“We all need more fruits and vegetables in our lives,” says Johnson, 57, who pays for the two bags with $8 in yellow coupons. “I love coming here to get [them] because they’re always fresh.” The price is right too. “You can’t go anywhere [else] and get a bag of pears like this for $4.”

At least, not too many places around this part of North Baltimore.

Johnson had long grown used to leaving the city once or twice a month to get fresh fruits and vegetables, paying high prices and carting them back to her apartment by bus. But that changed five years ago when nearby Loyola University established the FreshCrate program, using its food-service company to sell produce at cost to five small stores on York Road. Now Johnson buys fresh fruit three blocks from home, on the western edge of Govans, a neighborhood where nearly half of the kids live in poverty. FreshCrate, part of Loyola’s neighborhood outreach efforts, is just one of several programs that Baltimore nonprofits, universities and city government have sponsored over the past 15 years to combat a national obesity and diabetes epidemic by bringing bring more healthy foods to low-income neighborhoods where diet-related illness is highest and healthy food choices are most scarce.

Khawar Jamil, the owner of Family Food Market, says 20 to 30 customers a day come in to buy produce, some paying with cash, some with FreshCrate coupons distributed at a nearby free-food pantry. FreshCrate produce fills several wooden produce racks and fridges. Everyday foods are most popular: onions, grapes, strawberries, apples. FreshCrate’s offer to stock the store with fresh food filled a need, says Jamil, who has run the store for 15 years and is known to his customers as Mr. Jimmy. “People were asking me, ‘You have a tomato?’” he recalls. Giant Food, the nearest grocery store, is more than a mile away in suburban Towson. “But if you know it’s only one block, you can come here, you can send your kids to go get it.”

So-called food deserts like Johnson’s neighborhood in north Baltimore have become a buzzy concept in talk about urban inequality in recent years, an easily understood feature of left-behind neighborhoods. The absence of amenities like supermarkets is not just an inconvenience. There is a health consequence, too. In fact, health officials say that a lack of access to healthy food is a factor in obesity, diabetes and high blood pressure. Almost 40 percent of all Americans are obese, including 47 percent of blacks and Hispanics. Obesity is especially prevalent among the poor. So cities like Baltimore—where half of all low-income residents are obese—bear a heavy share of the economic costs of obesity-related illnesses, which account for an estimated 10 percent to 21 percent of all U.S. health-care spending and more than $8 billion a year in workers’ lost productivity. A 2009 Gallup study estimated that obesity-related conditions cost the nation’s 10 most obese cities $50 million a year per 100,000 residents.

But changing health outcomes by changing eating habits has proved to be one of the more vexing challenges facing cities. No one knows this better than Baltimore, which has emerged over the past decade as a national laboratory for urban healthy food experiments. Studies by Johns Hopkins have proven that carefully cultivated partnerships with corner stores, carry-out restaurants and recreation centers can increase sales and consumption of healthy foods and even help kids lose weight. University public-health researchers have mapped Baltimore’s food environment, helping the city designate Healthy Food Priority Areas—a term the city now prefers over food deserts. Baltimore’s city government, one of the few in the nation that has a full-time food policy director and staff, has leaned on Johns Hopkins’ research to figure out what works—and just as important, what doesn’t—to make decisions about what programs to invest in. The first round of city grant funding, coming this year, will include a grant to FreshCrate.

In Baltimore, food policy efforts often run up against Baltimore’s higher-profile problems, including poverty, historic segregation patterns and high rates of violent crime. Solutions that work in one neighborhood don’t always work in another. Baltimoreans who work on food policy say the relentless experimentation has taught them a lot. One of the big lessons is to think small.

“We’re not trying to solve issues of food security for the whole city,” says Marie Anderson, assistant director of Loyola’s York Road Initiative, which runs FreshCrate. “We’re really focused on one area, and that allows us to be more nuanced in the work that we do.”

FreshCrate—founded in 2015, informed by Anderson’s reading of Johns Hopkins research and programs elsewhere—tackles supply as well as demand. Educating consumers and nudging them to choose healthy foods can help, Anderson says. But at least as important are addressing the market economy’s failures to bring fresh-food distribution to small urban stores, which often order produce in batches too small to interest wholesalers in delivering to them. Also key is affordability, which means creating new hybrids of the market economy for food and the charitable food economy system.

In 2017, Anderson says, the FreshCrate program “was just kind of sputtering along.” Store owners were telling her the produce wasn’t selling well. So she used grant money to fund bus-shelter signage about the program, in-store branding of FreshCrate items, and a coupon program. First, FreshCrate sent coupons for produce to everyone in its ZIP code. Next came the $9 per month in produce coupons for clients of the local food pantry. That, Anderson says, was “the major turning point for the success of the program.” The coupons have resulted in the sale of $30,000 of produce.

Since 2015, FreshCrate has provided 14,000 pounds of fruits and vegetables to York Road corner stores—proof that increasing healthy food supplies in cities addresses a pent-up demand.

“I think there’s a narrative that people don’t want healthy food,” says Anderson, “and I’ve never found that to be the case.”

***

Joel Gittelsohn, a professor of public health at Johns Hopkins, doesn’t like the term “food deserts.” He prefers “food swamps.”

“There’s a lot of food available, but it’s high fat, high sugar, high sodium,” Gittelsohn says. “The deep fryer is king in carry-out restaurants in Baltimore.” A local fast-food classic is the chicken box: fried chicken wings with thick-cut “Western” fries and “half-and-half,” an iced tea-lemonade mix. “It’s inexpensive, it’s good, it’s filling,” Gittelsohn concedes. It’s also nearly 900 calories in all.

Since 2005, Gittelsohn has conducted six studies in Baltimore, forming the data-driven basis for much of the city’s policy decisions. After his team worked with corner stores to stock and promote healthy foods, from low-fat milk to whole wheat bread to fresh fruits, they documented increased sales and consumption of them. Their work with carryout restaurants on menus and new recipes resulted in increased sales of healthier dishes, sides and drinks, such as grilled chicken sandwiches, water and baked chips. A program that involved both corner stores and teens at city recreation centers even led to a modest reduction in the body-mass index of overweight or obese girls.

Gittelsohn credits patient relationship-building for his studies’ successes. Many corner-store and carryout owners in Baltimore are Korean immigrants, so Gittelsohn employed a project coordinator fluent in Korean and provided written material in the language. The carryout program started with a simple offer to create menu boards. “The menus were typically handwritten on cardboard, very unattractive,” he recalls. “We made them look more professional and emphasized healthier existing options on the menus. So if they offered a garden salad, we would highlight that.” To his surprise, the menu boards alone increased sales. Next, his team helped introduce healthier sides and drinks. Only in the third stage did they work with the cooks and owners to introduce healthier main dishes and healthy meal-combo deals. Gittelsohn thinks the program would’ve failed if they’d started with the main dishes: “The rapport wouldn’t be there.”

Success also requires addressing food supply chains, not just demand, Gittelsohn says. Consumer education is part of his studies. So is evaluating the feasibility of stocking healthy foods, since corner-store owners are skeptical of the financial risk of buying foods that spoil with time, such as produce and milk. But Gittelsohn also found that the food distribution economy pushes small stores to stock junk food and sugary drinks.

“They have informal and formal agreements with the potato chip guy, the ice cream guy,” Gittelsohn says. “Those guys give them incentives: free display racks, freezers, reduced prices, free product. But there is no such system if they want to stock low-fat milk or fresh produce.”

So while Gittelsohn’s team works on more interventions in small stores, they’re also working on new distribution models for them. His team is conducting price experiments with DMG Foods, a nonprofit grocery store in Baltimore operated by the Salvation Army. Meanwhile, he’s applied for a grant to create an app that would allow small-store owners to order small batches of produce from wholesalers. The app would pool stores’ buying power to bridge the gap between the small quantities they need and the minimums distributors set.

Holly Freishtat, Baltimore’s food policy director, says the city is also working with Morgan State, a historically black public university in Baltimore, on a pilot program with Lyft to offer $2.50 rides to grocery stores for up to 200 residents of South and West Baltimore. University of Maryland law students are holding clinics with vendors in Baltimore’s six public markets about how to adjust to new restrictions on who can accept SNAP, the federal food-stamp program.

Meanwhile, Freishtat’s office is working to spread food-policy innovations across the city and beyond. The city’s new tool is the Healthy Food Priority Area Fund, which will give $140,000 in grants to neighborhood nonprofit programs in 2020, including the FreshCrate program and an alliance of urban farms. The city health department’s virtual supermarket program, which allows seniors to order groceries online for delivery to neighborhood locations, helped inspire a change in Congress’ 2014 farm bill that allows SNAP benefits to be used online. Now, New York state is piloting wider online use of SNAP, with Maryland to follow in 2021.

Building on Gittelsohn’s insights into the food distribution system and FreshCrate’s use of Loyola’s food-service company, Freishtat’s office is working with local hospitals on how they might share their fresh-food purchasing power with neighboring corner stores.

“Rather than having a one-size fits-all model in Baltimore, we’re really trying to nurture and support a community-based strategy,” Freishtat says, “so that over in Cherry Hill, it maybe looks a lot different than [on] York Road.”

***

Inside West Baltimore’s city-owned Avenue Market building, across from a juice stand and a carryout fried-chicken stand, the nonprofit Fresh at the Avenue is selling shiny red and green apples, ripe red tomatoes and big leafy bunches of spinach and collards. It’s the Saturday morning before Christmas, and soulful holiday hits by James Brown and Ella Fitzgerald play from a speaker. Customers, one wearing a Ravens stocking hat, one wearing a Santa hat, browse the onions and mushrooms, limes and grapefruit.

This stand will receive a grant from the city later this year (the dollar amount isn’t decided yet). It’s operated by No Boundaries Coalition, a 13-year-old advocacy group in West Baltimore. About 40 percent of its 165 to 200 weekly customers pay with EBT, the electronic version of food stamps.

It’s located one mile from the neighborhood where riots broke out in 2015 over the death of Freddie Gray in police custody. Sache Jones, No Boundaries Coalition’s director of health and food justice, says the organization tapped into the philanthropic interest in West Baltimore after the unrest. Much of the produce at Fresh at the Avenue comes from Whole Foods, thanks to a partnership with its foundation arm, the Whole Cities Foundation. Fresh at the Avenue places orders with the grocery chain, which sells produce to the nonprofit at cost and delivers it for free. Other produce comes from local urban farms, including the Strength to Love farm, a few blocks away. “Whatever they have in season, we’ll buy it,” Jones, 29, says.

Strength to Love, founded in 2013, runs 14 hoop houses on 1½ acres in the city’s Sandtown-Winchester neighborhood. It employs seven farmers in peak growing season, about half of whom were formerly incarcerated. Denzel Mitchell, the farm manager, says Strength to Love has sold Fresh at the Avenue about 1,000 pounds of produce in the past couple of years, including kale, collards, turnips and herbs. For some in historically black Sandtown-Winchester, he says, “it’s been exciting to know their food is being grown by a black farmer in the neighborhood. It’s a bit of pride.”

Jones, 29, a former urban farmer herself, says she aims to make Fresh at the Avenue a dignified, positive place to shop. That’s important in a neighborhood where many shops closed during the 2015 riots and some didn’t return, where churches functioned as spots for food giveaways in the days after the unrest, where fresh food is scarce and supermarkets are a long bus or subway ride away. “If I can come in and pick and choose, and take my time and not feel rushed by you, I’m going to spend more, I’m going to enjoy the shopping experience more, and I’m going to come back,” she says.

Avenue Market is one of the city’s public markets, municipally owned spaces for food vendors that trace their origins to the 1700s and 1800s. Jones, who grew up nearby, remembers visiting the nearly windowless 34,000-square-foot building as a kid after its 1996 renovation. “It had fresh meat, fresh eggs, a deli, it had a small grocery space,” she recalls. “We’ve probably lost about 25 percent of the vendors that were here five years ago.” A deli closed after federal SNAP program rules changed to make delis ineligible to accept the program. One of Jones’ goals, she says, is “to carry on the legacy of public markets being a place where residents come for fresh groceries.”

The stand, which turns four years old next month, crowdsourced its redesign last year. Customers came in to help repaint it. One volunteer built new produce racks. “I feel really proud,” says Jones, “and really lucky to work in a community that I really care about.”