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If you were to try and list the biggest game-changers for the American food system in the last two decades, you might note the Food Network, or the writing of Michael Pollan, or maybe even the evolution of Walmart.

But you'd probably overlook NAFTA, the North American Free Trade Agreement.

And that would be a mistake, according to a lengthy report out early February from the U.S. Department of Agriculture.

In one fell swoop, the report finds, President Bill Clinton's 1994 landmark legislation unleashed a dizzying array of market forces on agriculture, with vast long-term impacts. And with greater access to the neighboring markets, farmers and other food producers in the U.S., Mexico and Canada have helped reshape diets in some pretty significant ways.

The Salt

The Fruits Of Free Trade: How NAFTA Revamped The American Diet

The Salt

Mexican Megafarms Supplying U.S. Market Are Rife With Labor Abuses

If you take the report at face value, NAFTA has greatly increased the "economic integration" between the U.S., Mexico and Canada. Instead of giving preferential treatment to domestic products by imposing tariffs on imports, the three NAFTA countries let goods flow relatively freely between them. And that includes food — a lot of it.

Today, Americans consume twice as much fruit, and three times as many vegetables, from both Mexico and Canada as we did two decades ago, according to the report. A parade of greenhouse tomatoes, peppers and cucumbers now come down, often by truck, from Canada. From Mexico, we've seen huge increases in imports of seasonal fruit.

Mexican berries are an obvious example, but 20 percent of the imported watermelon we consumed in 2010-2012 also came from Mexico, compared with 5 percent in 1991-1993. As for imported avocados, 49 percent now come from Mexico, up from 0 in 1991-1993. Lots more tomatoes and papaya are coming from south of the border, too.

This produce trade boom, says the report, is only partly a product of tariff changes. It's also a result of the improved food safety standards now in place in Mexican fields, which allow more produce to get past U.S. inspectors.

But while NAFTA has largely meant that we're getting more of our favorite fresh foods from our next-door neighbors, the USDA suggests that NAFTA is profoundly transforming the food system in Mexico, sometimes in less healthful ways.

While Mexico is now the largest market for American apples and pears, U.S. meat exports to Mexico have doubled in the last two decades. Our exports of feed corn for livestock also now account for nearly one-third of the country's supply — meaning that even when Mexicans eat domestic meat, it's often been fed on American corn.

But the biggest change is how much more processed food and American-style supermarkets our neighbors have been importing. Indeed, American investment in Mexican food manufacturing — rather than agriculture, for example — has tripled since 1999, as have sales of American processed food products there.

American companies are also sending Mexico the ingredients to make foods like high-fructose corn syrup; HFCS exports to Mexico are now 863 times what they were before NAFTA. And all of that ends upon the shelves of supermarkets, whose business model relies heavily on processed food. Walmart, which opened its first Mexican store in 1991, four years after it began selling groceries, now operates 2,114 stores that offer food in Mexico.

You've likely heard that America's in the middle of a craft beer revolution. Well, we're also, apparently, swooning for cerveza de Mexico. In 2013, we imported about 2 million tons of Coronas and Modelos, making beer Mexico's largest agricultural export to the U.S.

The Salt

With Cartels On The Run, Mexican Lime Farmers Keep More Of The Green

While we may be glad that Corona is now plentiful across the U.S. (and that we're washing down more guacamole made with Mexican limes and avocados with it), there is a dark side to how NAFTA has reshaped the region's food systems: working conditions. And you won't find much exploration of that in the USDA report.

While the USDA report discusses immigration and guest worker programs, it does not address the disconnect between improved attention to produce without a corresponding attention to workers' welfare. As a recent Los Angeles Times investigation of Mexican farms growing tomatoes bound for the U.S. market found, "The contrast between the treatment of produce and of people is stark."

Mexico has also likely paid a price for opening its gates to so much processed food laden with high-fructose syrup and other not-so healthful ingredients. As the Institute for Agriculture and Trade Policy, a Minnesota-based think tank, has shown, Mexico's recent spike in obesity and soda consumption correlates with the passage of NAFTA.

Tracie McMillan is the author of The American Way of Eating, a New York Times bestseller, and a senior fellow at the Schuster Institute for Investigative Journalism at Brandeis University. You can follow her on Twitter @tmmcmillan.

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She's the brains and showrunner behind two hit BET series — The Game and Being Mary Jane. He's a producer and director with credits including Jumping The Broom and Sparkle.

Together, Mara Brock Akil and Salim Akil make a powerhouse Hollywood creative team and couple who have created some of the most iconic African American characters on television.

They shared their "must-see" lists with Morning Edition Host Steve Inskeep — shows and movies that Salim Akil says, "really represent being an American."

Middle of Nowhere

The 2012 film from Selma director Ava DuVernay follows the story of a woman who is faithfully waiting for her husband's release from prison after an eight-year sentence. Then she finds out that her husband had an affair while in prison.

"It's about sort of her journey to let go and choose herself," Mara Brock Akil says. "Also I love how Ava [DuVernay] explores the hardship of what the prison system has done [to] families.

"It's not just punishing the criminal," she says. "It's punishing the whole family."

Do the Right Thing

In Spike Lee's 1989 film, Radio Raheem is a young black man who carries around a giant boom box playing "Fight the Power" by Public Enemy.

"When you talk about young black men walking around with radios blasting their music, all of a sudden it becomes a threat," Salim Akil says.

"I have two little black boys," Akil says. "And a film like Do the Right Thing can help illuminate the times for them with great storytelling.

"When I tell my 10-year old that 'Hey look man, you can't run through that wealthy neighborhood [...] Because if you do, a police officer may see you and he's not thinking you're outside having fun, he's thinking you're running away from something, that you've done something.'"

Do the Right Thing, Akil says, shows those types of conversations and in a way that still feels relevant today.

Getting On

HBO's Getting On is a dark comedy series about life in the geriatric ward of a hospital. "It's a place where people go to die," says Mara Brock Akil. "Who are the people caring for these patients?"

One of them is played by Niecy Nash, who Brock Akil says breaks the mold of the "sassy black woman" stereotype. "Her portrayal of the character is just so beautiful. Although it's just a job in some ways for her, she's reminded that [the patients are] people, and I think that's a good message to always remember."

Cooley High

"Michael Schultz's Cooley High is a classic," says Salim Akil. "Often times we don't get to see films about coming of age, especially for young African Americans."

Set in Chicago in the 1960's, the movies is about two black high school students at Edwin G. Cooley Vocational High School. Their lives change dramatically after they meet a pair of career criminals and get falsely arrested in connection with a car theft.

Akil says one of the powerful issues in the film is how young people's paths diverge. "Most guys have to go through this: When do you separate yourself from your friends?" Akil says. "Some of them are going to go left, some of them are going to go right, some are going to go straight. And you have to go on your path."

Akil remembers he had a really good friend in high school who wound up in the drug trade.

"You have to make those sorts of decisions and I think Cooley High really illuminates in a fun way but also in a dramatic way, the idea of growing up and making choices," Salim Akil says. "And we need those kinds of films."

This is the latest story from the NPR Cities Project.

In an abandoned building near Spain's Mediterranean coast, someone softly strums a guitar. Chord progressions echo through empty halls.

It's an impromptu music lesson, offered among unemployed neighbors in Alfafar, a suburb south of Valencia. The town was built in the 1960s for timber factory workers. It's high-density housing: tidy, identical two- and three-bedroom apartments, in huge blocks — some 7,000 housing units in total.

But the local timber industry has since collapsed. More than 40 percent of local residents are now unemployed. A quarter of homes are vacant. Apartments that sold for $150,000 decades ago, are going for just $20,000 now.

That guitar lesson is just one way residents are using their free time and empty space creatively. And it's here that two young Spanish architects saw potential.

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The Improvistos architects' plans involve revamping the apartments, with minimal structural changes. Neighbors would be able to trade rooms, and share kitchens, roof gardens and office space. Improvistos hide caption

itoggle caption Improvistos

The Improvistos architects' plans involve revamping the apartments, with minimal structural changes. Neighbors would be able to trade rooms, and share kitchens, roof gardens and office space.

Improvistos

While still in architecture school, Mara Garca Mendez and Gonzalo Navarrete drafted a plan to re-design a high-density area of Alfafar, called Barrio Orba, using the principle of co-housing — in which residents trade and share space and resources, depending on their needs.

"It's like up-cycling the neighborhood — connecting existing resources to make them work," Garca explains. "For example, all this work force that's unemployed, all these empty spaces that are without use, all these elderly people that need help, all these natural resources that are not being taken care of — making a project for all these things."

Through their architecture startup Improvistos, Garca and Navarrete submitted their Orba design to U.N. Habitat, a United Nations agency holding a competition for urban mass housing. And they won.

Redefining Public And Private Space

The architects, both in their 20s, were relatively unknown, working in a Spanish region — Valencia — that's famous for soaring space-age designs of museums and other public infrastructure — which have bankrupted the local government.

Valencia's native son is Santiago Calatrava, the famous Spanish architect who's now working on the new Ground Zero transit station in New York.

In contrast to Calatrava's work, the Improvistos architects sketched out a humble plan to revamp some 7,000 nearly identical apartments, with minimal structural changes, to adapt the current structures to residents' changing spatial needs. Neighbors can trade rooms, and share kitchens, roof gardens and office space.

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Architects Mara Garca Mendez and Gonzalo Navarrete sketch out plans to revitalize high-density urban housing in Alfafar, Spain. Courtesy of Improvistos hide caption

itoggle caption Courtesy of Improvistos

Architects Mara Garca Mendez and Gonzalo Navarrete sketch out plans to revitalize high-density urban housing in Alfafar, Spain.

Courtesy of Improvistos

"We're trying to redefine the limit between public and private," Navarrete says. "So the way you walk on your street, and where your house and your private space finishes or starts."

"A thing as simple as creating a new door — having a room with two doors — can give enormous flexibility," Garca chimes in. "So that this same room can be used by one or another, depending on the need."

Their plan also has a time bank element, trading space for services.

"For example, you have an 80-year-old person who needs some help once or twice a week, [living alongside] a family with three children that doesn't get enough income," Garca explains. "So maybe [someone from] the low-income family can help the elderly person once a week, and get, in exchange, one room. It's like an exchange system — so every house can gain or give out some space. And that can change with time."

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About 15 people live at the Threshold Center at Cole Street Farm, a shared living space in the Dorset countryside. Ari Shapiro/NPR hide caption

itoggle caption Ari Shapiro/NPR

About 15 people live at the Threshold Center at Cole Street Farm, a shared living space in the Dorset countryside.

Ari Shapiro/NPR

The Improvisto architects in Alfafar plan to sit down with residents and sketch out how their buildings can adapt to different families' needs. They can add doors, retractable walls and shared space.

Garca and Navarrete, the Spanish architects, came up with the idea on a study trip to rural India — watching how a poor family would enlarge their thatched hut for new children, and share cooking areas with neighbors. The architects think that system can work in the Western world as well.

Collective Living In Rural England

One place it's already working is on England's southwest coast, amid picturesque rolling fields. A decade ago, Jane Stott helped create the Threshold Center at Cole Street Farm, a community that consists of a central 300-year-old farmhouse surrounded by small, low houses and about 15 residents.

The goal here is quite different from in Spain: This isn't about revitalizing an existing neighborhood. It's about creating something new. People have come to the Threshold Center for a variety of reasons, ranging from a desire to live in an environmentally sustainable way to the meditative aspects of living with others.

There are some echoes of life on a commune at the Threshold Center, where there's an optional group meditation each morning and the residents raise chickens.

But everyone also has a day job: among the residents are a nurse, a gardener and a social worker, for instance.

More broadly speaking, each co-housing community is different: Some are very religious; some are very environmentally friendly; some have lots of children; some have lots of seniors.

And the movement is growing: Stott says that when she founded the Threshold Center 10 years ago, she could count on one hand the number of British co-housing arrangements. Now there are more than 35.

Real Solutions For Real People

But the idea is a newer one in Spain, and residents in Alfafar have many questions. Over a traditional Valencia paella, residents of the Orba neighborhood discuss the plan. Some ask, how would the value of a home change, with the addition or subtraction of a room?

But in general they say they're intrigued by the plan — and flattered that the two architects chose their neighborhood for it. Most of Orba's residents have been living side-by-side for decades. They're not strangers.

Take Nacho Campillo and Patricia "Patri" Sanchez, a couple in their early 30s. They've lived in Orba for eight years, and took over Sanchez's grandmother's apartment there when she died. The flat hasn't been renovated since the 1960s.

But the young couple wants to stay in the neighborhood. Sanchez spent her childhood there and loves it — but they need more space. They have a small two-bedroom on the fourth floor with no elevator — and Sanchez is three months pregnant.

"Going up and down four flights of stairs is tiring now, and I'm not sure I'll be physically able to do it when I'm nine months pregnant!" Sanchez exclaims. "And what about the baby's stroller?" she says, exchanging a look with her partner, Campillo, and laughing.

But co-housing may help. The couple may "borrow" a ground-floor bedroom from a neighbor for the last few months of Sanchez's pregnancy — or for stroller storage afterward. The couple currently uses their second bedroom as a home office. But the addition of a shared co-working hub in the apartment complex would free up space for the baby's nursery.

Fusion Of Architecture And Social Policy

People in working-class Alfafar aren't used to getting attention from award-winning architects. The local mayor, Juan Ramon Adsuara, says he's surprised and bewildered by all the interest — but proud his town has been chosen by the architects and awarded the U.N. prize.

"It's not just an architecture project. It's a fusion of architecture and rehabilitation. It's social policy," Adsuara says. "Architecture is not just for big star projects like museums. It's for the slums around them, too."

The big question, though, is how to pay for all this. The U.N. award comes with fame, but no funding. The mayor says the town hall is struggling to pay for basic services — let alone a progressive architecture revamp.

"I need to make payroll for municipal employees — the cleaning staff, the garbage collectors," Adsuara says. "But our economy is improving. We need to think about what model we want for our town's future. And that's where this project comes in."

The Improvistos architects have no price tag for their design. It's adaptable — based on what residents want. They all hope to begin workshops to sketch that out, this spring. The mayor is applying for funding from the European Union, to help launch this project — and also add bike lanes throughout the city. Garca and Navarrete are also thinking about launching a Kickstarter crowd-funding campaign. Residents have volunteered to even do some of the renovation work themselves.

Among all of them, they're determined to change this neighborhood, for the better.

In Medical Park Hospital in Winston-Salem, N.C., Angela Koons is still a little loopy and uncomfortable after wrist surgery. Nurse Suzanne Cammer gently jokes with her. When Koons says she's itchy under her cast, Cammer warns, "Do not stick anything down there to scratch it!" Koons smiles and says, "I know."

Koons tells me Cammer's kind attention and enthusiasm for nursing has helped make the hospital stay more comfortable.

"They've been really nice, very efficient, gave me plenty of blankets because it's really cold in this place," Koons says. Koons and her stepfather, Raymond Zwack agree they'd give Medical Park a perfect 10 on the satisfaction scale.

My poll of the family is informal, but Medicare's been taking actual surveys of patient satisfaction, and hospitals are paying strict attention. The Affordable Care Act ties a portion of the payments Medicare makes to hospitals to how patients rate the facilities.

Medical Park, for example, recently received a $22,000 bonus from Medicare in part because of its sterling results on patient satisfaction surveys.

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Medical Park Hospital's patients tend to be pretty happy customers, leading to thousands of dollars in rewards from Medicare. Novant Health hide caption

itoggle caption Novant Health

Medical Park Hospital's patients tend to be pretty happy customers, leading to thousands of dollars in rewards from Medicare.

Novant Health

Novant Health is Medical Park's parent company, and none of its dozen or so other hospitals even come close to rating that high on patient satisfaction. Figuring out why Medical Park does so well is complicated.

First, says Scott Berger, a staff surgeon, this isn't your typical hospital.

"It kind of feels, almost like a mom-and-pop shop," he says.

Medical Park is really small, only two floors. Doctors just do surgeries, like fixing shoulders and removing prostates, and most of their patients have insurance.

Another key is that no one at Medical Park was rushed to the hospital in an ambulance, or waited a long time in the emergency room. In fact, the hospital doesn't even have an emergency room.

The hospital doesn't tend to do emergency surgeries, says Chief Operating Officer Chad Setliff. These procedures are all elective, scheduled in advance. "So they're choosing to come here," he says. "They're choosing their physician."

These are the built-in advantages that small, specialty hospitals have in terms of patient satisfaction, says Chas Roades, chief research officer with Advisory Board Company, a global health care consulting firm.

"A lot of these metrics that the hospitals are measured on, the game is sort of rigged against [large hospitals]," Roades says.

Shots - Health News

Medicare Starts To Reward Quality, Not Quantity, Of Care

This is the third year hospitals can get bonuses or pay cuts from Medicare (partly determined by those scores) that can add up to hundreds of thousands of dollars.

More typical hospitals that handle many more patients – often massive, noisy, hectic places – are more likely to get penalized, Roades says.

"In particular, the big teaching hospitals, urban trauma centers — those kind of facilities don't tend to do as well in patient satisfaction," he says. Not only are they busy and crowded, but they have many more caregivers interacting with each patient.

Still, Roades says, although patient surveys aren't perfect, they are fair.

"In any other part of the economy," he points out, "if you and I were getting bad service somewhere – if we weren't happy with our auto mechanic or we weren't happy with where we went to get our haircut – we'd go somewhere else." In health care, though, patients rarely have that choice. So Roades thinks the evaluation of any hospital's quality should include a measurement of what patients think.

Shots - Health News

Hospitals' Medicare Quality Bonuses Get Wiped Out By Penalties

Medical Park executives say there are ways big hospitals can seem smaller — and raise their scores. Sometimes it starts with communication – long before the patient shows up for treatment.

On my recent visit, Gennie Tedde, a nurse at Medical Park, is giving Jeremy Silkstone an idea of what to expect after his scheduled surgery – which is still a week or two away. The hospital sees these conversations as a chance to connect with patients, allay fears, and prepare them for what can be a painful process.

"It's very important that you have realistic expectations about pain after surgery," Tedde explains to Silkstone. "It's realistic to expect some versus none."

Medical Park now handles this part of surgery prep for some of the bigger hospitals in its network. Silkstone, for example, will have surgery at the huge hospital right across the street — Forsyth Medical Center.

Carol Smith, the director of Medical Park's nursing staff, says that after she and her colleagues took over these pre-surgical briefings, "Forsyth's outpatient surgical scores increased by 10 percent."

But some doctors and patients who have been to both hospitals agree that the smaller one is destined to have higher scores. It is just warmer and fuzzier, one patient says.

This story is part of NPR's reporting partnership WFAE and Kaiser Health News.

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