee that used to cost about $1.50 in most diners.  The ingredients cost more, but not that much more, and, clearly, the barista added more labor value than the retail clerk at a traditional diner.  Thus, there is always a strategy of selling a premium product, and redefining the category.

The candy companies have used a somewhat different strategy.  They either keep the price flat or slightly increase it, but they reduce the size of the candy bar to increase profits.  The smaller portion size leads to reduced consumption, but increased profits.  The soft drink companies have done the same with the 8 ounce cans in place of the 12 ounce cans.

When I was a student in Madison, Wisconsin, in the late 1960’s, the state came up a clever way to address heavy drinking by students.  Instead of trying to ban alcohol from campus or to force bar owners to enforce a 21-year-old drinking age, they authorized the selling of on-tap 3.2% beer.  This watered-down beer tasted sufficiently like regular beer that it was very popular.  People got bloated with beer long before they could get drunk.  Air and water are great ways of reducing consumption without appearing to be operating in a “nanny” state.

Therefore, I take the view that there are a sufficient number of ways to transition to healthy offerings that we should never need to support partially harmful products and services.

Her description of certain union positions rings true to me because I recall that the Stamford Youth Foundation (Stamford, Connecticut) could not staff the variety and volume of after-school activities that it would have liked because union contracts required it to pay every teacher for the extra hours worked after the regular school day.  This deeply bothers me.

I am not against labor unions, and I believe they serve a useful purpose in being a check-and-balance on abusive management behavior.  However, the notion that volunteerism must be stamped out if there is a worker ready, willing, and able to do the same job for market-rate pay is wrong-headed.

One of the fundamental issues in all societies is the question of when and how much someone should be paid for performing a task.  If we believe that every activity that is currently the subject of volunteer work, or perhaps below minimum wage work (like the cutting of a neighbor’s lawn by a 12-year-old wielding a lawn mower) should be converted into unionized, market-rate wage-driven work, we will significantly reduce the number and variety of goods and services we can offer to one another.

The one story in Malkin’s op-ed piece that particularly troubled me was the reference to a complaint by union officials against volunteer firefighters who built sandbag barricades to protect the city from record flooding. Ultimately, the reason governments at all levels are in deep financial trouble is that they have wildly overpaid unionized workers for relatively low-skilled tasks, or for tasks for which there should not have been premium pay.  As I have said in previous blogs, I do not blame the unions for trying to get the pay and benefits they received, but I deeply blame the government officials who caved in to these demands.

As a society, we need volunteerism at all levels.  There has to be a zone of activities that we will do without expecting to be paid by the recipient of our services.  This zone should include character-building community projects by such organizations as the Boy Scouts or the Girl Scouts, emergency services by first responders and other volunteers in the event of a disaster, and charitable work.  If someone wants to donate services, as my daughter does when she performs at senior citizens homes, she should be able to do so.  Taken to a logical extreme, the position attributed to SEIU and other unions would suggest that a unionized musician charging the senior citizen home market rates should have the exclusive right to deliver performances to senior citizens.  This is an outrageous position, and I hope our government officials never allow it to become the prevailing view.

In the recording industry, the intermediary is the record label.  In movies, screenwriters have to approach producers through agents, and film producers have to reach the marketplace through sales agents or distributors.  TV producers have to go through agents to reach TV networks and other content buyers.  This is similar to what I experienced and saw in the broader business world: there are always gatekeepers between product and service producers and the end customer.

What is great about the Internet is how it has the potential to give those who want to reach a customer the ability to bypass intermediaries and create a better balance of power with those intermediaries.  I love the fact that Paranormal Activity, a movie produced for $15,000, which used predominantly low-cost direct marketing channels, including social media, has grossed over $100 million since its release. Too many intermediaries would be threatened if that became the norm on how to get a movie to the public.

Related to this, I was so happy when my younger son became a very capable online seller during his senior year of high school, and my daughter learned about to get harp performing engagements directly without needing a booking agent.

I believe strongly that we will see far more prosperity and a more equal distribution of income and wealth if individuals have the skills to sell their products, services, and labor directly to those who need them.  Intermediaries can serve a very valuable role, and many are essential to the people they serve.  However, just like any monopoly situation, when they have sole or primary access to the end customer, they can get complacent and not do the best possible for the seller.  That’s why I like the potential direct marketing opportunities the Internet provides.  It gives any seller, including me, the ability to say to an intermediary: “Either be as passionate and single-minded about what I am selling as I am, or get out of the way.”

One of my experiences was a lunch at a popular New York City restaurant on July 8.  When I looked at the menu, every item was labeled relative to the calorie content of the item.  I was ready to order the caesar salad as a low-calorie alternative, when I was shocked to find out that the salad contained 790 calories, and that the salad with chicken was 1,325 calories.  To my surprise, the 10-ounce filet mignon was only 390 calories, so I ordered it and also had a cup of soup.  Undoubtedly, absent the disclosure, I would have ordered the salad.

I also wear a pedometer every day and almost always am able to walk or run sufficiently to get to 10,000 steps per day.  On July 8, on my way to the restaurant, I was taking a subway from East 86^th Street in New York to Grand Central Terminal at East 42^nd Street.  While I was on the subway, I noticed that I had 20 minutes to spare when the train pulled into the 59^th Street station, and that I needed to log a number of steps.  As a result, I exited the train at 59^th Street and walked the rest of the way, because I saw that it would be difficult for me to get to my target.

At Pitney Bowes, we took one further action relative to marketing the benefits of walking.  At the bottom of our 3^rd floor stairway in our World Headquarters, we have a sign that informs someone that if they walk up and down these stairs every for a year instead of taking the elevator behind the stairs, they would lose 5 pounds.  I watch people make the discretionary decision to take the stairway rather than the elevator.

The Wall Street Journal article notes that the same behavior occurs relative to electricity usage when a home has a power monitor that informs the home owner minute by minute how much power has been consumed.  The author, Geoffrey Fowler, cites an Oxford University study in 2006 that found that “people getting direct feedback on their power consumption reduced use 5% to 15%.

There are two implications to these data points:

•       If we want to reduce overeating or to increase exercise, measuring, monitoring, and disclosing the quantitative aspects of a behavior will change the behavior.
•       Conversely, if we want to change an unconscious behavior by altering the environment that produces it, that will be successful as well. Eating, exercising, and other behaviors, good and bad, have a heavy unconscious, automatic aspect to them.

Reflecting on my behavior in the restaurant and on the subway, I am more convinced than ever that mandatory nutritional labeling works if it is quantitative.  Warnings like the Surgeon General’s warning on cigarette packages are much less effective because they are not quantitative.  Similarly, disclosures on prescription drug packages relative to side effects are also relatively ineffective because they are not quantitative.

My good friend Dr. Elliott Fisher of Dartmouth’s Health Policy Institute introduced me to a different form of disclosure relative to prescription drugs, a one-page chart that lists every side effect, but that specifically supplements the disclosure by listing in quantitative fashion the results of the clinical trials conducted for that drug.  Thus, for example, the chart does not simply say that Drug X has been shown to cause headaches in some people.  It specifically discloses that of the 2,500 people who took the drug, 17 of them, or .68%, experienced headaches.  There are some indications that individuals confronted with quantitative information react differently.  Some pay attention to the disclosure and decide they do not want to take the risk; others are reassured by a low-percentage risk disclosure and decide they will take the risk.  In both cases, the quantitative disclosure altered behaviors.

Because of all these experiences and observations, I have become a strong believer in more detailed labeling and disclosure, as well as much more quantitative disclosure, whenever such disclosure is not false or misleading.

Michael Pollan wrote an exceptionally informative article in the October 12 New York Times Magazine, entitled “Farmers in Chief.” Among other observations, he makes the following points:

• Our cheap grain-based diet, which includes simple carbohydrates like pasta, bread, pizza, and sugary desserts, meat, and high-fructose corn syrup is a result of government policies that heavily subsidize grains and fossil fuels.  I have talked previously about grain subsidies, which are in excess of $8 billion.  However, I had not appreciated the impact of previously cheap imported fossil fuels on food costs.  He points out the obvious:  cheap fossil fuel is a thing of the past.
• I was also unaware that government policies specifically suppress the supply, and raise the price, of fruits and vegetables by prohibiting the production of specialty crops on farms receiving commodity subsidies.  Therefore, a great deal of potential healthy food production is stifled by government policies that protect a small number of specialty food producers.
• The government also exempts feedlots from waste disposal regulations that would be applied to municipalities and other production facilities, which means that the cost of breeding animals in less healthy feedlot environments are artificially low.
• Governments also influence what people eat through its procurement policies.  It specifies minimum calorie meals for school breakfast and lunch programs, but makes no effort to enforce nutrition guidelines, which means that less nutritional food is the easiest and cheapest path for school lunch providers.  Government also fails to use its procurement power for the military, for government cafeterias, and organizations receiving federal funds to require nutritious foods to be served, to be affordable, and to be abundant.  Government micromanages many things in procurement, but it has ignored nutrition.

These are just a few examples from a great article.  The bigger point is that if the next president were to announce that health, a safe environment, and energy independence were to be high priorities, food policy would be a great place to address all three issues.

When I read this article, it occurred to me that the misuse of menthol and other sweeteners to attract people to cigarettes can be turned on its head to make healthy foods more attractive to eat. When our younger son, who is now 17 years old, was under 10 years old, we had a great deal of difficulty getting him to eat anything other than junk food. We had particular difficulty getting him to eat green vegetables.

My wife came up with the strategy of letting him put ranch dressing on his vegetables. It obviously increased his caloric intake in a less-than-optimal way, but it helped get him into the habit of eating vegetables. Over time, we started putting the ranch dressing on his vegetables, but we used less and less as time went on. Eventually, by the time he was 13 years old, he was still eating his vegetables, but had been weaned off ranch dressing.

My wife has understood that I have somewhat of a sweet tooth as well, so, over the years, she has incorporated bits of fruit in lettuce salads, fruit-like toppings on seafood, and interesting combinations of vegetables, like avocados, in salads. She has presented healthy food in a very attractive way, so we have eaten moderate portions of healthy food whenever we sit down at dinner tables. On my own, I have basted salmon with mustard before broiling it, squeezed lemon juice on swordfish, and added lemonade to green tea. As a result, our family has found eating healthy foods very attractive.

As we think about our obesity crisis, we need to recognize the reality that asking or forcing children to eat healthy foods when they have become addicted to junk food is going to be unsuccessful unless we can find ways to mimic the sweet flavors and tastes to which they have become accustomed. We also have to find ways of making the healthy food “cool” and a status symbol for young people, as cigarettes have become.

We also have to recognize that how food is presented and packaged matters greatly as well. To the degree that healthy food is made available in attractive packaging and with attractive flavoring at fast food retail outlets at which young people come together, it has a chance of being part of the diet, and, over time, to supplant less healthy food.

I recognize that weaning people from cigarettes is not as simple as making the substitutes flavorful, since the nicotine in the cigarettes is addictive and since there are many reasons people smoke. At the same time, the battle for the health of young people will be fought and won by making good food more fun to eat than bad food, and we can thank the cigarette companies for teaching us the techniques of how to make something people ingest more attractive to them.

However, just as I noted in a blog several months ago in which I described some of the findings in the book Mindless Eating, authored by Brian Wansink, the best behavior change drivers are those of which the individual is not conscious. Steve Victor’s Fit For Life blog provides a brief summary of the book’s key takeaways.

For example, in our World Headquarters at Pitney Bowes, we have created a healthy environment by the food we serve and the way we price it. We have an on-site clinic and on-site fitness center, and we have many outreach programs for preventive screenings and immunizations.

However, supplementing these more formalized approaches are the subtle things we have done to make healthy behaviors more prevalent. We have built very inviting and conveniently placed stairways as we have renovated the building. We have created an open office environment in most of the facility, and will renovate the remainder of the building consistent with what we have already done. We have created a layout that gives every employee in the renovated spaces direct access to natural sunlight. We have created a brighter color scheme and have used environmentally-friendly building materials and furnishings. We have also enabled people to get the functionality of a fixed office throughout the building by creating a robust wireless communications system. As pointed out in the Employee Wellness Blog, these small enhancements make a big difference, and can be particularly effective when combined with a structured wellness program.

Much of what we have done to encourage employees to walk more, to communicate more with their fellow employees, and to feel better about their surroundings was not obvious in terms of its impact. We did not mandate that employees increase their walking; the environment made walking more attractive. We did not mandate more communications and mutually supportive behavior; the environment made socialization a more attractive and natural option. We did not mandate a brighter outlook; the environment made access to the sun achieve that for us.

Take that principle and apply it outside our four walls. A lot has been written about how to create an inviting neighborhood environment for walking, exercise, and safety. William H. Whyte wrote a great book over 20 years ago called City, which consisted of his observations about how New York City residents reacted to different physical layouts. He found that they walked in certain areas more than others because the environment was more conducive to walking. This recent post in The Ground Floor blog reviews some intriguing facts for how and why the average life expectancy of New Yorkers has increased due to the walkable environment, among other factors.

Furthermore, Jane Jacobs, in her ground-breaking work The Death and Life of Great American Cities, talked about the benefits of mixed-use zoning, shorter blocks, narrower streets, and easy access to parks and bike paths, all of which were conducive to healthier living.

Similarly, in our headquarters neighborhood in the South End of Stamford, Connecticut, our Neighborhood Revitalization Zone Board, working collaboratively with the City of Stamford, under the brilliant leadership of Mayor Dan Malloy, has eliminated burnt-out automobiles, most of the abandoned, boarded-up housing, and the rubble-strewn parks and yards that make a neighborhood appear menacing and uninviting for walking. Years ago, I did not feel comfortable walking from our World Headquarters to the Stamford Train Station because I passed dangerous and deserted areas. Today, it is a relatively inviting walk, and will get better as the Antares Group completes its ambitious plan for mixed-use development.

Ultimately, people respond to both the formal and the implicit cues in their external environment to engage in good or bad behaviors. We need to create the healthiest possible environment for the right behaviors. Lower health care costs and a greater sense of well-being are the rewards we reap for those kinds of decisions.

But I have learned that the absence of healthy food is just one form of deprivation for low-income communities. They lack four other prerequisites for healthy living:

• Safe outdoor play areas, like parks, to get exercise;
• Primary care clinics for treatment of minor illnesses and injuries, preventive screenings, and immunizations, as well as referral to medical specialists;
• Pharmacies; and
• Information sources.

In effect, the “desert” label could be applied to all five of these areas. We incur more than $4 million in emergency room care in NY, although our employees have excellent coverage. We believe that the NY City health care system, while of high quality, is lacking in after-hours coverage for treatment of minor illnesses and injuries

Community health centers were funded back in the 1960’s to fill the gap in primary care. However, they have not been a strong solution. There are too few primary care physicians, and there is also a shortage of nurse practitioners and nurses. Dr. Richard Reese details some reasons for the physician shortage in his MedInnovation blog.

Too many of the centers have moved more into crisis counseling and counseling to assist people with behavioral health problems, all desperately needed services, but not ones that will help individuals who need basic physiologically directed health care. They are also unevenly funded, and, in many instances, are not open at the hours when people need the care.

An August 2007 report entitled “Access Granted” published by the National Association of Community Health Centers, reviews the impact community health centers can have on individual communities and the economy.

When individuals with health coverage live in these deserts, as is the case with many of our front-line employees, their primary caregiver tends to be the hospital emergency room. There are three fundamental problems with the emergency room care:

• It is a ridiculously inefficient and costly way to deliver primary care for minor illnesses and injuries;
• Emergency rooms are not set up for high-volume screenings and immunizations, so people whose care is rendered in emergency rooms tend not to get screenings and immunizations; and
• Because of the unpleasantness and long waiting times for emergency room care, people tend to hold off going there until they are seriously ill, which means that we miss an opportunity to get them treated earlier in the progression of a disease, an illness, or an injury, which means that the treatment is far more expensive and complicated than it needed to have been.

Not surprisingly, emergency room care is also not designed for the critical follow-up care needed for chronic disease patients.

Amy Ridenour’s National Center blog explains how a federal law adopted in 1986 further hinders emergency room care, particularly for the uninsured.

This “desert” is the most fundamental health care issue we have. I believe it is at the root cause of why coverage costs keep skyrocketing, why businesses discontinue providing coverage for their employees, and, therefore, why the uninsured population keeps growing. If we do not solve this problem, trying to extend coverage to more people will either be ineffective in containing costs, or it will contribute to more costs and make the health care system even more dysfunctional than it is today.

State and local governments can do something about this:

• They can be the catalysts for getting supermarkets, pharmacies, parks, and primary care facilities into these desert areas.
• They can fund more training and development for nurses and nurse-practitioners. They can also increase the population of primary care physicians, but that problem will take much longer to solve.
• They can help community health centers and other institutions provide basic screenings and immunizations at low costs, and can be a major factor in community outreach to get as many people in for screenings and immunizations as possible.

As I have said before, the current political debate on health care is misdirected. We have to attack the health and the access issues along with the coverage issue.

One of the main points I made is that convenient and affordable access to healthy foods, prescription and over-the-counter medications, and primary care physicians and nurses for preventive screenings, immunizations, and treatment of minor illnesses and injuries was a more important issue to attack than simply expanding coverage. The more I learn, the more convinced I am that I am right.

This morning, I was listening to an interview on WFAN-New York radio, and the interviewee, a founder of an organization trying to address the issue of hunger in America, referred to “food deserts,” a term I had not heard before. He defined the term as a geographic area in which many people live, but they do not have convenient access to a supermarket or any other food store that carries healthy foods. He said that the entire city of Detroit and major chunks of New York City have no supermarkets. As a result, residents of these communities eat fast food or they go to bodegas or convenience stores that stock inexpensive junk food and nothing else.

After researching this topic more, I discovered a collection of comprehensive studies on food deserts published by Mari Gallagher Research & Consulting Group. I also found some relevant blog postings. An entry in the Daily Kos blog details one blogger’s personal experience with a food desert. In addition, the U.S. Food Policy blog presents a few arguments on why this phenomenon occurs.

Similarly, when I have spoken with my Corporate Medical Director about finding a walk-in clinic for many of our employees that live in New York outside Manhattan, he told me that the supermarkets and pharmacies that might house such a clinic do not exist in these communities. I was in a CVS in Greenwich, Connecticut, which has a Minute Clinic adjacent to the CVS pharmacy. It’s open seven days a week, and the pharmacy is open 24 hours a day. However, such a facility would not exist in a poorer community because the economics would not support it.

Community health centers are supposed to fill this particular gap, but they are of uneven quality, they are often under-funded, and they do not offer a consistent broad base of primary medical services. They end up being referral services for behavioral health and other serious issues, a vital service for a community, but not one that helps address the community’s need for basic medical services.

States consistently try to mandate better health coverage to regulate insurance companies and pharmaceutical companies more tightly, to squeeze doctors and hospitals to reduce what the states have to pay for Medicaid, SCHIP, and other state-run medical programs. They would help the state of health and health care if they redeployed their resources to address the following issues:

• Working with major supermarkets and pharmacies to put convenient, affordable stores in areas under-served by them now. Years ago, I visited the Central Ward of Newark, New Jersey, to see what Monsignor William Linder and New Communities Corporation had done with Pathmark. New Communities had put a first-class supermarket and pharmacy in the middle of a very poor section of Newark. He had high-quality, healthy, affordable food offerings tailored to the needs of an ethnically and racially diverse neighborhood. People would take the bus or walk to the store, but to make shopping convenient, particularly for the elderly, he created a delivery service long before Webvan and Peapod got into business. He also had a pharmacy next door to the supermarket with affordable offerings for residents. Every state could work on this kind of program.

• Working with medical providers to put walk-in clinics in convenient locations, or, at a minimum, to offer convenient, affordable access to screenings and immunizations. Perhaps the community health centers could be the access point for this care, but each community has a different focal point for its residents. For example, African-American communities are best served by making the church the center point for health-service delivery. States are closer to their citizens than is the federal government, so it makes sense for them to identify the best delivery point in their poorest areas.

• Working with universities and community colleges to create more programs to train and certify nurse practitioners and nurses, and working with state medical societies to broaden the range of services that can be delivered by health care professionals other than physicians. There is a severe shortage of health care professionals, particularly nurses and nurse-practitioners. This is a problem that can be addressed at the state level. Colleges and universities, particularly community colleges, can help solve this problem. Nurse residency programs between hospitals and local universities are a good solution, as documented in this blog post that outlines the partnership between Wisconsin hospitals and Milwaukee-based Marquette University.

• Working with pharmaceutical companies and health care technology providers to enable more self-management of health. To the degree that individuals can monitor their own health, take care of their own disease management tasks, and self-administer a wider range of medications and treatments, there is more ownership of health issues at the patient level, and less strain on an overworked health care system. States can be a catalyst to improve this situation. Pharmaceutical companies have programs for low-income individuals to get free or very low-cost access to drugs, but many eligible individuals do not take advantage of them. States should help take the lead in getting the word out to their citizens to make sure these programs are accessed. This topic is further examined and critiqued in the World Health Care Blog.

These opportunities are real and significant, and states can pursue many of these without spending significant public dollars.