By summer 2000, High Point was more than 60 years old and in varying stages of deterioration. The original development consisted of 1,300 units. By the 1970s, 550 units had been demolished because of poor condition or because they were located in landslide-prone areas. By 2000, 716 of the remaining units were occupied by public housing residents; the rest housed social service providers (10). Community members reported an increase in gang activity and a crack cocaine epidemic. Asthma was so commonplace it was considered normal (13). Mold developed from leaking windows that had soaked the plasterboards over the course of years. Dust mites and roaches, common asthma triggers, were prevalent (14). Residents were aware of the problems but lacked the resources to make changes.

In the 1990s the Seattle Housing Authority began applying for funding from the Housing Opportunities for People Everywhere VI (HOPE VI) (10), a US Department of Housing and Urban Development (HUD) program to revitalize severely distressed public housing. In 2000 the Seattle Housing Authority was successful in obtaining $35 million for redevelopment of High Point under HOPE VI. The High Point coalition, a group of 30 to 40 High Point residents, was formed to advise the Seattle Housing Authority on the redevelopment of High Point. In addition to community members, other members of the coalition were the City of Seattle, the Seattle Health Department, Rotary Club, the High Point Community Council, Sunrise Heights Neighborhood Association, Morgan Community Association, the Delridge and Southwest District Council, High Point Neighbors, Highland Park Action Committee, West Seattle Chamber of Commerce, West Seattle Kiwanis, and the King County school district. Partners met monthly to determine project goals, design strategies, oversee implementation and evaluation methods, and review evaluation findings (10). High Point residents received stipends for participating and represented the community at meetings.

Seattle’s mayor and city council members were champions for the High Point redevelopment initiative. Community leaders in West Seattle circulated a petition and contacted civic and government officials to obtain their support for the project.

A local business partner provided tax credit syndicators. (A syndicator acquires low-income housing tax credits from affordable housing developers by investing equity in their housing developments in exchange for their tax credits.) Builders purchased property at High Point, which provided an additional $165 million to the project budget, bringing the total project budget to $200 million. Three consultants from University of Washington with expertise in social and built environments assisted the High Point coalition in structural design.

Seattle Housing Authority conducted a needs assessment in the summer of 2001. Of 609 households contacted, slightly more than a third (34%) said that people at High Point had problems with alcohol, and 41% said they thought that High Point residents had a problem with tobacco (10). Most residents (77%) said they thought that High Point was a safe place. Among minority residents who said that High Point was unsafe, the most frequently problems cited were drug dealing or drug use (80%), outsiders causing trouble (77%), gangs (74%), noise (61%), and car vandalism (60%) (10).

The High Point revitalization project was developed and implemented by a partnership of residents, community organizations, Seattle Housing Authority staff, public health practitioners, university faculty, and other public agencies. The coalition intentionally used community-based participatory approaches to guide its formation and operation (15). The values that guided its work included development of community capacity and equitable partnerships, linguistic and ethnic inclusivity, and community ownership. Equitable partnerships require sharing knowledge, power, and resources and providing reciprocal appreciation of what each group offers the partnership. For example, High Point’s Community Council identified asthma as a problem in the community and, in collaboration with the structural design experts, developed the residences as “Breathe Easy” units (http://www.seattlehousing.org/redevelopment/high-point/breathe-easy/).

The coalition supported the development of youth and adult community action teams. Each team consisted of 8 to 10 community members who convened to assess community conditions, discuss community concerns, build leadership and social capital, and develop activities to address changes to the built and social environment. More than 450 High Point residents and their West Seattle neighbors participated in a design survey and hands-on workshop that considered what the redeveloped High Point should look like. The Seattle Housing Authority Board of Commissioners approved the High Point redevelopment plan to serve residents whose incomes were below 30% of HUD’s area median income for King County.

The redevelopment of High Point occurred in 2 phases. Phase I began in 2003 and was completed in December 2007. Phase I consisted of construction of new public housing units. Phase II, infrastructure construction, began in 2006 and was completed in 2010 (Table 2). An integrated team of architects, interior designers, landscape architects, urban designers and planners, High Point residents, West Seattle community members, and Seattle Housing Authority staff worked together to create High Point’s redevelopment plan. The plan included 3 major components: quality design, a healthy environment, and an engaged community. The redevelopment plan created a safe, high-quality, and healthy residential environment with a range of housing types, each constructed to Built Green standards (http://www.epa.gov/greenbuilding/index.htm) and fully integrated with the surrounding community (13). New streets were realigned and reconnected with the West Seattle grid, and new neighborhood facilities and community services were operating at more inviting locations. The mix of housing types and resident income levels became more compatible with the greater neighborhood. Principles of New Urbanism guided the redevelopment process (16). New Urbanism is a revitalized urban design system that promotes social interaction, creates walkable spaces, and supports physical safety (eg, sidewalk-facing porches, windows facing streets to allow observation) (17,18).

Families began moving into rental and for-sale housing in Phase II of the neighborhood redevelopment, which began in 2006 and was completed in 2010. Seven hundred and sixteen units were ultimately replaced. Three hundred fifty of these are operated by Seattle Housing Authority and serve extremely low-income households. Private home development will continue until the nearly 1,700-unit capacity of the site is reached. In addition, Providence Health Systems built and leased Elizabeth House, a 75-unit supportive housing program for low-income elderly residents. The community engagement process created plans for a new, mixed-income community with health as its focus. High Point residents wanted the kind of healthy living conditions that wealthier neighborhoods usually take for granted.

The renovation of High Point resulted in a green and sustainable community (http://www.seattlehousing.org/redevelopment/high-point/photos/). The neighborhood has energy-efficient housing, a community clinic, a public library, rebuilt community-raised garden beds, a community center that offers child care and employment placement services, an assisted living facility (Elizabeth House), lush green parks, and walkable sidewalks that enhance social interaction and physical activity. The redevelopment incorporated many sustainable development principles. The site and rental housing are certified at the highest Built Green levels. Nearly all rental housing and homeowner units are Energy Star (http://www.energystar.gov/) rated. The site features porous sidewalks and parking areas and the only porous pavement street in Washington State. The site is situated on 120 acres with an engineered natural drainage system, which uses the ground to filter rainwater instead channeling water into a traditional conveyance system. The rebuilt homes have ventilation systems designed to bring in fresh air from the outside. According to Takaro et al, “Even small particles that might be bad for health, such as diesel particulate or any pollen in the case of an asthmatic, will be filtered out so the air in the home is actually healthier than the air outside” (14).

The High Point neighborhood redevelopment has been recognized with prestigious land use and development awards (Figure 1) and has gained national attention for its progressive approach to redevelopment (10). In 2004, High Point was awarded the Pacific Coast Builders Conference’s prestigious Gold Nugget Award for “Best Plans on the Boards.” More recently, the American Institute of Architects honored the project with a coveted “Show You’re Green” award, 1 of only 8 in the nation awarded for sustainable innovations and affordability. High Point is also featured in 2 PBS documentaries, Edens Lost and Found and Hidden Epidemics. The former profiles redevelopment activities in Seattle, Los Angeles, Chicago, and Philadelphia, and the latter examines socioeconomic and racial disparities in health.

By the end of the decade, High Point had nearly 1,700 new affordable and market-rate units. High Point includes housing units for residents with very low incomes (50% of area median income or below) and low incomes (80% of area median income or below) in addition to market-rate rental and for-sale housing. Most houses have private yards and porches. They sit on safe streets with controlled traffic and show great variety in architecture, character, and styles on each block. Proceeds from the land and home sales have helped fund low-income housing in the neighborhood and elsewhere. In addition, the land has been returned to the city’s property tax rolls, where it can generate revenues to help keep the neighborhood economically self-sufficient (10).

High Point’s redevelopment success resulted from close cooperation among planners, residents, and other community stakeholders. All landscaping is well maintained, housing is uniform in style, and an observer would not detect differences between properties owned and properties rented. However, shrubbery is sometimes not properly trimmed; if it grows to sufficient heights, criminal activity may increase. Thus, continuous accountability and oversight are crucial, and all residents are responsible for making recommendations as needed relating to strategic planning, property management, and ongoing evaluation of customer services and needs to ensure the stability of the social and built environment.

Social science research has demonstrated a strong link between the social and built environments and their roles in contributing to healthy outcomes. For example, Takaro et al (14) examined the asthma-related clinical outcomes of living in High Point’s Breathe Easy Homes. A quasi-experimental design was used to compare the asthma outcomes of 2 groups of low-income children and adolescents with asthma. One group of 34 participants who moved into a Breathe Easy Home was matched with a second group of 68 local residents who had received a previous asthma-control intervention. Both groups received in-home asthma education. The group in the Breathe Easy Homes had less asthma-related illness than the comparison group, but most differences in improvements were not significant. The researchers reported that “Breathe Easy Home residents’ asthma-symptom–free days increased from a mean of 8.6 per 2 weeks in their old home to 12.4 after 1 year in the Breathe Easy Home.” Furthermore, the proportion of Breathe Easy Home residents with an urgent asthma-related clinical visit in the previous 3 months decreased from 62% to 21%. Breathe Easy Home caretakers’ quality of life improved significantly. Residents in the Breathe Easy Homes group improved more than did those in the comparison group, but most differences in improvements were not significant. However, exposures to mold, rodents, and moisture were reduced significantly. Children and adolescents with asthma who moved into an asthma-friendly home experienced large decreases in asthma morbidity and trigger exposure.

As stated previously, High Point’s redevelopment plan was based on features of New Urbanism. These features, which contribute to a healthy community, include pedestrian friendly street designs (porches, hidden parking lots, wider sidewalks, tree-lined and slow-speed streets), a pond, multiple parks, walking trails, and separation of sidewalks from traffic by swales designed to manage storm water runoff and increase rainwater infiltration (14).

Using the Centers for Disease Control and Prevention’s (CDC’s) Guide to Community Preventive Services as a resource (19), community action teams developed multiple interventions to promote walking, including establishing walking groups, improving walking routes, providing information about walking options, and advocating for pedestrian safety. Self-reported walking increased among walking group participants from 65 to 108 minutes per day (13). The proportion of walking participants who reported being at least moderately active for at least 150 minutes per week increased from 62% to 81% in a 3-month period (13). General health improved, and walking group participants reported fewer days when physical health and mental health were not good.

The social environment affects physical activity through community safety, social support, and access to recreation and activity programs (13). Community action teams introduced the concept of walking groups as an effective social environmental strategy to promote physical activity. Teams modified the Walk Kit from the California Center for Physical Activity (http://www.caactivecommunities.org/resources/walk-kit/). High Point’s walkers were encouraged to meet Healthy People 2010 recommendations of at least 30 minutes of moderate physical activity (ie, 30 minutes of exercise or 10,000 walking steps) on 5 or more days per week (13). The walking groups met 5 times per week at weekday, evening, and weekend sessions. Walking appears to have collateral benefits. Participants reported walking more for errands, and social interactions with their neighbors increased. Walkers received T-shirts, pedometers, and prizes as incentives for meeting individual walking goals. The walking sessions promoted walking among other community members who saw their neighbors walking together in a group identified by the T-shirts or bright yellow rain ponchos they were wearing (Figure 2).