Collaboration meets opportunity: The Baltimore Food Policy Initiative

As cities across the nation seek to improve healthy food access, this participant observer case study highlights how one midsized city successfully developed a collaborative infrastructure to understand and address inequity in healthy food access. We trace the genesis and evolution of Baltimore’s Food Policy Task Force, the hiring of a food policy director, and the establishment of the Baltimore Food Policy Initiative, which is an intergovernmental partnership to increase access to healthy, affordable foods in urban food deserts. While some cities have approached food access issues through community coalitions pressuring city government or government edicts, Baltimore successfully identified its need, used available research to drive and inform action, established priorities, and acted expeditiously with a focus on sustainability. This case study is relevant and applicable for those seeking to influence change in local food policy in midsized urban settings.


Introduction
Since the 1980s, food system stakeholders across North America have formed entities to consolidate their efforts to increase the accessibility, consump-tion, and affordability of healthy and sustainable food (Clancy, Hammer, & Lippoldt, 2007;Scherb, Palmer, Frattarolli, & Pollack, 2012). They are motivated by a variety of issues -frustration with supermarket chains relocating to the suburbs, increasing rates of diet-related diseases, loss of farmland, and the poor quality of school mealsall of which reflect broader trends in the food system (Scherb et al., 2012). As a result, the nation has seen an increase in food policy groups, councils, or coalitions that are attempting to change food policy at the city, state, regional, and tribal level (Neuner, Kelly, & Raja, 2011;Scherb et al., 2012). These policy actions have the opportunity to create organization and institutional changes, potentially modeling effective solutions for the federal, state, and local level, and can also help nonprofits seeking to improve access to nutritious foods and address food insecurity in urban settings.
How and where food policy councils (FPCs) originate has a lasting influence on their evolution and potential impact. Some of the earliest iterations of FPCs were started in the 1980s by city governments to cope with hunger, nutrition, and food supply issues (Clancy et al., 2007). A recent report analyzing 13 U.S. municipal food policy directors (sought out through the Urban Sustainability Directors Network) found that over half of the cities' efforts originated from within local government through a centralized, top-down approach directed by the mayor, a city council member, or another civil servant (Hatfield, 2012). While that government model remains commonly used by various jurisdictions, nonprofits have also housed and supported FPC efforts, particularly when potential FPC members may not have a favorable attitude toward government (Schiff, 2008) or, as in the case of the Los Angeles FPC, the founders sought to establish a larger, more inclusive, and public-driven coalition of working groups (Hatfield, 2012). Oakland's FPC took a hybrid approach (Schiff, 2008) by having city government initiate a food system study, passing a city council recommendation to create an FPC, and then selecting a nonprofit to house the council (Harper, Shattuck, Holt-Giménez, Alkon, & Lambrick, 2009).
The experience of the City of Baltimore and its creation of the Baltimore Food Policy Initiative (BFPI) illustrate this hybrid model. BFPI was prompted by the coordination of work between several community stakeholders and city officials, but its formation, particularly its unique rendition of the role of the food policy director, was more centrally directed and ultimately centrally funded. The series of events that led to the BFPI's current status arose in an opportunistic manner that contributed to its noteworthy and prompt progress in consolidating various efforts to improve food access and food security. The City of Baltimore has been described as "one of the most progressive cities in addressing food insecurity" (Messner, 2012). While each community is unique and there is no straightforward formula for addressing public food policy, the Baltimore experience is illustrative of what can happen when utilizing a strategic approach in a progressive environment. In this case study, we examine the issue of food access and insecurity in Baltimore; the founding of the Food Policy Task Force; the hiring of one of the country's first food policy directors; the subsequent development of the BFPI, currently the country's largest food policy program in terms of full-time salaried positions; and the structure, functioning, and jurisdiction of this interdisciplinary, comprehensive body. Finally, we will discuss what others working on local food policy can learn from Baltimore's model and experience.
It should be noted that the authors of this paper have been and are currently involved with various aspects of Baltimore's food policy efforts. Anne Palmer has been involved in Baltimore food policy since 2007. Rachel Yong was the Healthy Food Coordinator for the Baltimore Food Policy Initiative from 2011 to 2013. Raychel Santo was a public health studies and global environmental change and sustainability double-major senior at Johns Hopkins University. We have striven to provide an accurate account; however, we fully acknowledge that while our engagement in the development of the BFPI as participant-observers gives us a unique perspective, there is also the potential for a bias. To maximize the accuracy of our account, the draft manuscript was shared and revised with key stakeholders' input.

Methods
The information presented in this case study was gathered primarily through document analysis, interviews, a literature review of other local food policy initiatives, and, as mentioned above, direct experience with the events. Document analysis included reviewing reports and website information provided by the Baltimore City Planning and Health departments; archives of the Baltimore Sun and other local newspapers; and meeting agendas, transcripts, and reports from the original Baltimore Food Policy Task Force. During October 2012, Raychel Santo conducted taped interviews with Holly Freishtat, the Baltimore Food Policy director, and co-author Anne Palmer to collect details about the development of the BFPI. The authors later conducted a literature review to contextualize Baltimore's progress with similar efforts in other cities. To ensure accurate representation of the events, final drafts of the paper were shared with key participants Holly Freishtat, Seema Iyer, and Joyce Smith, and edited based on feedback.

Overview
Baltimore City is a midsized city of approximately 620,000 residents who identify themselves with 55 unique neighborhoods (Baltimore City Health Department, 2012;United States Census Bureau, 2013). Food insecurity affects nearly 14 percent of Baltimore households (Food Research and Action Center, 2013). These families report not having "enough food for an active and healthy lifestyle" (Food Research and Action Center, 2013). The median family income in Baltimore is US$40,100 and its population is predominantly African American (63.6 percent) (U.S. Census Bureau, 2013). Racial disparity plays a role in food insecurity. The Baltimore City Health Department's Office of Epidemiology and Planning (2010) gave the city a "D" in the disparity between blacks and whites on food insecurity, with almost 2.5 times more blacks than whites reporting concerns about not having enough healthy food. Access to nutritious food is recognized by the city as an important social determinant of health (Baltimore City Health Department, Office of Epidemiology and Planning, 2010).
In Baltimore, areas where inhabitants have limited access to supermarkets and healthy foods correspond to higher rates of diet-related disease (Center for a Livable Future, 2012). Obesity and poor diet are associated with the first and third leading causes of death in Baltimore, cardiovascular disease at 26.7 percent and stroke at 5.3 percent, respectively (Baltimore City Health Department, n.d.). In Baltimore, 67.7 percent of adults and 38.4 percent of high school students surveyed, respectively, randomly through the Behavioral Risk Factor Surveillance System and Youth Risk Behavior Surveillance System, in 2007 were overweight or obese, and obesity prevalence is about 30 percent higher in Baltimore than in Maryland as a whole or nationally (Baltimore City Health Department, 2008). In its efforts to address these public health issues, Baltimore City followed the national trend in the formation of a city-level food policy group, but through a unique, circumstantial, and notably successful way. This case study details, in chronological order, how Baltimore developed an infrastructure for food policy work during this time (see Figure 1).

Existing Local Policies (2000-2008)
In response to supermarket chains increasing their presence in the surrounding suburbs, then-Mayor Martin O'Malley launched a grocery store initiative in 2000 that attracted 17 grocery stores to the city in 2.5 years (Baltimore City Planning Department, 2003). Following this development, the Planning Department adopted a comprehensive plan in 2006 that included a goal to "Ensure all residents are within 1.5 miles [2.4 km] of quality groceries and neighborhood services." The comprehensive plan acknowledged the role of the Health Department in achieving this goal; as a result, senior staff from both departments met in 2007 to discuss the plan. In addition, the Baltimore City Council later convened the Task Force on Childhood Obesity in 2007 (Baltimore City Council, 2007). In 2008, they released final recommendations related to the food environment to "improve access to and affordability of healthy foods for low-income populations in Baltimore City" and to "develop policies that will support healthy eating among Baltimore City residents" (Baltimore City Health Department, 2008). With funding from the Robert Wood Johnson Foundation, the Associated Black Charities (ABC) also launched its own task force on childhood obesity in 2007. ABC highlighted the food policy council model as a promising institution and committed to providing support to community partners to improve the local food environment (Associated Black Charities, 2011). In March 2008, the City Council, and subsequently then-Mayor Sheila Dixon, approved a ban on the sale of all restaurant foods with trans fats, 1 which went into effect in September 2009 (Dash, 2008). 1 Trans fats (found in partially hydrogenated oils) are industrially created fats made by the transformation of liquid vegetable oils into solid fats. According to the American Heart Association, trans fats raise levels of LDL (bad) cholesterol and lower HDL (good) cholesterol levels, thereby increasing one's risk for heart disease, stroke, and type II diabetes. As a result of these poor health consequences, many cities have been banning the use of trans fats in restaurants in order to reduce public consumption of trans fats.

Individual Organization Efforts (2000-2009)
Food insecurity and health disparities were becoming increasingly apparent to policymakers, funders, nonprofits, community advocates, leaders, and academics in Baltimore in the early 2000s. It is important to note that Baltimore in particular had a relative absence of large-scale, coordinated efforts on healthy food access from the nonprofit sector. While many organizations and institutions were already addressing some food system issues, they were working in relative isolation from each other up to that time.
In early 2009, the Health Department created the Charm City Health Award for Nutritional Information, to be awarded to food facilities that display point-of-purchase nutrition information about menu items including calories, saturated fat, carbohydrates, and sodium (Baltimore City Health Department, Bureau of Food Control, 2009). Meanwhile, the Planning Department began its first zoning code rewrite in decades, a process that Anthony Geraci assumed the position of the Baltimore City public school director of food and nutrition in July 2008. Under his leadership, Great Kids Farm, a 33-acre (13-hectare) farm in a Baltimore suburb owned and operated by the city public school system, was founded to provide handson educational opportunities for students (Simmons, 2009). Geraci also began sourcing produce from local farms and significantly increased participation in the school breakfast program.
Little was happening in the commercial sector during the early 2000s. The city had seven farmers' markets, two limited grocery delivery services, and a community supported agriculture program through One Straw Farm that had established several drop-off sites.
In the nonprofit sector, Maryland Food Bank operated a popular free Produce Giveaway Program, distributing produce to a statewide network of soup kitchens, food pantries, and emergency shelters, including some in Baltimore City. Produce Giveaways typically delivered 7,000 pounds (3,175 kg) of fresh produce one to three times a week in Baltimore City (Maryland Food Bank, n.d.). The Food for Life food and nutrition education program was also in operation at two Baltimore City public schools (Riddims, 2007).
The local food environment was an active topic of interest for researchers in Baltimore's academic institutions. Joel Gittelsohn of the Center for Human Nutrition at the Johns Hopkins Bloomberg School of Public Health has led a team since 2002 in conducting research on food store-based environmental nutrition interventions. In 2006, the team partnered with the Baltimore City Health Department and other community organizations to begin an intervention study called the Baltimore Healthy Stores Project (BHSP). BHSP was aimed at improving the availability and purchasing of healthy food in low-income Baltimore corner stores and supermarkets (Song, Gittelsohn, Kim, Suratkar, Sharma, & Anliker, 2009). Gittelsohn worked in collaboration with the Korean American Grocers & Licensed Beverage Association of Maryland (KAGRO) to assist storeowners in stocking healthy foods in local corner stores. He then assessed their opinions and perceived barriers to offering healthy foods. As an extension of the BHSP, Gittelsohn also initiated the Baltimore Healthy Eating Zones Project to improve the availability of healthy foods in corner stores near 12 Baltimore City recreation centers, training peer mentors and recreation center staff in nutrition and healthy eating promotion for kids.

Needs Assessment (2007-2009)
In 2007 Johns Hopkins Center for a Livable Future (CLF), an interdisciplinary academic center based at the Bloomberg School of Public Health, partnered with Operation ReachOut Southwest (OROSW), a coalition of community associations led by Joyce Smith that organizes community associations in Southwest Baltimore. As part of work by OROSW's health committee to reduce health disparities, it conducted a community food assessment (Palmer, Smith, Haering, & McKenzie, 2009). This study identified community members' key food and nutrition concerns and measured the availability of healthy foods in Southwest Baltimore City. Out of a complete sample of the 41 food stores OROSW residents shopped in (35 within OROSW boundaries -including two supermarkets -and six nearby stores), the assessment found that 75 percent of the stores did not offer any fruits, and 68 percent did not offer any vegetables. In addition, residents reported that 46 percent of their food-related shopping visits were made to corner stores.
Meanwhile, Manuel Franco, a PhD student and Innovation Grant recipient from the CLF, was in the process of mapping healthy food availability and health outcomes across 159 contiguous Baltimore neighborhoods and in the 226 food stores within them. He noticed a significant association between the availability and price of healthy food and risk for cardiovascular disease (Franco, Diez-Roux, Glass, Caballero, & Brancati, 2008). Franco et al. found that racial and economic disparities were notably present, with 43 percent of predominantly black neighborhoods and 46 percent of lowincome neighborhoods having the lowest healthy food availability rating, compared to only 4 percent and 13 percent in predominantly white and wealthy neighborhoods. A strong correlation between healthy food availability and dietary patterns was also noted, as individuals living in neighborhoods with lower availability of healthy food had higher intakes of fats and processed meats and lower intakes of whole grains and fruits (Franco, Diez-Roux, Nettleton, Lazo, Brancati, Caballero, Glass, & Moore, 2009). Moreover, the availability of healthy foods was inversely related to body mass index (BMI), a recognized cardiovascular and metabolic disease risk factor (Franco et al., 2009).
At the invitation of Baltimore's Health Commissioner, Dr. Joshua Sharfstein, Franco gave a presentation of his research findings to the Baltimore City Health Department in 2007. Recognizing the need to consolidate efforts currently underway, such as the implementation of the city's comprehensive plan, Sharfstein requested that the CLF meet with the Planning and Health departments to discuss what could be done.
The first meeting included senior staff from the Planning and Health departments, Dr. Gittelsohn, and Joyce Smith, the community partner from the OROSW southwest Baltimore food assessment. The group members talked about their respective work and where there were opportunities for collaboration. Surprisingly, the city departments had not previously interacted because the Health Department was organized by disease and the Planning Department was organized by geography. Everyone's interest was piqued. Several months earlier, Palmer had sought out Mark Winne, a noted expert on local and state food policy, at the Community Food Security Coalition's annual conference and asked his opinion on what Baltimore should be doing. Winne recommended that Baltimore convene those already working on food issues to talk about joint opportunities through a type of food policy council. Palmer mentioned this option to the group and it was well received.

Overview
As mentioned earlier, a variety of stakeholders, including public health researchers, policymakers from the city's Planning and Health departments, hunger advocates, and other nonprofit organization representatives, were working on various food system-related problems, but were not working together to solve them. In 2009 these stakeholders were brought together when Mayor Sheila Dixon appointed the Baltimore Food Policy Task Force, convened by the health commissioner and the Planning Department's director of research and strategic planning, to assess local food system features and offer recommendations for how to improve the overall system.
After one year, the Baltimore City Food Policy Task Force (2009a) issued a report with 10 goals addressing many different issues related to healthy and sustainable food -a "roadmap" for action. This report led to the funding of the Baltimore food policy director in 2010, who would establish a new intergovernmental collaboration, the Baltimore Food Policy Initiative (BFPI), to carry out these recommendations. Within the BFPI, a Food Policy Advisory Committee (Food PAC) -Baltimore's version of a food policy council, comprising 60 stakeholder organizations in the Baltimore community -was brought together to collaborate and drive the coordinated implementation of the task force recommendations.
In the past three years (and in a timeframe coinciding with the nation's economic recession) BFPI has achieved many significant goals that have earned it widespread media attention, both locally and nationally (Baltimore City Planning Department, n.d.b). This has included changing zoning code to allow for urban agriculture, addressing policy barriers related to accepting SNAP benefits at farmers' markets, improving food options at public markets, and supporting online grocery shopping for SNAP customers. At the end of 2011, Mayor Stephanie Rawlings-Blake assumed national leadership on the issue as vice chair of the U.S. Conference of Mayors (USCM) Food Policy Task Force, bringing together mayors throughout the country to share ideas and facilitate conversations regarding food policy change. Baltimore Food Policy Task Force (2008-2009 In February 2008 the CLF invited and supported Winne in coming to Baltimore and holding a workshop with 25 participants representing various stakeholders in the local food system. He introduced participants to the food policy council concept and discussed the various efforts underway across the country to improve community food systems. The group agreed that collective action was key to moving forward and recommended that Mayor Dixon get involved. Staff from the Health Department suggested they talk to Dr. Sharfstein, Baltimore's health commissioner, to encourage his support.

Development of the
A few months later, Dr. Sharfstein contacted Palmer and recommended that he and the head of the Planning Department 2 convene a task force that would meet for one year to decide how to move forward. This development boded well because getting city government's buy-in was crucial to any progress. Several months passed and it appeared the task force idea and interest had waned. However, in November 2008 Mayor Dixon announced that the Baltimore Food Policy Task Force would be appointed to facilitate the necessary collaboration among food system stakeholders. Using the precedent from the Swan Park Task Force, commissioned by Mayor Dixon in 2007 to address an arsenic contamination issue in South Baltimore (Goldman, Moore, Nilson, Sharfstein, & Simms, 2007), this new body agreed to convene three times between February and November 2009 in order "to identify means to create demand for healthy food through awareness and education and to ensure opportunities for all Baltimoreans to access affordable healthy food options in order to achieve and sustain better health outcomes and a higher quality of life" (Baltimore City Food Policy Task Force, 2009a). In essence, the group was tasked with creating specific, actionable solutions that would address these recognized needs for improved healthy food access, demand, and affordability.
The task force was composed of 18 stakeholders representing the Baltimore City Planning Department, the Health Department and its Division of Environmental Health, the Development Corporation, and the Department of Recreation and Parks; grocery chains including Giant, Santoni's, Safeway, and KAGRO; the Maryland Food Bank; Baltimore City Public Schools; the Johns Hopkins Bloomberg School of Public Health; the University of Maryland School of Medicine; Operation ReachOut Southwest; and Park Heights Community Health Alliance.
The task force members' inexperience in food policy proved to be an advantage because it allowed the group to learn and evolve collectively in their efforts. Members did not attempt to change laws; they did not even know what food laws existed. In the beginning, many members attended without a clear idea of why they were invited. Over the course of the year, however, they came to realize that at the city level, zoning, regulations, procurement contracts, and ordinances all constitute local food policy.

Task Force Recommendations (2009)
On February 9, 2009, the first meeting was held.
The key objectives included understanding the food policy council model; reviewing what was happening in Baltimore; and working in small groups to produce a list of opportunities. The groups developed 23 actionable programs, projects, or policy ideas to create a food system that would better ensure equal access to healthy food for all residents. The Planning Department also vetted the list with other food system stakeholders. During the second meeting, members used that list to concentrate on the feasibility of each strategy and to develop action plans for those opportunities selected for the short list. A brief amount of time was allocated to reviewing the draft mission statement and goals. At the final meeting in December 2009, the members prioritized the actions and voted for the following 10 key recommendations (not ranked hierarchically). The CLF drafted the Food Policy Task Force Report, which was issued in December 2009 (Baltimore City Food Policy Task Force, 2009a As the task force was assembling in the fall of 2008, the Planning Department simultaneously was drafting Baltimore City's first Sustainability Plan. Palmer was asked to participate in the green infrastructure working group, where the topic of food was located. When the group learned how the task force recommendations were shaping up, it was clear that they should be cross-referenced and incorporated into the City Sustainability Plan for consistency and dual accountability. As a result, the plan's Greening Goal 2 was to "establish Baltimore as a leader in sustainable local food systems" through the following strategies (Baltimore Commission on Sustainability and Baltimore City Planning Commission, 2009): • Increase the percentage of land under cultivation for agricultural purposes; • Improve the quantity and quality of food available at food outlets; • Increase demand for locally produced, healthy foods among schools, institutions, supermarkets, and citizens; • Develop an urban agriculture plan; • Implement Baltimore Food Policy Task Force recommendations related to sustainability and food; and • Compile local and regional data on various components of the food system.
Thus before the task force made much progress, it was designated as a "means of implementing the City's adopted Sustainability Plan," and "its recommendations should help to inform the TransForm Baltimore zoning code rewrite project to ensure that the city's built environment does not impede access to healthy foods" (Baltimore City Food Policy Task Force, 2009b).

Baltimore's Food Desert Map
Partly due to the third task force recommendation, Baltimore City officials and the CLF continued their research on food deserts. Baltimore City operationally defined a food desert as "an area where the distance to a supermarket is more than ¼ mile [0.4 km], the median household income is at or below 185 percent of the Federal Poverty Level, over 40 percent of households have no vehicle available, and the average Healthy Food Availability Index score for supermarkets, convenience and corner stores is low (measured using the Nutrition Environment Measurement Survey [as reported in Franco et al, 2008])" (Baltimore City Planning Department, 2012, p. 2).
The research showed that many areas in Baltimore and other urban inner-city settings are food deserts. According to data compiled by the Baltimore Department of Planning using 2010 Census data, 20 percent of Baltimore's population (around 125,000 people) lives in food deserts, which are found in one in three neighborhoods (Center for a Livable Future, 2012). Racial disparities are particularly prevalent, as 26 percent of the African American population lives in food deserts, compared to only 7 percent of the white population. In the absence of supermarkets, which typically offer a better variety of healthy foods than other food stores, residents in food deserts are surrounded by cheap, mostly high-fat and highcalorie foods and meals from the high proportion of corner stores and carryout restaurants. These features have led some experts to use the term "food swamp" over "food desert" to more adequately describe the phenomenon (Maryland Department of Planning, 2012).

Food Policy Director
Once the task force recommendations were established, the next challenge faced was how to implement them. The Association of Baltimore Area Grantmakers had member funders who were interested in supporting more work related to food systems, so they offered a forum to educate their members about what was happening in Baltimore with regards to the food system. Seema Iyer, cochair of the task force from the Planning Department, Palmer, and others discussed the food system mapping project that CLF was undertaking, the task force recommendations, and urban agriculture initiatives. The task force considered the idea of funding a food policy position to carry out and oversee implementation of its recommendations. A mentor of Palmer's, Kate Clancy, recommended that several foundations jointly contribute to the position. She argued that while funders need to narrow their focuses based on their missions, any foundation working on public health, food security, urban development, etc., would benefit from having a dedicated position for food policy. This share-the-burden strategy was also popular because the foundations were anticipating a financial hit from the 2008 recession. Several foundations invited the city to submit letters of interest. As a result, four external donors, the Abell Foundation, Annie E. Casey Foundation, Baltimore Community Foundation (BCF), and Kaiser Permanente, provided a total of US$70,000 to initially fund the position as a contractor to city government, with the BCF serving as the fiscal agent. The role and responsibilities of the food policy director would be to work with members of city government to review and develop specific food-related policy and assist with facilitating those policy changes; partner with community, political, academic, private, and nonprofit stakeholders to facilitate food system changes; expand current projects and initiate new ones to expand access and availability of healthy food choices in targeted Baltimore communities; and more.
On May 1, 2010, Stephanie Rawlings-Blake, the former City Council president and new mayor of Baltimore, announced the city's Food Policy Task Force recommendations and Baltimore's food policy director. Demonstrating the city's timely developments, the White House released its report on childhood obesity around the same time, which served as a frame for First Lady Michelle Obama's "Let's Move" campaign. The major points and recommendations of the White House report mirrored many of the Baltimore Food Policy Task Force recommendations and accomplishments that Baltimore had already made, such as starting a food policy council.
Native Baltimorean Holly Freishtat accepted the job as Baltimore City's first food policy director as a part-time, 15 hours-per-week position with the intention that, once additional funds were secured, it would become full-time (Marsh, 2011(Marsh, ). A 2007(Marsh, -2008 Kellogg Food and Society Fellow through the Institute for Agriculture and Trade Policy and graduate of Tufts University with a master's degree in food policy and applied nutrition, Freishtat had previous experience in the food system realm as the founder of a farm-to-school program and a farm-to-healthcare project in Washington state (Cohn, 2010).
Having the task force assembled and recommendations established before Freishtat arrived was invaluable to the progress of the BFPI. Moreover, the roadmap of recommendations was general enough to provide Freishtat with the flexibility to carry it out with appropriate timing based on the present priorities of the Mayor's Office and community needs, a crucial aspect of the job. Having a broad food policy framework provides the opportunity to develop the detailed food policy agenda over time.
One unique aspect of Baltimore's arrangement is the relationship between Baltimore City and the Sustainability Food Fund at BCF, which was established to support the city's food policy work. The intention of the Food Policy Task Force recommendations was to have a permanent city employee solely focused on food policy and food access issues, yet its designers anticipated that the position would require some years of outside grant funding. BCF agreed to act as a fiscal agent for the consultant position, a role they had played for other city initiatives. Within a short time, Freishtat was hired as the food policy director through a consultancy with BCF, yet she had an office in the Office of Sustainability and "looked and felt like a City employee" (H. Freishtat, personal communication, October 18, 2012). "Having the option to start as a consultant allowed the Planning Department to hire someone without asking the City for funding," Palmer noted. Within one year, Freishtat became a city employee and no longer relied on grant funding for her salary. The relationship between the city and the Sustainability Food Fund is still very important, and Freishtat uses the fund to write proposals for additional staffing as well as program and policy implementation through the city.

Baltimore Food Policy Initiative
In 2010, Freishtat proceeded to create the Baltimore City Food Policy Initiative (BFPI), an intragovernmental collaboration among the Baltimore Department of Planning, Office of Sustainability, Baltimore Development Corporation, and the Health Department aimed "to increase access to healthy and affordable foods in Baltimore City food deserts…through a holistic and comprehensive food system approach" (Baltimore City Planning Department, n.d.c). BFPI is a planning and policy shop that works to identify barriers across city agencies to improve food access, increase food production, and address these and many other food system issues through local, state, and national policy changes.

Baltimore Food Policy Advisory Committee
Within the BFPI, Freishtat assembled the Food Policy Advisory Committee (Food PAC), composed of over 100 stakeholders representing more than 60 organizations currently working on local food system projects in nutrition, hunger and food access, schools, gardening, sustainability, and urban agriculture. The purpose of Food PAC is to break down silos between organizations working on all types of food issues. By the very nature of their work, these groups are already implementing the task force recommendations, and Food PAC provides an opportunity for the organizations to coordinate and collaborate on their efforts. Food PAC groups are "on the ground" and have the pulse of neighborhoods and the community at large. In addition to ongoing communication, the group meets six times per year to provide updates and raise policy issues and barriers to the food policy director so that BFPI and city government are abreast of all issues and can help drive solutions (Baltimore Food Policy Initiative, n.d.). While Food PAC is essentially Baltimore's equivalent to a food policy council, its distinction as a purely advisory group, and not a council, is important. It is not a formal, decision-making body (H. Freishtat, personal communication, October 18, 2012).
Having the task force assembled and recommendations established before Freishtat and the Food PAC arrived were important contributions to the process. The task force report established the case for how the city could engage in food policy issues that would contribute to better health outcomes. Without the report, there would have been little evidence that hiring anyone to focus on food policy would make a difference. The process also allowed Freishtat to step into the position and immediately use her skills and knowledge to act on the recommendations. Moreover, the roadmap of recommendations was general enough to provide her with the flexibility to carry it out with appropriate timing, a crucial aspect of this job. "So much of what I do is successful because of timing," Freishtat noted, and a very detailed roadmap would have proven a hindrance to her efforts (H. Freishtat, personal communication, October 18, 2012).

Attention to Food Access
Within the first month on the job, Freishtat already had 50 media calls. By the end of the first year it was apparent that BFPI was filling a needed role in the city through its successful initiatives: an educational campaign called Get Fresh Baltimore, an effort to get EBT cards accepted at farmers' markets, incorporation of urban agriculture into rezoning laws, and more. Other city initiatives, such as the Health Department's virtual supermarket program for pickup in inner-city libraries, garnered more media attention because Freishtat was able to highlight them.

Financial Sustainability
BFPI has grown from solely Freishtat as a consultant to two city-funded positions, and one to two grant-funded employees. The growth of the BFPI and the support, both internal and external, harnessed in such a short time frame and in a relatively difficult economic climate was no small accomplishment. In the last four years, BFPI has secured approximately US$1 million in grants to address food access (as of 2013) (H. Freishtat, personal communication, August 4, 2013).

Governance
The BFPI's role within city government, technically located under the Office of Sustainability but in reality under a multi-agency governmental collaboration, directly influences its functioning and power. Working with the Health Department, the Baltimore Development Corporation, Department of Planning, Office of Sustainability, Food PAC, and others, Freishtat can connect these groups' efforts to address other recognized challenges in the food system. Her role is to identify policy opportunities, so she focuses on collaborating and explaining policies in ways that encourage these groups to act on issues that affect food policy on multiple levels. She is able to officially interact with these other agencies because she has been appointed to various cabinets and committees throughout the city and is able to organize meetings with their directors and administrators when needed.

Assessment and Evaluation
The Baltimore Food Desert Map is one tool that helped Freishtat and the BFPI provide the sense of urgency needed to successfully frame the highest priority policy needs and interventions. Initially created by the Johns Hopkins Center for a Livable Future as part of its Maryland Food System Map Project, the first food desert map of the city was released in May 2009. Using geographic information system (GIS) technology, this map overlayed household income with proximity to supermarkets to show the areas of the city that were in greatest need of access to healthy foods (Baltimore City Planning Department, 2012). It was updated in 2012 with additional information on vehicle availability and the quantity and availability of healthy food within all food stores, from corner stores to supermarkets. Jointly published with the city in 2012, this map proved to be an invaluable resource. According to Freishtat, "Having the cityapproved food desert map was one of our greatest successes. It's not an external report or from somewhere nationally, it's from us. It was how we were able to get the buy-in of establishing need very clearly; as such, it's really driving our policies, our urgency" (H. Freishtat, personal communication, October 18, 2012).

Focus on Policy
Freishtat cites her background in policy as another key force behind the BFPI's initiatives. While other food policy directors across the country have come to the position as former chefs, lawyers, public health officials, or other food system stakeholders, she came in with extensive experience in grant writing, food policy, and food system media training. This background has allowed her to see where her efforts can be most efficiently implemented. Compared to other food policy councils that often struggle to balance their focus between programs and policy, she spends virtually all of her time on policy. More specifically, she focuses on details of policy implementation, such as permitting, requirements, and procedures, and has found that making changes in the small policy details has led to substantial positive impact on the city's food environment (H. Freishtat, personal communication, October 18, 2012). Through her education and past experience, she is able to recognize these gaps and address them to the best of her ability.

City-centric Priorities
Around the country there are places where food policy directors are commonly located within city government: the mayor's office, office of sustainability, the department of planning, health, economic development, etc. A unique aspect of Baltimore is that the food policy director position is located in the Office of Sustainability (a division of the Department of Planning), yet has a very close relationship with the Mayor's Office without being located within the mayor's office. Freishtat has found that it is important to maintain a close relationship with the mayor but to remain in separate offices (H. Freishtat, personal communication, October 18, 2012). Food policy directors in other cities have learned this the hard way, as their positions located within the mayor's office became threatened when the incumbent mayor left. Freishtat maintains her relationship with Mayor Rawlings-Blake by providing briefing memos, in which she describes the background issue at hand and various needs related to it, before each major media event. By having frequent events, she maintains direct communication with the mayor while simultaneously increasing the mayor's media coverage on the issues.
Freishtat had a fortuitous opportunity to accompany Mayor Rawlings-Blake to a round-table summit on improving healthy food access that was hosted by First Lady Michelle Obama in Chicago. Observing the need and urgency described by the mayors and the first lady at this summit provided the impetus for the mayor to be chosen for national leadership in food access. Following the event, Mayor Rawlings-Blake helped form the U.S. Conference of Mayors (USCM) Food Policy Task Force, a national committee of which she is vice chair that brings together mayors throughout the country to share ideas and consolidate efforts (United States Conference of Mayors, n.d.). The mayor's national leadership is having far-reaching effects at home as well, helping drive the momentum and change that Baltimore is now seeing.

Conclusion and Lessons Learned
When the Baltimore food policy director started there were only a handful of similar positions embedded in city governments across the country, and none with the same mandate as Baltimore's. As of 2013, 16 food policy director equivalents have been established throughout the country. Similarly, in the few years of BFPI's existence the number of food policy councils has more than doubled. In 2010, there were 92 food policy councils (Scherb et al., 2012). In 2013, the Center for a Livable Future's Food Policy Network program conducted a census that recorded over 270 active councils in the U.S. and Canada (Center for a Livable Future, 2013). As the movement addressing policy at the food system level continues to expand, the formation, structure, and functioning of BFPI may help guide future efforts with similar missions.
Ultimately, the Baltimore Food Policy Initiative is one example of how much progress can be made in only a few years' time. Before BFPI, there were many disparate efforts with the same goal of improving healthy food access and demand in Baltimore, but nothing to coordinate them to make greater impact. Circumstances placed the city in a proactive role to provide and shape how food policy would look in its midsize urban setting. The case study of BFPI provides an example for other midsize urban cities to consider.
(1) Identify need and priorities first: Baltimore convened a task force specifically focused on identifying how the city would address food access and food policy. The task force created short-, medium-, and long-term goals for tangible outcomes and developed a timeline based on available financial resources. Setting priorities before a food policy director was hired was effective because attention could be focused strictly on implementation.
The food policy director's mandate to implement a predetermined set of recommendations led to her unique relationship with the Food PAC as an advisory committee instead of a food policy council with decision-making abilities (Hatfield, 2012). The flexibility imparted by this structure has given her the influence needed to implement stakeholder recommendations without as many bureaucratic limitations as typical councils, which often need members to vote in order to implement action items.
(2) Balance evidence and action: The task force understood the need to improve food access but was willing to make decisions based on available data instead of waiting for complete and perfect evidence. The task force was highly effective in bringing academic, governmental, and community partners together in order to use available evidence and members' expertise in research to drive decisions. Yet more importantly, it looked for opportunities for what could be done immediately to improve food access. It spent less time waiting for complete data or determining exact strategies and instead focused on how to gain momentum in fixing the city's broken food system. Notably, the process of selecting which activities to include in the task force report did not involve reviewing all the scientific literature to determine which activities were more likely to be successful. At that time few peerreviewed journal articles had been published that evaluated food system interventions. Instead, the task force contacted similar initiatives around the country and sought out potential opportunities despite the economic hardships that came as a result of the 2008 economic recession.
(3) Ensure financial sustainability: In the midst of an economic downturn, Baltimore successfully found a way to work on food policy within the city. In creating the Baltimore Food Policy Initiative, key partners and funders invested in -and continue to invest in -the vision set by the task force. Through briefings and participation in activities, each funder recognized that working on a systems problem meant that all sectors could be engaged in solving the problem. BFPI built its credibility in the city through work funded by nonprofit grants. As the city took note of its work, BFPI leveraged the funds to become partially funded by the local government, creating a sustainable way to work on Baltimore's food system. BFPI now has three full-time positions dedicated exclusively to food policy work, one of the largest offices in the country. The funding for these positions, which came through its demonstrated need and notable achievements, has allowed BFPI to achieve even more progress simply by having more devoted staff time to facilitate effective policy changes.
(4) Maintain agility: One of the notable goals absent from the task force report was the opening of supermarkets in food deserts, which all the retail task force members agreed was untenable in the current economic climate. Now is it central to Baltimore's focus. Baltimore has been successful because of its ability to stay agile and use the task force report as a blueprint to start its work.
Further, the media spotlight on Baltimore's food policy initiatives, first used by Freishtat as a tool of garnering attention and further highlighted by the mayor's efforts nationwide, have contributed to the continued interest in and support of the BFPI's efforts. Baltimore is working to continue to evaluate and show the impact of its efforts. Its current metrics are mainly centered on the food desert map and include the number of residents living in food deserts and the percentage of the city designated as a food desert. Future evaluation efforts may include reporting on a range of measures relevant to the city's effort to improve access in different sectors, such as urban agriculture or healthy food availability in existing food stores. This would include combining evaluation metrics used in existing programs and by Food PAC partners.
Within three years, Baltimore became a national leader in food policy (Hodgson, 2012). Future challenges BFPI may face include incentivizing new or improved supermarkets in underserved neighborhoods; supporting the sustainability of all healthy food sources; increasing demand for and affordability of healthy foods; addressing health disparities and diet-related disease; ensuring fresh, healthy foods in school meals; and addressing barriers that arise as unintended consequences of federal and state policies. Baltimore's unique ability to address food policy through BFPI attests to the promising ability of its approach, both structurally and functionally, to tackle the issues of healthy and sustainable food access.