Walk across the farm at Caja Solidaria in Western North Carolina in early spring, and you will find one of the first signs of the coming season: the distinctive deep burgundy blossoms of the native pawpaw tree. By September, the tree will produce one of Appalachia’s most distinctive fruits, nourishing people, wildlife, and our regional identity. However, the pawpaw harvest tells only part of the story. Beneath the soil lies an intricate ecosystem of roots, nutrients, and microorganisms that forms the foundation for local economic opportunity, a sustainable environment, and a healthy community. We celebrate the fruit. We rarely celebrate the roots.
Food is Medicine—or the broad range of approaches that promote optimal health by providing nutritious foods through collaborations with Health Care—in North Carolina has developed in much the same way.1 Over the past several years, community-based organizations, farmers, food hubs, and health care organizations have demonstrated that healthy food interventions can improve health while honoring local culture, participant dignity, and choice.2–5 North Carolina’s Healthy Opportunities Pilots (HOP), a regional approach to addressing health-related social needs, invested approximately $60 million in capacity-building for 147 community-based organizations to develop the infrastructure needed to deliver food, housing, transportation, and interpersonal safety services (authors’ calculation from NCDHHS monitoring reports).6
At Caja Solidaria, that investment included cold storage, delivery vehicles, and technology platforms. Those foundational investments enabled us to purchase more than $2.5 million in food from 27 local farms and food businesses while providing healthy food and housing support to more than 450 households. Across HOP, community organizations strengthened local food systems, expanded participant choice, met people where they were through neighborhood markets and home delivery, provided relationship-centered support, and improved quality of life while reducing health care spending.2,4,5 The investments did more than improve health outcomes for the more than 43,000 North Carolinians served by April 2025.7 In Western North Carolina, HOP service spending also generated measurable economic activity across agriculture, construction, retail, and other sectors.8 These are the visible fruits of Food is Medicine. Much less attention has been paid to the living infrastructure that made those outcomes possible.
Current Food is Medicine frameworks can help health systems match interventions to clinical need, including the organization of services along a continuum from population-level nutrition strategies to medically tailored meals.9 That clinical lens is essential, but it answers a different question from the one this commentary raises: what community, organizational, and economic infrastructure is required to deliver those interventions equitably and sustainably? And what forms of value are created beyond the immediate clinical encounter? Emerging whole-person health work similarly argues that value is multidimensional and experienced across participants and families, community organizations, health systems, payers, and communities.10 From that perspective, local purchasing, organizational capacity, community resilience, and participant dignity are not peripheral benefits; they are interconnected dimensions of the same value story. Wholesome Wave’s Fidelity, Equity, and Dignity Principle likewise reinforces the importance of centering dignity and equity in produce prescription design.11 It provides a framework through which Food is Medicine practitioners can assess how their program implementation is addressing whole-person and whole-community health.
Food is Medicine infrastructure is not limited to warehouses, software, or distribution assets. Community food systems are also built from relationships. Network analysis of a food security network found that locality and personal ties shape collaboration and network efficiency, underscoring that social relationships are themselves a form of operational infrastructure.12 Before a produce prescription can be written, someone has spent years cultivating relationships with farmers willing to grow food for uncertain markets. Food hubs have developed aggregation and distribution systems. Community organizations have earned trust door by door. Workers have learned to navigate both agriculture and health care. Technology has been adapted to connect clinics, farms, and community organizations. Local leaders have built governance structures capable of coordinating dozens of independent partners. Like the roots of the pawpaw tree, this infrastructure is largely invisible when Food is Medicine succeeds. Without it, none of the visible interventions can flourish.
North Carolina’s Rural Health Transformation Program (RHTP) presents a unique opportunity because it is fundamentally an infrastructure initiative. Rather than simply expanding Food is Medicine services, RHTP can cultivate the living systems that allow those services to endure long after individual grants or pilot programs conclude. Our experience in Western North Carolina suggests five design principles for cultivating rural Food is Medicine infrastructure.
1. Use Procurement to Build Rural Health and Food System Infrastructure
The procurement choices made by Rural Health Transformation Programs extend far beyond purchasing food. Every procurement decision shapes agricultural markets, determines which businesses participate in the health system, influences production practices, and directs where public dollars circulate. Public food procurement can be used deliberately to advance healthier diets and more sustainable food systems.13
In rural Food is Medicine, local and regional purchasing can also strengthen producer capacity, stabilize rural businesses, preserve or create jobs, reinforce supply chains, celebrate community culture and identity, and increase resilience long after individual prescriptions have been redeemed. Food hubs, in particular, can serve as intermediaries that connect farmers and consumers while building education, relationships, markets, and community capacity.13 State and local governments may also have policy tools to support local purchasing, although the legal options depend on the funding source and applicable procurement rules.14 RHTP should therefore treat procurement strategy and food-system capacity as part of health infrastructure, not simply as downstream implementation choices.
2. Measure Network Adequacy Through Community Resilience
Health care has long measured provider network adequacy. Rural Food is Medicine also depends on food-system adequacy. The goal is not local self-sufficiency or having every food available locally in every season; resilient systems require diversification, redundancy, and the ability to adapt across local, regional, and broader supply channels. Network adequacy should therefore be evaluated under dynamic conditions, such as demand variability, disruptions, information delays, seasonality, and changing operating environments, rather than only under expected conditions.15 For a Food is Medicine network, dynamic network adequacy would answer these questions: Can local farms adjust to changing demand and growing seasons? Can food hubs aggregate and distribute food when a major supplier or transportation route fails? Can community organizations continue reaching isolated households during disasters? Can the network shift sourcing or delivery strategies when benefits, infrastructure, or supply chains are disrupted?
Hurricane Helene illustrated the importance of social capital and community networks during a major disruption in Western North Carolina.16 For example, Caja’s infrastructure was resilient in the aftermath of Hurricane Helene, and we continued purchasing from local farms and sharing food with the community without disruption. These experiences suggest that resilience itself is a form of community health infrastructure. Measuring network adequacy should therefore include not only provider counts and geographic coverage, but also adaptability, redundancy, relationships, and the capacity to maintain essential functions under stress.
3. Build Appropriate, Interoperable Technologies
Innovation in rural Food is Medicine should be measured in part by whether technological supports are resilient, accessible, equitable, and interoperable.17 Small farms, food hubs, community organizations, and rural clinics need technologies that are affordable, multilingual, secure, and designed around existing workflows. Nonprofit organizations may face distinct barriers to technology adoption, including limited capacity, competing operational priorities, and implementation burden.18 Open source and interoperable systems can help organizations of different sizes participate without forcing every partner into expensive or highly specialized infrastructure. Technology should make coordination easier and information more useful and not shift administrative complexity downstream to the organizations closest to communities.
4. Share Production and Payment Risk Across the Health System
As a farm, Caja makes production decisions each winter, months before crops are harvested or Food is Medicine services are delivered. Yet program funding and service volume may remain uncertain until long after those decisions have been made. HOP also demonstrated the cash-flow implications of reimbursing community organizations after service delivery: in the program’s first rapid-cycle assessment, 56.2% of invoices were paid within 30 days, 90.3% within 60 days, and 97.9% within 90 days.19 For farm-based organizations, that lag can mean financing production, purchasing food from farm partners, delivering services, and carrying operating costs before reimbursement arrives.
Payment design should not default production, eligibility, documentation, or payment risk to the smallest organizations in the system. Health care already uses prospective payments,
shared-risk arrangements, bundled payments, and other mechanisms to distribute financial risk and reward outcomes. Food is Medicine financing can draw from the same principle: payment arrangements should support viable service delivery, timely cash flow, and transparent allocation of risk across payers, intermediaries, community organizations, and producers. This is also a question of responsible financial stewardship: a payment model is not sustainable if apparent savings for one stakeholder are achieved by transferring uncompensated risk or administrative burden to another.9
A strong rural health infrastructure would equip farmers and community-based Food is Medicine organizations to enter negotiations with network hubs, health plans, and health care systems with a clear understanding of their true costs, service requirements, and contractual risks. Farmers and community organizations should not have to finance the health care system’s food interventions through their own operating capital. Sustainable payment design must recognize the full cost of readiness, service delivery, administration, and the capacity required to remain available when communities need it most.
5. Treat Community Knowledge as Infrastructure
Local Food is Medicine organizations generate more than meals. They generate knowledge and the capacity to be nimble and responsive to changing local conditions. Community organizations learn which crops thrive locally, which foods carry cultural meaning, which distribution models reach isolated households, and which partnerships foster trust. These insights should remain assets of the communities and organizations that generate them, not only on principle, but because the conditions are living and dynamic. Culture, growing seasons, microclimates, road conditions, partnerships, and household realities constantly change. Local organizations are the infrastructure that can detect and respond to those changes. Data governance, open standards, and shared learning networks are therefore as important to long-term resilience as roads, warehouses, or software.12,17
The visible products of Food is Medicine are healthier diets, improved clinical outcomes, and lower health care spending.4,5 With local procurement and community engagement, its less visible products can include stronger farms, healthier local economies, trusted relationships, resilient supply chains, skilled workforces, community knowledge, and local institutions with greater capacity to care for their neighbors.8,10 These outcomes are interconnected: value experienced by a participant can strengthen an organization; stronger organizations can stabilize a network; and a more resilient network can improve population and community health. That broader-value ecosystem is easy to miss when evaluation focuses on a single stakeholder or outcome.10 Like the roots beneath the pawpaw tree, these systems are easy to overlook precisely because, when they work, they make everything above ground possible.
Conclusion
North Carolina’s RHTP offers a rare opportunity to invest below ground. If we cultivate the living infrastructure of Food is Medicine alongside its clinical interventions and measure the value created for people, organizations, health systems, and communities, we achieve far more than healthier patients.9
Acknowledgments
We would like to thank Kathryn Jantz and Hannah Erickson for their helpful review and commentary.
Financial Support
The authors received no financial support for the development of this commentary.
Declaration of Interests
The authors have no conflicts of interest to disclose.
Correspondence
Address correspondence to Sonya Jones, 75 Bryson Road, Mills River, NC 28759