









































October 2020 Volume  5 Issue 1

PROMOTING HEALTH EQUITY THROUGH THE BUILT 
ENVIRONMENT IN DULUTH, MN: EXTERNAL RESOURCES 

AND LOCAL EVOLUTION TOWARD HEALTH IN ALL POLICIES

Katrina Smith Korfmacher, PhD

Abstract: 

Communities, professionals, and researchers recognize that environmental factors contribute 
to the health inequities experienced by vulnerable populations in the U.S.  These environmental 
health injustices persist despite well-developed systems for both public health and environmental 
protection. The root cause of these issues is often “siloed” decision-making by separate health and 
environmental institutions. Health Impact Assessment (HIA) can be an important tool for bridging 
these silos to promote health equity at the local level. This raises the question: how can external 
resources best support local initiatives? This paper examines the interaction between national, state, 
and non-governmental efforts to promote HIA and local actions to promote healthy and equitable 
built environment in Duluth, MN. A wide range of local activities in Duluth aimed to alter the long term 
trends, decision processes, and institutions shaping its built environment. These included integrating 
health in brownfield redevelopment, local land use plans, food access, and transportation decisions. 
Technical and financial support from external groups played a key role in developing the community’s 
capacity to promote health equity across public, private, and non-profit organizations. These multiple 
streams of action culminated in the mayor’s declaration in 2016 that health and fairness would be 
adopted as key goals of the city’s new Comprehensive Plan. How did such innovative efforts thrive 
in a small, post-industrial city with limited resources?  Duluth’s experiences provide insight into how 
external governmental, funding, academic, and non-profit entities can more effectively, efficiently, 
and equitably support the evolution of local initiatives.

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Introduction
In her first State of the City address in March 
2016, Mayor Emily Larson referenced the 11 
year life expectancy disparity between adjacent 
zip codes in Duluth, and commented that “our 
right to a good and healthy life should not be 
determined by our zip code, or our income, 
education, race, gender or religion…My vision 
is of a healthy – prosperous – sustainable – fair 
– and inclusive community” (Larson, 2016). 
This small, post-industrial city may seem an 
improbable place for such a strong vision for 
health equity to be expressed by a city leader. 
This statement built on over ten years of local 
work promoting the importance of a healthy 
and equitable built environment. This work 
evolved through a complex interplay of external 
resources and local activities that developed 
capacity in HIA. Duluth’s efforts to promote 
health equity involved improving access to 
transportation, healthy food and opportunities 
for physical activity. The literature is rich 
with examples of communities where initial 
efforts at Health Impact Assessment evolved 
into broader adoption of Health in All Policies 
(Collins & Kaplan, 2009) (Armijo et al., 2019; 
Calloway, 2019; Rudolph et al., 2013). This 
raises the question of whether and how external 
institutions (funding, training, etc.) can support 
such local evolution. This paper explores 
the role of external resources, relationships, 
and initiatives that helped to grow Duluth’s 
local initiatives over more than ten years. The 
paper concludes with lessons learned about 
the potential impact of external support and 
recommendations for future efforts to support 
evolution towards Health in All Policies in other 
communities.

The Setting: Duluth, Minnesota
Duluth, Minnesota is a small city (86,000 
residents) on the western tip of Lake 
Superior. Duluth emerged in the 1800’s 
as a transportation hub for the Midwest’s 

agricultural and industrial products. Later, it 
became an important industrial center focused 
around steel and other heavy industries. With 
the decline of the steel industry and growth 
of alternate transportation routes, Duluth’s 
economy shrank, resulting in a 30% population 
loss between 1960 to 1980. As of 1983, Duluth 
had an unemployment rate of 16%, more than 
double the statewide rate and among the 
highest in the country (Bunnell, 2002).

Because of this industrial history, the City has 
a large number of brownfields, sites of known 
or potential environmental contamination (U.S. 
Environmental Protection Agency, 2020). Two 
former industrial sites totaling around 800 
acres together comprise the largest Superfund 
site in Minnesota. The western part of the city 
is located on a narrow strip of flat land between 
the lake and a steep escarpment, limiting 
land available for new development. Duluth’s 
economy has expanded in recent years, with 
several new businesses locating on former 
industrial sites. Duluth has become a regional 
center for healthcare and a gateway to outdoor 
recreation in the region. The city is renowned for 
its extensive network of bike and hiking trails, 
contributing to its being named the “Best Place 
to Live in the U.S.” by Outside Magazine in 2014 
(Pearson, 2014).

Despite the city’s growing prosperity, significant 
disparities exist in economic and health status, 
particularly for racial and ethnic minorities. 
Recognizing this, community groups, public 
health professionals, and city staff have 
engaged in a wide range of “policy, systems, 
and environmental” (PSE) change efforts to 
promote health equity (Honeycutt et al., 2015).  
This “Healthy Duluth” work has included several 
Health Impact Assessments, brownfields 
redevelopment, transportation planning, and 
a comprehensive plan update. Taken together, 



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these efforts aimed to reduce health disparities 
by focusing on the built environment in low-
income neighborhoods. Table 1 traces how 
external resources fostered and enhanced local 
health equity initiatives in Duluth between 2005 
and 2017. Although the city has not formally 
adopted Health in All Policies, health equity is 
now infused in many local decision processes.

Initiation of Healthy Duluth Efforts
Building on its reputation as an outdoor 
activity and recreation-focused community, 
the City of Duluth applied for and was granted 
designation as a Governor’s Fit City in 2007 
(Duluth to be named,” 2007). Fit City was a 
voluntary designation established under the 
Minnesota Department of Health (MDH) in 2005 
to encourage and highlight cities’ commitment 
to supporting healthy living (New Ulm, 2006). 
Through Fit City, city staff convened a group of 
community stakeholders to promote physical 
activity opportunities in Duluth. 

This city-led effort soon spun off into a 
community organization also called Fit City. Fit 
City members attended a CDC conference on 
“Community Approaches to Obesity Prevention” 
where they learned about other communities’ 
efforts to pursue health equity through work to 
change “policies, systems, and environments” 
(PSE). Convinced of this approach, Fit City 
members decided to focus on policy work, 
which transitioned into the Healthy Duluth Area 
Coalition (HDAC). HDAC aimed to bring together 
multiple groups that were working to promote 
health and equity in the community. According 
to its website, “The Healthy Duluth Area 
Coalition is committed to changing the policies, 
systems and environments of our city to 
encourage active living and affect how residents 
access healthy foods. We bring together the 
people who can facilitate the greatest change, 
who advocate for wellness, and who strive for 
health equity. We are here to help everyone be 

well by supporting active living and healthy 
eating, and by working to make the healthy 
choice the default choice.” HDAC’s efforts were 
organized into five objectives, the most active 
of which were to promote “A Comprehensively 
Healthy Local Food Environment and 
a “Balanced and Diverse Community 
Transportation System” (Healthy Duluth Area 
Coalition, 2018). HDAC has been supported 
by a variety of local and external funders over 
time, including grants from foundations and 
state agencies. For example, the Center for 
Prevention at Blue Cross Blue Shield Minnesota 
provided several grants to the Healthy Duluth 
Area Coalition, including support for the Fair 
Food Access campaign’s work in Lincoln Park 
in 2014 and funding to establish a Health Equity 
Collaborative in 2016 (Center for Prevention at 
Blue Cross Blue Shield of Minnesota, 2020). 

The HDAC partners varied over time depending 
on current funding and projects.  HDAC 
leveraged the knowledge and contributions 
of multiple partners whose work aligned with 
these initiatives, but whose organizations had 
limited ability – whether due to staff, financial, 
legal, or institutional constraints - to directly 
advocate for policy change. In addition to 
HDAC’s activities and convening functions, 
many individual organizations in Duluth engaged 
in related activities to promote health equity 
through changes in the built environment. Taken 
together, these activities are referred to here as 
“Healthy Duluth” efforts. 

The St. Louis County Health Department was a 
key player in many of these efforts.  In 2008, the 
Center for Prevention at Blue Cross Blue Shield 
of Minnesota distributed copies of the video 
“Unnatural Causes” to local health departments 
across the state. “Unnatural Causes” showcases 
how the environment significantly impacts 
disparities in public health (Unnatural Causes, 
2008). Health department staff who viewed 



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this video connected its message with health 
disparities they observed in Duluth.  As one 
health department staff member noted, “I don’t 
think the impact that Unnatural Causes had 
on us can be overstated” (J. Gangl, personal 
communication, March 17, 2016).  By sharing 
this video of systems change efforts in other 
communities, the Center for Prevention 
played a role in mobilizing health department 
engagement in health equity.

The growing focus of the local health 
department on changing systems to promote 
health equity was strengthened and sustained 
by Minnesota’s State Health Improvement 
Program (SHIP, renamed the State Health 
Improvement Partnership in 2016). SHIP was a 
cornerstone of Minnesota’s 2008 health reform 
law and funded local health departments to 
conduct community-based activities aimed 
at reducing risk factors for chronic disease. 
The program explicitly encouraged health 
departments to engage in “policy, systems, and 
environment” (PSE) change, and later SHIP 
grant guidelines added a health equity focus. 
With SHIP support, St. Louis County health 
department staff played a significant role in 
building coalitions, sustaining local partnerships, 
and participating in planning efforts. For 
example, health department staff supported 
convening the Safe and Walkable Hillside 
Coalition, which contributed to community 
engagement in the first Health Impact 
Assessment in Duluth (6th Avenue HIA).

Health Impact Assessment in Duluth
Another important external contribution to 
the Healthy Duluth work was MDH support for 
three Health Impact Assessments (HIAs). As 
described below, these HIAs built community 
partners’ capacity and complemented HDAC’s 
ongoing efforts to promote health equity 
through shaping decisions about Duluth’s built 
environment.  

Health Impact Assessment (HIA) is a voluntary 
approach to identifying the potential health 
impacts of non-health decisions (Bhatia, 2011; 
National Research Council Committee on Health 
Impact Assessment, 2011; Ricklin et al., 2016; 
Rhodus, et al., 2013). HIA has been promoted 
as a way to build consensus, engage affected 
communities, and develop recommendations 
that improve health equity. Starting around 
2008, the Minnesota Department of Health 
made a significant and sustained commitment 
to supporting HIA as a tool to promote health 
equity. MDH obtained grants from federal 
agencies and foundations to help build capacity 
for HIA throughout the state (as of 2018, the 
program had identified 34 HIAs conducted in 
Minnesota (Minnesota Department of Health, 
2020)). As part of these efforts, Duluth received 
technical support and funding for three HIAs 
between 2010 and 2014. These opportunities 
allowed local stakeholders to learn about 
HIA, use health data to analyze how built 
environment decisions affect health disparities, 
and gather community input on ways to improve 
environmental health equity. Although the HIAs 
were led by MDH, the experience of working 
together on these HIAs built local stakeholders’ 
capacity and provided data, analyses, and 
recommendations that informed future work.

6th Avenue Redesign HIA, January-June 2011
The first HIA in Duluth was supported through 
a MDH grant from the Association of State and 
Territorial Health Officials (ASTHO) to conduct 
three HIAs in the state. The HIA examined 
an ongoing effort to redesign 6th Avenue, a 
busy road that bisects the low-income Hillside 
neighborhood in downtown Duluth (St. Louis 
County Health and Human Services, 2011). 
6th Avenue posed a major challenge to the 
walkability of the neighborhood. Consolidation 
of two neighborhood schools in 2011 required 
many children to cross 6th Avenue to get to 
their new school. Due to the dangerous traffic 



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on 6th Avenue, many of these children were 
bussed to school, despite living only a few 
blocks away.  The HIA assessed the health 
impacts of the proposed 6th Avenue redesign 
with respect to accessibility, safety, physical 
activity, and livability, with a focus on vulnerable 
populations including children, older and 
disabled adults, and low-income residents. The 
HIA recommended increasing the number of 
bus stops, adding a traffic signal, enhancing 
crosswalks, creating a designated bike lane, 
and improving snow clearing (Minnesota 
Department of Health Climate & Health 
Program, 2014). The HIA’s public engagement 
efforts built local stakeholders’ understanding of 
how transportation planning affects community 
health. 

Gary-New Duluth Small Area Plan Health 
Impact Assessment, June 2013 – June 2014
In 2013, Duluth conducted a second HIA on an 
ongoing Small Area Planning (SAP) process 
with MDH support through a grant from the 
Health Impact Project, a partnership of Pew 
Charitable Trusts and the Robert Wood Johnson 
Foundation (Korfmacher, 2019; Korfmacher 
2020). The Gary-New Duluth neighborhood, 
located around 10 miles west of downtown, 
was a disinvested area that had originally been 
developed  to house workers at the nearby 
U.S. Steel Duluth Works plant (City of Duluth, 
2006; Minnesota Department of Health Climate 
& Health Program, 2014). The neighborhood 
lost 50% of its population between 1950 and 
1980 (Bunnell, 2002). The HIA team conducted 
several public meetings, focus groups, and a 
community survey to solicit feedback from the 
public. The survey identified “jobs and economic 
development, crime prevention, and access 
to goods and services” as top community 
concerns. 

The HIA identified “children, older adults, low-
income people, people with lower educational 

attainment, disabled people, and people with 
pre-existing health conditions” as potentially 
vulnerable community members, and focused 
its analysis on how the SAP might affect 
the health of these groups in particular. 
The HIA provided for significant additional 
community engagement in the SAP process. 
For example, residents suggested incorporating 
a “community events board” into the design 
of new neighborhood entrance monuments 
recommended in the SAP (Minnesota 
Department of Health Climate & Health 
Program, 2014, p. 51). 

In addition to increasing community 
engagement, this HIA built diverse professionals’ 
understanding of HIA. The HIA’s Technical 
Advisory Committee (TAC) included community 
groups and representatives from the county 
health department, Arrowhead Area Agency 
on Aging, the city Department of Parks and 
Recreation, regional transportation planners, 
and the local hospital. Because several 
members of the HIA TAC also served on the SAP 
Steering Committee, they were able to enhance 
additional stakeholders’ understanding of how 
the plan’s recommendations could promote 
health equity.

Lincoln Park HIA, January 2014 – September 
2015
Whereas the Gary-New Duluth HIA was 
conducted parallel to the Small Area Planning 
process, Duluth’s third HIA (also supported 
by the MDH Health Impact Project grant) 
integrated HIA fully into the planning process. 
This reflected a growing appreciation of 
HIA among community leaders. This third 
HIA addressed Lincoln Park, a low-income 
neighborhood just to the west of downtown 
Duluth. It is a dense urban neighborhood with 
some of the highest racial and ethnic diversity 
in the city (Minnesota Department of Health 
Climate & Health Program & Division, 2015). 



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The 2011 St. Louis County Health Status Report 
identified Lincoln Park area as having the lowest 
life expectancy in the city (Gilley, et al. 2011).  
Non-profit and government agencies had been 
actively pursuing community revitalization of 
the Lincoln Park neighborhood for many years. 
One goal of the SAP process was to provide 
steps the City could take to build on these 
efforts. 

In 2011, a study by University of Minnesota-
Duluth and UMN Extension had documented 
residents’ food access challenges, including 
distance to full service grocery stores (10 
minutes by car, 30 minutes by bus) and higher 
prices for food at local convenience stores (Pine 
& Bennett, 2011). Since 28% of households 
in the study area did not have a car, the study 
concluded that 10-15% of residents experienced 
significant barriers to accessing healthy food. 
The HIA made several recommendations to 
increase food access for residents. The HIA’s 
housing recommendations focused on the 
potential to increase social cohesion through 
more home ownership, reducing housing 
costs so people had more money to purchase 
healthy food, and improvements in housing 
quality with stronger enforcement of housing 
codes.  Additional recommendations related 
to increasing safety, community building, 
and social cohesion, and creating a positive 
sense of place. This HIA process strengthened 
connections between local stakeholders around 
health equity and enhanced their focus on food 
access.

Summary: HIA in Duluth
These three HIAs together had a significant 
impact on integrating health in public decisions 
in Duluth, including:

1. Providing an evidence base and data that 
could be easily referenced to inform future 
implementation decisions, grant proposals, 
and evaluation efforts.

2. Increasing public engagement, which 
enhanced community involvement in 
future efforts.

3. Building the capacity of local stakeholders 
to do HIA, strengthening relationships 
between professionals in diverse 
organizations, and increasing leaders’ 
commitment to promoting health equity.

However, without external funding, the city 
could not provide the resources needed to 
complete additional HIAs on a regular basis.  
One more HIA was conducted in Duluth with 
support from the U.S. EPA on waterfront habitat 
restoration (Williams, et al. 2020)). Nonetheless, 
the experience of doing these HIAs motivated 
stakeholders to find other ways to integrate 
health into ongoing local decisions. The next 
sections describe additional approaches 
through which stakeholders in Duluth have 
considered health when making decisions that 
affect the built environment.

Integrating Public Health in Brownfields 
Redevelopment
In addition to Health Impact Assessments, 
efforts in many other sectors, agencies, and 
groups in Duluth aimed to promote a healthier, 
more equitable built environment. The 
Duluth Business and Economic Development 
Department was in an important early 
contributor to promoting health equity 
through brownfield redevelopment. State 
and federal brownfields programs have 
increasingly emphasized the broad public 
health improvements that may be gained 
by constructive reuse of contaminated land 
(U.S. Environmental Protection Agency, 
2018). Starting around 2008, city staff noted 
that the U.S. EPA’s requests for brownfields 
redevelopment proposals prioritized projects 
that would improve public health outcomes. 
This guidance from U.S. EPA encouraged 
local officials to identify health-promoting 



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redevelopment projects. For example, with 
the Business and Economic Development 
Department’s leadership, the 10.2 acre Clyde 
Iron Works brownfield site (“Clyde Park”) 
was developed into a multi-sport complex 
with a restaurant and event venue. Clyde 
Park anchored the redevelopment of the 
distressed Lincoln Park neighborhood as a hub 
for recreational and sports activities. With a 
documented 400 blighted and/or brownfield 
sites in Lincoln Park alone, the ongoing focus 
on promoting public health through brownfield 
redevelopment is expected to have a significant 
impact on shaping this neighborhood’s future.

Duluth’s groundbreaking work on linking 
brownfields with health, in turn, leveraged 
additional outside resources.  For example, staff 
at the Agency for Toxic Substances and Disease 
Registry (ATSDR) Brownfield/Land Reuse 
Initiative heard about Duluth’s ongoing efforts 
and in 2010 invited the City to partner with them 
on a proposal to the Great Lakes Restoration 
Initiative to assess the public health benefits of 
restoring the St. Louis River and Lake Superior 
waterfront. Although the project was not funded, 
it resulted in a stakeholder workshop in July 
2012 to identify community health indicators 
for successful restoration.  This workshop 
strengthened the brownfield program staff’s 
connections with the ongoing Healthy Duluth 
efforts.

Another example of leveraging outside 
resources came from Duluth’s Business 
Resource Manager Heidi Timm-Bijold’s ongoing 
relationship with the statewide nonprofit 
Minnesota Brownfields. In 2012, Minnesota 
Brownfields partnered with Duluth to develop 
and pilot their Health Indicator Tool, which 
bolstered the city’s ability to identify health 
benefits of redevelopment projects. The Health 
Indicator Tool has since been disseminated as a 
statewide resource for documenting the public 

health impacts of brownfields redevelopment 
(Minnesota Brownfields, 2018). 

The City of Duluth continued to integrate 
health assessments in numerous brownfield 
plans and related infrastructure projects, 
such as expansion of bike paths in low income 
neighborhoods. For example, in 2014 Duluth 
received a U.S. EPA Area-wide Planning grant for 
the Irving Fairmount Brownfields Revitalization 
Plan that included health department staff on 
the team and emphasized health equity as a 
goal for redevelopment. As Duluth Business 
Resource Manager Heidi Timm-Bijold said, 

“We were not intentional about the health 
conversation (before), but now …we are very 
clear about the conversation as it relates 
to food, safety, connectivity – it is just part 
of the discussion. So as we move forward… 
it is becoming normalized to think about 
health as part of the process” (H. Timm-
Bijold, personal communication, March 17, 
2016).

Transportation Equity
As noted above, Duluth’s initial efforts 
focused around promoting healthy lifestyles 
by providing trails and other resources for 
physical activity. Over time, the Healthy Duluth 
efforts came to reframe their efforts in terms 
of “transportation equity” – shaping the local 
transportation system so all Duluth residents 
could access health-supportive resources, 
including opportunities for active and public 
transportation. As St. Louis County health 
department educator Josh Gorham stated, 

Not only is transportation about health – 
active living - it’s about getting to healthy 
food, healthcare, social activities, and much 
more… As socio-economic disparities 
became more of a priority in Public Health 
efforts in Duluth, we needed to reframe our 



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approach. We were no longer just talking 
about active transportation; we were talking 
about transportation equity” (J. Gorham, 
personal communication, March 18, 2016).  

Although individual groups still relied on outside 
resources to support staff and specific projects, 
these efforts were sustained by the integration 
of transportation equity goals into existing 
organizations’ agendas and activities.

For example, the HDAC organized a series of 
activities to highlight the potential for promoting 
health equity in the built environment. Some 
of these events were inspired by similar efforts 
in other cities, and supported by local financial 
and staff resources. The HDAC coordinates 
an annual “Bike/Bus/Walk” month, including 
a “bike with the mayor” event (French, 2014). 
“Parklets” have been created by businesses 
temporarily taking over parking spaces as public 
seating and recreation spots (French, 2015).  
These and other events helped engage the 
public and raise the community’s awareness of 
Healthy Duluth’s efforts. 

In addition to these “pop up” events and 
projects, Healthy Duluth stakeholders engaged 
in ongoing efforts to promote transportation 
equity.  For example, the Lincoln Park HIA 
identified low-income residents’ challenges 
accessing healthy and affordable food.  In 
response, the city established a “Grocery 
Bus” specially equipped with racks for bags 
of food with scheduled runs from high need 
communities to the nearest full service grocery 
store (Lundy, 2016).

On an ongoing basis, Healthy Duluth Area 
Coalition members participated in public 
hearings and commented on street redesign 
programs, advocating successfully for traffic 
calming, bike lanes, and improved bus stops. 
In 2014, Duluth initiated a “St. Louis River 

Corridor Initiative” to expand trails, parks, 
and neighborhood improvements after the 
floods of 2012 (City of Duluth, 2016). In 2016, 
Mayor Larson affirmed her commitment to 
implementing the plan, prioritizing segments 
that serve lower income neighborhoods. 
Meanwhile, the Metropolitan Planning 
Organization’s Technical Advisory Committee 
appointed a public health representative to 
ensure that health equity was “at the table” for a 
wide range of regional transportation decisions.  
These and other ongoing transportation equity 
efforts reflected stakeholders’ success in 
building community understanding and support 
for improving the built environment into ongoing 
local decisions in a wide range of sectors. 
Having health equity-oriented stakeholders 
involved helped counter concerns about costs 
and negative impacts on private businesses 
(e.g. loss of public parking, added construction 
costs).

Toward Health in All Policies?
These examples show how Healthy Duluth 
efforts increased consideration of health 
equity in a wide range of decisions. These 
initiatives started with voluntary efforts to 
encourage healthier lifestyles. After learning 
about the power of other communities’ efforts 
to promote systems change, Healthy Duluth’s 
efforts began to focus on policies, plans, and 
programs that shape the built environment.  
Funding and directives from the Minnesota 
Department of Health through the local health 
department supported local efforts to promote 
health equity, as did funding for three HIA’s 
over a period of 4 years. At the same time, 
with encouragement from the U.S. EPA, the 
City of Duluth’s brownfields redevelopment 
programs increasingly focused on public health 
outcomes. The robust network of community 
and government groups fostered by these 
activities increasingly integrated health equity 
considerations throughout their work, notably in 
the area of transportation planning.



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Despite this highly evolved ecosystem for 
considering health in a wide range of decisions, 
these efforts remain decentralized and 
vulnerable to loss of staff and technical capacity 
developed through past experience. The City 
of Duluth considered adopting a Health in All 
Policies resolution, but it did not decide to do so. 
Stakeholders reported concerns that adopting 

an HiAP resolution might result in a “checklist” 
mentality, rather than meaningful consideration 
of systems changes. However, these ideas have 
clearly been taken up by the city leadership, 
as evidenced by Mayor Larson’s declaration 
that health and fairness would be key goals in 
Duluth’s 2016 comprehensive planning process 
(Larson, 2016) . 



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Date External Resource Local Initiative

2005
Minnesota Governor Pawlenty establishes 
voluntary “Fit City” program 

Duluth recognized as a “Governor’s Fit City, 
forms advisory committee

2007

2008

Blue Cross Blue Shield’s Center for 
Prevention distributes copies of 
Unnatural Causes video to local health 
departments

Fit City Duluth obtains non-profit status as an 
organization

St. Louis County health department staff view 
Unnatural Causes video

Fit City members attend CDC conference

2009

CDC hosts “Community Approaches to 
Obesity Prevention” conference

Fit City Duluth forms 10-person team to 
attend CDC conference 

St. Louis County health dept. initiates of Safe 
and Walkable Hillside Coalition

2010 Health Duluth Area Coalition begins meeting

2011

MDH supports first HIA in Duluth 
(redesign of 6th Avenue) 

St. Louis County Health Status report issued; 
credits “Unnatural Causes” 

Stakeholders participate in HIA

2013
MDH supports second HIA (Gary-New 
Duluth Small Area Plan)

Stakeholders participate in HIA to support 
Small Area Plan for Gary-New Duluth

2014

MDH supports third HIA (Lincoln Park 
Small Area Plan)

U.S. EPA awards brownfield planning 
grant for Irving Fairmount 

BCBS Center for Prevention grant to 
HDAC for Fair Food Access work

HIA integrated into Small Area Plan process 
for Lincoln Park 

City pilots Brownfields Health Indicator Tool 
in Lincoln Park

St. Louis River Corridor Initiative begins
HDAC engages Lincoln Park residents in Fair 
Food Access work 

2015 “Grocery Bus” begins running

2016
BCBS Center for Prevention grant to 
HDAC for health equity work

Mayor sets “health and fairness” as goals of 
city’s Comprehensive Plan
HDAC initiates Health Equity Collaborative

2000-2017
U.S. EPA emphasizes public health as goal 
of brownfields redevelopment

City receives over $17 million in brownfield 
grants; leverages over $100 million

Table 1. External resources and evolution of Duluth’s local health equity initiatives*

*This table highlights several types of external resources (financial, technical, or human) supporting health 
equity initiatives in Duluth, but is not comprehensive.



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11

What Can We Learn From Duluth About 
Supporting Evolution of HiAP in Other 
Communities?

“There has been a momentous but 
intentional aligning of the stars around this 
work” (Heidi Timm-Bijold, City of Duluth 
Business Resource Manager, personal 
communication, 2016)

The experience of Duluth, MN offers insight into 
how one small city embraced and implemented 
the idea of enhancing health equity in the 
built environment through policy change. 
By creating informal yet robust networks for 
collaboration, stakeholders in Duluth were able 
to leverage varied community, local, state, and 
national resources to promote a healthier, more 
equitable built environment through a wide 
range of systems and policy changes. Duluth’s 
experience endorses the idea that local cross-
section collaboration around HIA can evolve into 
pervasive and powerful changes in systems to 
promote health equity.

At the same time, the Healthy Duluth efforts 
also may be viewed as a case of how national, 
state, and non-governmental efforts to promote 
community innovation can make an impact 
at the local level. Duluth’s efforts benefitted 
from staff support, funding, and technical 
resources from external private, non-profit, and 
government groups. Indeed, several national 
programs that supported particular initiatives 
point to Duluth as a successful model of how 
their ideas, programs, and resources that can be 
replicated in other communities.

Looking closely at Duluth’s efforts over time 
shows that the whole story is more complex. 
There was an ongoing exchange of ideas, 
initiatives, and opportunities between local 
stakeholders and external resources. Local 
stakeholders took advantage of state and 

national programs, expertise, and funding to 
build a strong network of diverse organizations 
working to promote health equity through 
changes in the built environment. Stakeholders 
in Duluth attributed the sustained growth of 
these health equity efforts to the community’s 
size, progressive nature, and commitment to 
collaboration. These characteristics allowed 
them to develop relationships across and 
collaborate between organizations with minimal 
formal structures. These relationships also in 
turn helped them identify, successfully access, 
and sustain resources from external agencies. 
These outside resources were particularly 
helpful during the initial development of Duluth’s 
initiatives.  However, continued support – 
for example, through the MDH State Health 
Improvement Program, Center for Prevention 
funding of health equity projects, and federal 
agencies’ (particularly U.S. EPA and Department 
of Transportation) integration of health equity 
goals in their funding, policies, and programs – 
has been essential to sustaining these efforts. 

This version of the story suggests that Duluth’s 
evolution toward Health in All Policies may not 
be replicable in other communities that lack the 
ability to initially access resources, collaborate, 
and build local capacity. However, it does 
suggest strategies for regional and national 
actors to make such local initiatives possible in a 
broader range of communities: 

• Provide opportunities for locals to learn. 
Duluth stakeholders reported numerous 
examples of learning from others’ 
initiatives and ideas about how to promote 
health equity.  Even the simple act of 
distributing the Unnatural Causes video 
affected locals’ thinking. The opportunity 
to convene a team and travel to the 
Building Healthy Communities conference 
to learn from national – and particularly 
other local – leaders was even more 



Promoting Health Equity Through the Built Environment in MN Korfmacher

12

impactful. Bringing such opportunities to 
communities that are not actively seeking 
HiAP assistance may help seed new local 
initiatives.

• Make collaboration an expectation. 
By its nature, HiAP requires cross-
sector collaboration. However, many 
organizations inadvertently discourage 
collaboration, because it can take time 
away from achieving direct institutional or 
professional goals. Building collaboration 
into job descriptions, performance 
reviews, and reporting can counteract 
these barriers.  External institutions can 
encourage this. For example, the State 
Health Improvement Program’s guidance 
to local health departments to foster local 
partnerships had a tremendous impact on 
the human resources available to health 
equity efforts in Duluth.

• Build health equity into review criteria 
for funding. An increasing number of 
funders, including both foundations and 
government agencies (e.g. the U.S. EPA 
and U.S. Department of Transportation) 
include public health promotion among 
the criteria for evaluating proposals 
for non-health projects. These cues 
were acted upon by Duluth’s brownfield 
redevelopment and transportation 
agencies, significantly advancing the local 
focus on health in externally funded plans 
and projects. Providing incentives and 
guidance on how to address health in a 
non-health funding opportunities could 
significantly boost local efforts.

• Support sustained convening. It is 
particularly difficult for local groups to 
sustain funding for convening collaborative 
efforts. Collaboration by definition takes 
a long time, has uncertain outcomes, and 

often results in unexpected new directions. 
As the Duluth case reaffirms, sustained 
convening over many years is necessary 
to build local capacity, leverage additional 
funding, bring in new partners, and adapt 
action agendas over time. Modest long-
term support for local conveners can 
have a multiplier effect on local initiatives’ 
evolution toward HiAP.

• Be patient. Collaboration takes a long 
time, but making impacts on local decision 
processes takes longer. Evidence of policy, 
environmental, or health outcomes – 
takes longer still. As well, local systems 
changes can seldom be attributed to a 
single effort. Duluth’s experience shows 
how stakeholders can “help the stars align” 
toward health equity-promoting decisions, 
but that the process may be indirect, 
diffuse, and non-continuous. Funders 
should be mindful of this timeline as they 
set expectations for outcomes, encourage 
documentation of process changes, 
and integrate intermediate metrics like 
increased capacity into evaluations.

With increasing recognition that environmental 
factors contribute to the health inequities 
experienced by vulnerable populations, moving 
toward Health in All Policies at the local level is 
critical. Strategically deployed human, financial, 
and technical resources from external sources 
can fertilize local cross-sector collaborations 
and build local capacity for HiAP. Duluth’s 
experience shows that such local initiatives 
have tremendous potential to bridge the silos 
between environmental and public health and 
address the root causes of environmental 
injustices.



Promoting Health Equity Through the Built Environment in MN Korfmacher

13

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epacomptox.11740134.v1

CORRESPONDING AUTHOR
Katrina Smith Korfmacher, PhD
Department of Environmental Medicine
University of Rochester 
Box EHSC
601 Elmwood Avenue
Rochester, NY 14642
Katrina_korfmacher@urmc.rochester.edu

CHIA Staff:

Editor-in-Chief 
Cynthia Stone, DrPH, RN, Professor, Richard M. Fairbanks School of Public Health, Indiana 
University-Purdue University Indianapolis

Journal Manager 
Angela Evertsen, BA, Richard M. Fairbanks School of Public Health, Indiana University-Purdue 
University Indianapolis

Chronicles of Health Impact Assessment Vol. 5 Issue 1 (2020) DOI: 10.18060/24034
© 2020 Author(s): Korfmacher, K.
       This work is licensed under a Creative Commons Attribution 4.0 International License

Acknowledgement: 
This paper builds on a case study included in (Korfmacher, 2019). This work was supported in part by the 
National Institute of Environmental Health Sciences through grant P30 ES001247. Research protocols 
were deemed exempt by the University of Rochester’s Research Subjects Review Board. The author greatly 
appreciates the information provided by numerous stakeholders involved in the Healthy Duluth efforts. The 
content of this manuscript is solely the responsibility of the author and does not necessarily represent the views 
of the National Institutes of Health, interviewees, or organizations featured in the case study.

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https://doi.org/10.23645/epacomptox.11740134.v1 
mailto:Katrina_korfmacher%40urmc.rochester.edu%20?subject=

