The Next Wave: Healthy Communities and Public Policy
from Health Forum Journal, January/February 2000
By Christopher Freeman Adams


Abstract:

As healthy community initiatives across the nation mature, many of them are discovering that their work in building community consensus about improving health and quality of life can be transformed into public policy. This article shows how healthy community initiatives have had important effects on policymaking at both the county and state levels.

Background

"Imagine.it's the year 2020 and Lancaster County is a community of neighbors who, though diverse and from many different cultures, have joined together to create a high quality of life for all residents." These are the opening words of the county-wide vision contained in the Lancaster County, Pennsylvania Comprehensive Plan.

Given that just a few years ago the County Comprehensive Plan was essentially a land use document, this is a remarkable change. What has brought about this evolution? According to County Commissioner Ron Ford, the major reason is Lancaster Healthy Communities, the five year-old effort created in partnership with the county's five hospitals to involve citizens in improving health and quality of life.

The Vision statement goes on to say, "Our County is a well-planned, healthy, and safe community where people are valued for both their civic contributions and their strong family lives. Education is lifelong, and recreational, arts and cultural opportunities are plentiful. We enjoy a high level of physical and mental well-being."

"The healthy communities movement," says Ford, "has made us rethink the Comprehensive Plan. Historically it has been about open space, land use issues and natural resources. One result of the healthy communities movement is that it now includes social issues-such as education, housing, and cultural opportunities."

Lancaster County Administrator Timothea Kirchner adds, "What we have done so successfully is to marry the comprehensive plan with the vision that Healthy Communities came up with. For example, now we see that land preservation and strong families are married to each other. The two are together because one depends on the other. There have been major changes as a result of the participation of the healthy communities initiative."

A Partnership That Works - The Lancaster, PA Story

Though Lancaster County is fortunate to have the combination of forward thinking hospital leaders and progressive elected officials who have capitalized on the opportunities presented through the healthy communities movement, it is not unique. As the healthy communities movement in this nation matures-last November it celebrated its tenth birthday-one of the most important outcomes is that local initiatives are starting to influence public policy in meaningful ways. And in the process, those hospitals that have chosen the healthy communities model as a way to serve their community are seeing tremendous dividends.

According to Alice Yoder, Director of Community Healthy at Lancaster General Hospital, one of the founding hospitals, "The Commissioners have worked with our movement to get a finger on the pulse of what people want for the future of Lancaster County." In this case, the people wanted the Commissioners to integrate traditional planning concerns with health and quality of life issues.

The recently adopted Policy Plan reflects these concerns. It includes six Key Focus Areas: Protecting and preserving our natural and cultural heritage; Revitalizing our urban communities; Developing livable communities; Creating a sustainable economy; Celebrating, investing in, and mobilizing the talents of our human resources; and Promoting strong leadership, awareness, responsibility, and involvement in community issues.

Some of the actions called for in the plan include encouraging businesses to permit flex-hours and job sharing in order to support the increasing number of two-wage earner and single-parent households, providing incentives for carpooling and the use of mass transit, adopting zoning regulations that encourage traditional neighborhood design elements such as shallow building setbacks, front porches, narrow streets, alleys and sidewalks, and making citizen participation the cornerstone of every planning process.

One of the actions that the Policy Plan calls for and has already acted on is to use community indicators to gauge progress toward a healthy and sustainable community. Community indicators are a set of items to measure that help show progress (or lack of progress) toward goals. Lancaster Healthy Communities has played a lead role in both developing the set of indicators and will help monitor them.

The partnerships in Lancaster County between the healthy communities initiative, government, businesses, civic organizations, schools and others has provided a way both to envision the best possible community and to make it a reality. According to Kirchner, "The partnerships ensure that what the initiative comes up with is more than just a nice group of people who say that they would love for the world to work a certain way. County government is pragmatic-it deals with the toughest problems. In this partnership we add the practicality and healthy communities provides us with the vision."

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Helping Government Work the Way It Should - Summit County, CO

In the heart of Colorado's Rocky Mountains, another healthy communities initiative is making a major contribution to improving health and quality of life for residents of Summit County. Shaping Our Summit (SOS) is one of the initiatives started with a grant from the Colorado Trust (a foundation created from the proceeds of the sale of Presbyterian/St. Luke's Medical Center in Denver) and is committed to the goal of creating opportunities for civic involvement.

Through numerous stakeholder meetings since 1994, residents have identified growth as a key issue for the county. The stunning beauty of the mountains and the great ski conditions are attracting so many people-both residents and owners of vacation homes-that the very qualities that bring people to this place threaten its demise.

Realizing that this is a long-term problem that requires long-term solutions, SOS has created the Summit County Citizens Planning Academy, a seven-session course offered in collaboration with Colorado Mountain College. According to SOS director Jennifer Pratt Miles, "One of the major problems is that the average citizen wants to become involved in the planning process only after they see a bulldozer headed for their favorite meadow. But that is too late. If they want to be effective they have to begin during the master planning."

The Academy covers issues such as how the planning process works, zoning regulations, the private sector perspective and how citizens can be effective players in this process.

County Commissioner Gary Lindstrom sees the increased citizen participation that SOS helps to bring about as a distinct advantage to an elected official. "I see this," he says, "as an opportunity to make government work the way it should." And when government works the way it should, the health and quality of life of a community is improved.

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Mobilizing the People - The Burlington, VT Story

Burlington, Vermont's Champlain Initiative was created in 1994 when the area's two major hospitals, a physician group and the medical school announced the possibility of a merger. Seeking to make this eminent transition a positive experience, the local United Way convened a series of meetings to discuss the overall health of the community. After assembling a diverse group of people from the community, this group made an important discovery. "We quickly came to the realization," said Martha Maksym, vice president of the United Way of Chittenden County, "that 90 percent of what constitutes the health of a community has nothing to do with medical care. Feeling safe on your street, safe in your home, having a healthy economy, these and other non-medical factors make for a healthy community."

One of the key players in creating and sustaining the Champlain Initiative was Fletcher Allen Healthcare, the newly merged health system which has offered financial and staff support. The other key player was the United Way, which has lent administrative services. Their shared goal was to enable a broad-based community wide effort. Rosemary Dale, vice president of Community Health Improvement at Fletcher Allen Healthcare, says, "There was a need to create partnerships to make a difference in our community."

One way that it has and is continuing to make a difference is by using its network of concerned citizens to make better policy for the state. Last summer with only four weeks notice the Governor announced a summit on youth. In order to ensure a strong and articulate voice at the summit, the Champlain Initiative worked through its Our Children, Our Future task force to get the word out to youth. Over 700 youths and parents attended, and 200 more were turned away due to lack of space.

"This was just remarkable to me," said Dr. Paula Duncan, a senior aide to the State Secretary of Human Services. "They have created the civic infrastructure for dialogue and communication to happen at unprecedented levels. This is changing the way we do business." This civic infrastructure is one of the most valuable outcomes of a healthy community initiative. It is the basic network of relationships that insures that community voices can communicate effectively with policymakers. In the most effective healthy communities this civic infrastructure is intentionally built. But even when it is not done intentionally, any community that undertakes the process of becoming healthier increases this capacity.

In Vermont one of the results of this civic infrastructure is that the state Board of Education is actively considering a proposal that came out of the summit to place youth representatives on the board-an action that would itself help extend the civic infrastructure. In addition, a dialogue has been opened between the governor and youths about how to address youth issues, with the commitment that if a good proposal emerges it will receive favorable funding consideration.

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From the Ground Up-California Smoke-Free Cities

Probably the most dramatic example of a healthy communities-approach influencing policy-and in turn, improving health and quality of life-comes from California Healthy Cities and Communities. In 1990, this organization used funds generated by the tobacco tax to sponsor California Smoke-Free Cities (CSFC), an initiative that used healthy communities principles and tools to fight the health hazard of second-hand tobacco smoke.

Relying on the principle of broad-based participation and the tool of education, the project supported cities in passing smoke-free ordinances by providing training and consultation to local officials. In California, as in most states, city officials are not usually accustomed to dealing directly with health issues, so education was crucial. Information offered to them included facts about the health threat posed by second-hand smoke, what other cities had done to fight it, the availability of resources to begin a tobacco control campaign, and what could be expected from an organized opposition. After a few hard won battles with the tobacco industry at the local level, a pool of local officials emerged as leaders in the effort to educate others in municipal government.

One outcome of this work that built on the wave of local ordinances that were passed from 1990 to 1993, was the passage of a state law that banned smoking in all workplaces, including bars, in 1994. Even though it is still early to measure the health effects of the legislation, the California Department of Health Services announced in 1998 that cancer incidence and deaths in the state are declining at rates faster than the nation as a whole. Former State Health Director, Kim Belshé remarked, "We are just beginning to see the long-term impact of the reduction in tobacco use in California."

By focusing on policy at the local level where the tobacco industry has less clout, this citizen-driven approach to tobacco regulation has been successful, whereas efforts at higher levels of government often have not. The healthy communities-approach capitalizes on the power of local people taking control of their own health and quality of life. According to CSFC Coordinator Anne Klink, "One of the important side effects of this project was the creation of an opportunity for citizens to become involved in fighting for something important, something close to home-and winning."

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Community Voices/Community Dreams - the Key to Effective Policy-Making

Healthy communities initiatives and approaches often begin with the seemingly simple question, "What would make your community a healthier community?" But they never end there. The answer to this question-actually the ongoing process of answering it-has brought many initiatives (and projects such as CSFC) to the point where they are able to articulate in a strong and clear voice what they need and what they want from government. And to the surprise of many of the participants, they are finding that government is eager to hear what they have to say. The healthy communities principles of a broad definition of health, broad public participation, consensus-building and others are beginning to reshape how public policy is made as well as the eventual policy itself.

At the national level, the Coalition for Healthier Cities and Communities will release the Healthy Communities Agenda Action Guide on January 25, 2000. Based on hundreds of dialogues that included nearly 2000 people, the Action Guide will identify common patterns in a healthy community-such as an ongoing dialogue about improving health and quality of life-and will include policies and actions that will help communities incorporate these patterns into the shared life of their own communities. Information on the Agenda can be found at healthycommunities.org.

Building a healthier community is neither quick nor easy. According to County Administrator Kirchner, "This is tough, tough work. You have to devote a whole lot of time to this-even just to get to know each other. But it's worth it." Communities across the country are discovering everyday that she is right: it is worth it.

Christopher Freeman Adams (chris@chris-adams.com) is president of Healthy Outcomes, and frequently writes and speaks about healthy communities.