Growing up in Detroit as the son of two hard-working parents, Preston Maring was told by his mother when he was 11 years old, "You want breakfast? Make it yourself." Lunch too.
Then — this was a lesson in self-reliance, not a sloughing of maternal chores — she showed him how to put together appetizing, balanced meals.
Fifty-six years later, Preston Maring, M.D., can appreciate how that moment shaped a lifetime's pleasure in preparing and eating good food. More importantly, thanks to Maring's initiative and energy, it has reshaped the relationship of many American hospitals to the nutritional and economic health of their patients and their communities.
It's California, After All
A graduate of the University of Michigan Medical School, Maring began his residency in obstetrics and gynecology at California's Oakland Medical Center, the flagship hospital among 37 (flanked by 611 outpatient facilities) in the nine-state (plus D.C.) Kaiser Permanente health care system. He's been at Kaiser Oakland ever since, rising to physician-in-chief in the 1990s. During his tenure he helped establish a pediatric intensive care unit that is now the San Francisco Bay Area's tertiary care referral center and a pediatric neurosurgery program. Since then, he's served as an assistant to successor chiefs, with, he says, "the freedom to start other programs"; the crucial knowledge of "how the organization works, who needs to know," etc.; and the consequent ability to "anticipate problems and mitigate them ahead of time."
Maring lives in neighboring Berkeley. His house is only a couple of blocks from the Gourmet Ghetto where Alice Waters led a revolution in American fine dining by concentrating on locally grown, seasonal ingredients at her famed Chez Panisse restaurant. Each morning Maring swings by the original Peet's — the epicenter of the roasting renaissance that spawned Starbuck's and a million specialty coffee shops nationwide — to fill his thermos with strong black organic decaf before bicycling through residential back streets to his office in the hospital's Piedmont district.
For his own kitchen, in which he cooks regularly (following the tradition of his father, who shared responsibility for family meals by manning the stove Thursdays through Sundays), Maring long has been an aficionado of farmers markets. These are where small- and medium-scale growers, ranchers and artisanal producers sell their fresh, sustainably farmed viands directly to consumers. That allows them to pocket 90 percent of the proceeds, versus less than 20 percent when they sell the fruits of their labors at the bottom of a chain of middlemen.
One day it occurred to Maring that a place where a lot of people congregate routinely — like a hospital — would be an ideal location for a nutrition-promoting farmers market. He began asking questions of vendors at the markets he frequented for leads on how to start one. He was met by shrugs of uncertainty until, at the market in Oakland's Jack London Square, he was pointed to a man who happened to be standing nearby: John Silveira, director of the Pacific Coast Farmers Market Association. Maring introduced himself and made his pitch. "Your mission and our mission are basically the same," he said. "We're both trying to improve the health of the community [including the health of the local farm economy]."
Silveira was sold. And in the summer of 2003 Maring oversaw the opening in a street-side plaza next to the Oakland Medical Center's emergency entrance of what he believed to be the first year-round health system-sponsored farmers market in the country. (Duke University's employee wellness program might argue precedence, he later learned, having backed an on-campus seasonal farmers market since 2000.)
Thronged every Friday year-round, Kaiser Oakland's was indisputably the first hospital-based market in the nation to offer only organic produce — admittedly less of a selection in winter, but always some. This is California after all.
If you've ever watched television in one of the eight regions serving 9 million Kaiser health plan members, you've probably seen a commercial touting the organization's slogan "Thrive!" That's a distillation of the Kaiser ethos, says Maring — "a focus on prevention as opposed to just treating illness." It's also a theme born when creative heads of Kaiser's advertising agency happened upon the farmers market one Friday. The first commercial in the campaign featured the cornucopious produce stands outside Kaiser Oakland; the letters in the Thrive! logo are formed from fruits and vegetables.
But Maring wasn't content to have fathered just one exemplary market. He talked up the idea to Kaiser colleagues in other regions. Emphasizing studies that indicate more than 40 percent of Americans will be grossly overweight by 2030 if current trends continue, he repeated his mantra: "Good food matters!" And he made it widely known that he was more than eager to advise anyone, from any health care organization anywhere, on how to set up a farmers market. In just a 30-minute phone call and by pulling up Google Earth, he says, he can help a potential sponsor decide where exactly the best spot on campus for a market would be.
"I can tell where they'd have Venturi effects of wind blowing between buildings," he explains. "I can see where there is or isn't access for rolling pallets in and out." And so on. But the equation is simple. "All you need," he summarizes, "is suitable congregating space of sufficient size for foot traffic, and consumer demand will drive supply."
To supplement and substitute for Maring's telephone consultations, Kaiser compiled a 75-page resource guide. It describes in detail the various farmers market models and how hospitals and clinics can adapt them to local conditions. Options range from regular market association–run assemblages of many individual vendors, as at Kaiser Oakland (ideal because the association does the organizing, setup, direction and even cleanup), to collaborative efforts with other community agencies, to farm stands where a single vendor sells a collation of local farm products, to one-off farmers markets staged in conjunction with events like, say, a women's health month.
Maring even developed a program at Kaiser Oakland for employees who are too busy during market hours — like surgeons and nurses — to wedge in a shopping trip. Called Best of the Market, it puts a $10 or $20 prepaid bag of fruits and veggies selected by the market manager in their office or station at the end of the day.
"That can work for any health care institution," he proposes, "even if the farmers market is a mile away. The HR folks or employee benefit folks can go pick up the bags and bring them to the staff."
Of course, Maring acknowledges, "in a lot of parts of the country, the growing season is only three or four months of the year. But you can make the best of what you've got."
Indeed, the U.S Department of Agriculture reports, a quarter of the nation's farmers markets are now open in winter: "Consumers can find a variety of products such as fresh or preserved fruit, root vegetables, hearty greens, tree nuts, meat, poultry, eggs, honey, herbs, handmade soaps, baked goods, pumpkins, ornamental crops like Christmas trees, gourds and other holiday foods or decorative items."
Due in large measure to Maring's proselytizing, 52 Kaiser Permanente facilities around the country now host a farmers market. And almost as many outside health care organizations have followed suit. According to Florida's Sun-Sentinal newspapers, of 7,853 farmers markets listed in the USDA's online directory nationwide, 94 were being hosted by a health care institution as of last September.
"Every hospital in America has a community benefit function," Maring observes. "When you get down to it, helping people to eat healthy food" meets that goal. "It's a tested, really well-done program that's expanding," he asserts. "And the thing about this kind of program is that for minimal cost it's possible for any facility to partner with local farmers if enough farmers are looking for direct market outlets."
Seeing what he modestly styles his "small idea" take wing "has been magic for me!" exclaims Maring. "It's a miracle! Getting to know the farmers who grow the food I eat. … I even watch the weather reports for the Central Valley now. I've developed such a respect for the people working so hard to grow food for us!"
Maring is hardly a man of limited imagination, however. Looking into his hospital's patient and staff meal service menus, he discovered that the organization was buying several tons of red grapes annually from Chile. But red grapes are grown sustainably on nearby family farms, he knew. So are lots of other foodstuffs conventionally imported from foreign sources. So, working with Jan Villarante, Kaiser Permanente's director of national nutrition, Maring fostered an organizational switch in food purchasing practices. That meant leveraging Kaiser's clout — in Northern California alone about 7,000 meals are dished up daily — with big institutional food distributors.
Result: Last year, nearly half of all the fresh fruits and vegetables served throughout the Kaiser system were grown within 250 miles of the facility. Sixteen percent of the system's food purchases are now sustainably produced, Maring notes, and the goal for next year is 20 percent.
Maring since has bulked up Bay Area health care providers' food purchasing heft by enlisting three big counterparts — the University of California San Francisco Medical Center, the San Francisco VA Medical Center and Contra Costa County's John Muir Health — in a combined purchasing program that last summer fed their patients and staff with more than 700 pounds of organic strawberries, 3,800 pounds of green beans and 1,400 pounds of stone fruit grown by local family farmers using environmentally friendly cultivation methods.
At Maring's urging, Kaiser has awarded community benefit grants to fund outside nutrition programs like Northern California's Community Alliance with Family Farmers, whose board he served on for six years, and Wholesome Wave, an advocacy organization working to improve access and affordability of fresh, healthy, locally grown produce to historically underserved communities.
Wholesome Wave's Double Value Coupon program, for example, provides vouchers to recipients of federal nutrition benefits in 26 states, enabling them to buy twice as many fresh fruits and vegetables when they shop at a farmers market. And Wholesome Wave's Fruit and Vegetable Prescription Program assists overweight and obese children and pregnant women who are at risk of developing preventable diseases such as type 2 diabetes. The "prescriptions" are handed out by local health care providers, to be redeemed at participating farmers markets for fresh, locally grown fruits and vegetables.
"Any hospital looking for a community benefit will find Wholesome Wave a worthwhile project," Maring suggests.
Many small community agencies have established their own farmers markets through Kaiser funding largesse. An enormously successful example is operated every Saturday by the Watts Counseling & Learning Center in what Maring describes as "a neighborhood [of East Los Angeles] with limited access to fresh fruits and vegetables.
"One of the visions I keep having," Maring muses, "and I don't know whether it exists or not, is of a large trauma center located in a 'food desert' supporting a farmers market that has 20 or 25 vendors weekly. With 15,000 employees, it could easily do that. Every employee with a cellphone and a biweekly paycheck could support the market and benefit the community. There'd be a real synergy."
Meanwhile, Kaiser is about to launch Maring's latest brainstorm, a pilot program to deliver appetizing, economical ($5.95), tasty, oven- or microwave-heatable, dietician-approved, condition-specific meals for 30 days as a bridge between hospital and home for patients who might otherwise be readmitted because of their inability to eat healthfully by themselves.
"We've built scalability into the model and chosen a vendor who can deliver nationally," Maring says. "This could be a turnkey operation in any other Kaiser region. Patients will either like this or they won't, but here's the pipe-dream part. We discharge 50 people a day from my hospital. Even if only a small number decide to use the model, we have 23 hospitals in Northern California and 35 in the state. If it works here, if I can show some day that readmissions for congestive heart failure are reduced through this program … well, then," he concludes in understatement, "it could be advantageous."
Anybody Can Cook
You can see an aproned Maring in his own kitchen in Julia Child mode, chopping vegetables, imparting tips and whipping up easy recipes (pasta sauces, Caesar salad, pan-roasted chicken breast) in a series of "Get Cooking" videos on YouTube. (To date he's counted 177,000 visits.) He also offers recipes on his blog. And he's a peripatetic invitee for cooking demonstrations before groups like, most recently, one of Kaiser's strongest employee unions. (He invited the union president to don an apron and slice onions beside him. The audience gave them a standing ovation.)
"I'm not a nutritionist," he declares. "I talk about ease, taste, the family budget, fun, getting your kids involved … never nutrition. I tell people that to eat healthfully, all you need is a sharp chef's knife, two cutting boards and a salad spinner. My theory is that if I can cook it, anybody can cook it."
He's equally unpretentious when he describes the health care–based farmers market movement he inspired, and its logical, planet-friendly, local farmer-boosting, social-, personal-, institutional- and health-enhancing ramifications.
"We're not trying to create some precious system," he asserts. "We're just saying, 'Food is being grown here. Let's figure out a way to use it.'
"I know there are hospitals in many places creating best practices," he acknowledges. His advice to them: "Let's do what we can do and not whine about what we can't do."
David Ollier Weber is a principal of The Kila Springs Group in Placerville, Calif., and a regular contributor to H&HN Daily.