Obesity used to be a privilege reserved for wealthy people in wealthy countries. Now, however, this and other lifestyle diseases also afflict better-off people in poorer countries and poorer people in richer ones, particularly the United States. In 2007, the Robert Wood Johnson Foundation—the biggest US philanthropy devoted solely to health care and health, with roughly $8 billion in assets—announced that it would award $500 million in grants to reverse the soaring incidence of US childhood obesity over the past 40 years. These grants support programs designed to raise levels of physical activity and improve nutrition for kids; to identify other levers for reversing the childhood obesity epidemic; and to determine, advocate, and implement the requisite policy and environmental changes. The foundation also focuses on issues such as improving the quality of the US health care system; increasing access to stable, affordable health care; strengthening the public-health system; and addressing the health needs of vulnerable populations.
Risa Lavizzo-Mourey, who holds both an MD and an MBA, has been president and CEO of the foundation since late 2002. Matt Miller, a senior adviser to McKinsey, and Lynn Taliento, a principal in the Washington, DC, office, interviewed her at the foundation’s headquarters, in Princeton, New Jersey.
The Quarterly: The current financial environment scares everyone. What does it mean for the Robert Wood Johnson Foundation over the next few years?
Risa Lavizzo-Mourey: We’ve taken a hit just like everyone else, but we are standing by all of our existing commitments. In fact, we increased our grants substantially in 2008 and expect to increase our payout rate considerably, even though our total dollars granted will likely be a little lower than in 2008. We know that this crisis is real and almost unprecedented, and we’re preparing for it to last a while. But our objectives can’t be achieved overnight, so we take a long-term view of our work and how we measure progress. We typically make multiyear grants, and we have to be sure that we can meet our obligations, because we don’t want to pull back once we commit. We therefore have to understand how our financial assets are doing and focus our resources on meeting those long-term goals.
Even before the crisis started, we knew we had to focus. When I became CEO in 2002, frankly, we had way too many strategic objectives—maybe 36. At any one time, we had roughly 2,500 to 2,700 grantees. They weren’t all singing from the same songbook, and they had different objectives, which weren’t necessarily aligned with social change. Today, our work is focused in seven strategic areas, with 1,244 active grantees. That’s still a lot, but it’s much more manageable.
We’ve concentrated on the areas where we think substantial progress will make people healthier and will have a positive impact on costs—for instance, reversing the epidemic of childhood obesity. We also focus on issues such as health care quality and getting value for money in health care, which is going to be important for comprehensive health reform.
The Quarterly: The social safety net is weaker now than it has been in a while, and it’s looking to become even weaker. Does the foundation play any role in trying to strengthen it?
Risa Lavizzo-Mourey: Yes, we also focus on strengthening public-health systems, because in hard times that’s where a lot of people go. We’re trying to make those systems more responsive to the needs of the populations they serve and to make public-health policies and the allocation of resources more evidence based.
We also have what we call our vulnerable-populations portfolio, representing about 20 percent of our grant making. These programs address health issues in the places where people live, work, learn, and play, because access to quality health care isn’t the only thing that affects the health of Americans—so do things like housing, education, and the environment. We therefore support programs that address them. For instance, CeaseFire, which started in Chicago, uses a public-health approach to contain and reduce gun violence. We are helping this program expand to other places. Another example is the Nurse–Family Partnership, which focuses on postnatal visits and follow-up with new mothers in poverty. We’ve been supporting the partnership for almost 30 years, and the research we’ve funded shows that children whose moms participated in the program have much better health and other social outcomes—lower rates of teen pregnancy, fewer encounters with the juvenile justice system, and higher college-going rates.
The Quarterly: The foundation has a reputation for being quite active in advocacy. Can you talk about that role in your work?
Risa Lavizzo-Mourey: In the past, we often relied on our grantees to carry the message, but now we are much more active and direct in that respect. Five or six years ago, most of our staff thought of us, essentially, as a philanthropic bank. In 2003, we realized that we are really about creating social change, not just giving grants. So we’re making the transition from “cash is our major product” to “ideas, information, data, and social change are our major products.” When we internalized this new mind-set, we realized that our communications had to be managed. Our staff began to develop strategies and tactics to manage what we say and how we say it. Rather than spreading our messages through our grantees, we now disseminate them with our grantees. And we do so far more proactively.
Advocacy is now part of almost all aspects of our work. When we think about promoting social change, one of our main levers is strong, evidenced-based communication. We are very careful, and we want to make sure we can defend our position with strong data and stick with it. But we do have a point of view, based on that evidence, about the kinds of changes necessary to improve health for all the people in this country. We’ll keep refining the messages as the evidence gets stronger, particularly for childhood obesity.
The Quarterly: What’s the message there?
Risa Lavizzo-Mourey: The childhood obesity epidemic won’t be reversed unless we all are engaged—parents, schools, government at all levels, philanthropies, and the business community. The people and companies that grow food, develop food products, and market them must be a part of the solution. And to create healthy communities where people can get lots of physical activity, we have to engage planning agencies and transportation departments and think about zoning laws, access to parks, and how to create communities where people can walk and bicycle. All of those things require across-the-board engagement with business. In the past, we had an adversarial kind of engagement with the tobacco industry over smoking, but our effort to help reverse the childhood obesity epidemic is very different. It has to be.
A good example of what’s possible is the Alliance for a Healthier Generation—a partnership of the American Heart Association and the Clinton Foundation—whose work is supported by our foundation and others. In May 2006, the alliance negotiated an agreement with the American Beverage Association and the top three US beverage manufacturers to cut deliveries of sweetened drinks to schools. A report found that the number of beverage calories delivered to schools in the 2007–08 school year dropped by 58 percent since the agreement’s been in place.
The Quarterly: Do business leaders today get it, or do they require further education to understand the childhood obesity problem?
Risa Lavizzo-Mourey: At least some business leaders do get it, because they see the business case. Thanks to the Alliance for a Healthier Generation, major beverage companies decided to change the way they do business, partly because a single set of standards—not one for each state—established clear guidelines and leveled the playing field for companies. The outcome was a win–win, for kids and for companies.
In fact, if you talk to food companies, they will tell you that some of their best-selling products are healthy ones. Clearly, a foundation like ours can work together with food manufacturers and retailers to educate the public. We’re strong advocates for menu labeling in restaurants, for example, because the evidence tells us that little “nudges” help people make healthier choices for themselves and their kids. In areas that have had menu labeling for a while, for example, we’re starting to see restaurants and other vendors change their recipes to cut calories. Companies are likely to feel more pressure to reformulate their foods and change their menus if we are able to demonstrate that, given the right information, people will make healthier choices. That’s the kind of work we can do.
The Quarterly: Will people in inner cities make healthier choices too?
Risa Lavizzo-Mourey: In many inner cities, it’s hard to find grocery stores that sell leafy green vegetables, produce in general, or fresh meat and fish. In Philadelphia, a nonprofit called The Food Trust was able to work with partner organizations and the Commonwealth of Pennsylvania to create a financing program called the Fresh Food Financing Initiative, which brings supermarkets and grocery stores back to underserved communities. Typically, in West Philadelphia all you could find were bodegas or corner stores that might sell bananas or potatoes, but most of the foods they carried weren’t healthy. Today, supermarkets and grocery stores are returning to the inner city, where obesity rates are high. People are shopping there. The stores are employing people from the community. Grants and loans offset some initial costs, but the stores are self-sustaining. Owners are finding that these are profitable businesses, that inner-city residents would much rather shop there than travel out of the neighborhood to buy groceries or go to expensive convenience stores.
One great thing about The Food Trust’s work was that it showed how much money people in underserved communities were spending outside their own neighborhoods to buy groceries. It made the economic case for full-service grocers—thousands of dollars are exiting the inner city every day that could be spent in your store if you had one there. This connection between smart economic policy and good public-health policy is a great model for addressing childhood obesity. With support from the Robert Wood Johnson Foundation, The Food Trust is working in Louisiana, Illinois, and New Jersey to explore ways of replicating its success in Philadelphia.
The Quarterly: Let’s turn to the other half of the equation. America refuses to burn calories. How do we change that?
Risa Lavizzo-Mourey: Our foundation focuses on kids and how and why they do or don’t exercise. Over the past 25 years, our kids’ lifestyle has become a lot more sedentary. For most of them, much of that change can be attributed to the fact that they spend so much time in front of computer and TV screens—sometimes multiple screens. That has two effects: one, kids usually aren’t moving when they’re in front of a screen; two, they’re getting bombarded with ads for unhealthy foods.
Children and adolescents spend an average of nearly six-and-a-half hours a day watching TV, playing video games, and using other types of media. That’s a big change from the way kids spent their time a generation ago. Changing the amount of screen time is essential—or at least making it active screen time, so that instead of sitting passively in front of a computer, they’re getting exercise through something like the video game Dance Dance Revolution or Wii Fit. We’re investing more than $31 million over the next three years to gather evidence about what can help kids get more active.
The Quarterly: Tell us about your work promoting physical activity in schools.
Risa Lavizzo-Mourey: When you think about how much time kids spend at school, you can see that physical education could have a big impact, particularly if kids don’t have recreational facilities closer to home. What we do know for sure is that physical education is the only way to influence the physical activity of all kids every school day, so we support efforts like the Alliance for a Healthier Generation’s Healthy Schools Program, which aims to change nutrition and physical-activity polices in schools.
When I was young, most kids walked to school, and you almost always had physical education and recess when you got there. Now studies from the Federal Highway Administration and the Bureau of Transportation tell us that most kids—even those who live within a mile of their school—are driven or bused. Only one state requires daily physical education from kindergarten through 12th grade, and that’s Illinois. We think physical education should be mandatory everywhere every day. Kids were meant to move.
Another thing: lots of kids don’t have recess in school any more. One of our grantees, the Sports for Kids Foundation, has shown that recess is probably the single biggest opportunity to give children more physical activity during the day. Sports for Kids brings recess back to schools, and in a constructive, organized way, not the chaotic, fight-filled recess we’re used to hearing about. At a school I visited in a poor part of Baltimore, the principal had to find $25,000 to get this program into her school. She told me the money was worthwhile because when kids don’t get physical activity, they’re bouncing off the walls—they fight and they get suspended.
There are inexpensive ways to make the right changes happen. We see all kinds of innovation and ingenuity on the part of principals, teachers, school nurses, and parents to make schools healthier environments. We see inexpensive exercise equipment being brought into schools, teachers and other staff members leading walking clubs, parents rounding up five or six kids and walking them to school while teaching them how to cross streets safely.
Of course, physical activity isn’t important only for controlling obesity. We’ve also been funding efforts to determine the impact of exercise on a kid’s ability to learn. Older people definitely focus better when they get a little exercise, because they have better blood flow to the hippocampus. Studies show that kids also are more focused when they get exercise and that for them too there is a connection between physical activity and learning and achievement.
Of course, it’s a lot easier and quicker to eat 100 calories than to burn 100 calories. We’ve got to pay lots of attention to what people put into their bodies, because it’s so much more efficient to focus on that part of the equation. The reason for focusing on physical activity as well is that the health benefits are irrefutable. You can build habits early on that you keep for a lifetime.
The Quarterly: How do you evaluate your own strategy and the programs you support?
Risa Lavizzo-Mourey: We have a strong history of basing our strategy on evidence. Once we have a strategic objective, we develop indicators that serve as our guideposts for measuring change, and we hold ourselves accountable for meeting those indicators. Some of them are process indicators that help move us along a path, but as we get closer to realizing an objective, we focus on outcome indicators. If we’re not hitting them, we adjust our strategy or tactics.
The Quarterly: Very few foundations share data on their own performance. Do you?
Risa Lavizzo-Mourey: We commission reports evaluating our progress, both midterm and at the close of grant programs, and we post the reports on our Web site. In addition, we examine clusters of grants retrospectively by commissioning an outside writer, often an investigative journalist, who digs into the results of the cluster and reports on how well we’ve done. We publish many of these reports in print and on our Web site, rwjf.org, in an annual series called the RWJF Anthology. Most recently, we’ve added another way of measuring performance: asking an independent evaluator to look at the entire body of grants over 20 years for improving end-of-life care—nearly $200 million in grants over that time. We’ll be publishing the results of that assessment soon.
The Quarterly: How do you ensure honest input?
Risa Lavizzo-Mourey: In the reports I mentioned, having an independent evaluator know that we are going to give him or her free rein to be critical is key. In addition, when we develop strategy, I sometimes ask people from outside who are familiar with the foundation to send me a brief, anonymous recommendation—something I can read in a minute. Some of them sign it. Also, we periodically ask people who are familiar with the foundation, but aren’t funded by us, to comment on what we’re doing, and we have learned mightily from that. For example, we’ve learned that we need to be clearer about our objectives and the reasons for changing them and for making midcourse corrections.
I also listen to what our staff members say, because we’re a pretty reflective and self-critical bunch. I have a “Dear Risa” mailbox on our intranet site, where people can send an anonymous e-mail telling me what troubles them and, sometimes, what they like about what we’re doing. And every year, we survey our grantees and benchmark our results, using data from the Center for Effective Philanthropy, against how other foundations are doing. So we use a variety of mechanisms—some quantitative, some qualitative—to take the pulse of our work.
The Quarterly: What are you hoping to do better in the next couple of years?
Risa Lavizzo-Mourey: I want to make our metrics much more tightly aligned with our strategy, so that we can see, earlier in the game, whether we’re on the right trajectory. Also, we need to do more for less. The problems we want to help solve will get bigger, and we’re not sure our resources will.