Healthy Communities: The Movement
by Monte Roulier and Michael McGrath, Partnership Perspectives, Spring 1998

    When Tom McGuiness heard that a small West Covina, California, health clinic was closing because of money problems, he did what only a few years ago would have been unthinkable -- he went to his employer, Queen of the Valley Hospital, and asked for $68,000 to keep the clinic open. Although the clinic, which served mostly low-income patients, was in no way affiliated with the San Gabriel Valley health consortium that McGuiness works for, it was an important community asset with links to other community institutions. If the clinic closed, he reasoned, thousands of uninsured patients would wind up in the emergency rooms of hospitals like Queen of the Valley.

    As part of an innovative new community partnership, the clinic has been expanded and refurbished with hand-me-down furniture from area hospitals. Area hospitals also do lab work for the clinic. In exchange, the clinic staffers have agreed to treat hundreds of area homeless people for free and to train peer health counselors at a nearby high school. This new partnership is only one of scores of collaborative projects funded by Citrus Valley Partners, a consortium of three hospitals that is expanding the definition of health in the San Gabriel Valley with its "community benefits program."

    McGuiness has gained widespread recognition for his successes in pulling together collaboratives among 18 cities, 14 school districts and countless nonprofit agencies in the valley. In one instance, he convinced a food wholesaler to provide food to food banks and senior centers for a fraction of the cost. Only a few years ago, McGuiness was a hospital vice president with a desk job. Now, more often than not, he finds himself out in the community looking for solutions, sharing ideas, pooling talents and creating partnerships. Those who know McGuiness know that the business rationale for what he and his institution are doing is matched with a moral rational: they are part of the community as neighbors and fellow citizens.

    McGuiness exemplifies a new approach to both health care and community renewal, the "healthy communities" movement, which draws on the energy and resources of health care institutions as well as business, non-profit organizations and, particularly, grassroots community groups and individuals. Healthy communities proponents are taking on issues not ordinarily associated with health care delivery -- education, economic development, public safety, transportation, to name a few.

    Leaders like McGuiness view citizens as assets rather than simply clients or customers. They realize that health care systems can't do it alone (nor can any single sector), although they have tremendous impact and can leverage vast resources. These leaders tap into the often-underutilized resources -- community-based organizations and associations, local businesses and individual citizens. They look to mobilize entire communities, not just through funding, but also by improving their capacity to solve their own problems.

    The healthy communities movement has been spurred along by a series of new realities in American communities. The movement away from federal spending on social issues has put more emphasis on local and regional community problem solving. There is a growing sense that many of our communities are disconnected and gripped with unsolvable social pathologies. And the sweeping changes in health care institutions, as well as the move toward managed care with its emphasis on cost containment, have caused citizens, employers and employees to struggle with health care concerns. All of the above mentioned factors have increased interest in the need for community-wide approaches that go more deeply and broadly to the root health care problems.

    Another factor that has aided the growth of the healthy communities movement is the growing philosophical interest in basic questions of civic and community life. Writers and social thinkers such as Robert Putnam, Paul DuBois, Frances Moore Lappe and John Gardner have focused attention on the importance of community identity and capacity as important first steps toward solving social problems. Others such as John McKnight and John Kretzmann have developed a practical approach for communities to identify and build on their assets rather than focus on their deficits and needs. These ideas have gained influence among decision-makers in the public, private and nonprofit sectors. More and more philanthropic foundations are seeking to fund strategies that help rebuild the unofficial community links or "civic infrastructure" that allow communities to effectively function. More and more government agencies are seeking to find ways of "leveraging" public resources by linking up with private and nonprofit groups to deliver services and address social needs.

    Many proponents see healthy communities as something broader than an attempt to improve the physical health of communities. They see it as an attempt to improve the quality of life, share power among groups and individuals, develop social capital and rekindle a spirit of community democracy.

    In some cases, these initiatives arise from institutional arrangements such as the Citrus Valley Health Partner's community benefit program. In other cases, these initiatives may arise from grassroots community-wide planning processes, which are largely citizen-led by nature. These initiatives include the broad interests and perspectives of a community in an effort to define a future vision of their community and to take the steps necessary to fulfill that vision.

    An example of how the healthy communities movement views problem solving is the Chicago suburb of Lawndale, Illinois. In recent years, the teen pregnancy rate among high school girls had exceeded 30 percent. Some might assume this to be expected from an impoverished community where over 50 percent of the resident live below the poverty line. But the situation in Lawndale took a surprising turn when leaders from churches, schools, hospitals, civic organization, and local government emerged to reclaim responsibility for their young people the future of their community. Lawndale did not wait for money from the federal government or foundations. They decided to tap into existing community assets rather than focus on needs or deficits.

    These assets came in the form of volunteers -- from retired seniors to local business people. They developed a comprehensive mentoring program in which every teenager in high school was teamed with an adult in the community. The program required few financial resources, but the community began to re-establish a culture of embracing its young people. Within two years, one of the partners, Sinai Hospital, confirmed that the teen pregnancy rate had been reduced by nearly 100 percent.

    There are many other examples of healthy communities initiatives. In South Bend, Indiana, Memorial Hospital "tithes" from its net revenues to benefit initiatives to improve the community's overall quality of life. In Central Oklahoma, local officials from across the region meet regularly to develop and act on regional strategies for transportation, economic development, air quality and crime prevention. All of these initiatives have resulted from healthy communities efforts, and "healthy communities thinking."

    The historic roots of this movement go back to the Healthy Towns movement in mid-19th Century Britain to improve the health of the working poor in Britain's growing industrial cities. A Healthy Towns commission looked into the causes of health and saw a direct correlation between poor health and the conditions within those towns and cities. The work of this particular movement, which spread to American and other parts of Europe, led to major improvements in public health and sanitation measures such as housing standards, sewers, hygiene measures and sanitary water supplies.

    The modern Healthy Communities movement, however, was sparked by the World Health Organization in 1986. In 1988, the National Civic League was selected by the U.S. Public Health Service to develop and implement a national healthy communities initiative. The first Conference on Healthy Cities and Communities in the United States was organized in San Francisco in 1993 by Len Duhl, a UC Berkeley public health professor and leading advocate of the movement. The conference attracted delegates from all over the world and stimulated greater interest in the United States. Since then, hundreds of American cities have undertaken healthy communities projects.

     As Tyler Norris, Director of the recently formed Coalition for Healthier Cities and Communities has argued, "health" has become a metaphor for a broader set of concerns. "Health," he says, "is a common denominator that cuts easily across lines of race, class, culture, and sector. The health metaphor has proved to be a gateway for citizen re-engagement in community renewal. The question: `What is a healthy community?' usually elicits a clear and relevant answer whether it is asked of a business executive, a homemaker, or a child."

    Advocates like Norris argue that healthy communities are directly linked to other contemporary efforts that may not use the health metaphor. These efforts go under various names such as "sustainable communities," "livable communities," "good communities," "safe communities," or "caring communities."

    "Some focus on health care," says Norris, "others focus on the relationship between the economy, the environment, and social equity. Still others focus on youth and family issues or increased civic participation."

    Another facet of healthy communities is the effort to develop tangible "indicators" of community health or sustainability by which to measure progress and success. More than one hundred communities nationwide have launched efforts to develop and measure community indicators. Many of these efforts are being undertaken in conjunction with community-wide planning processes. The indicators help them focus their ideas on what a healthy community should look like which then in turn can be used to monitor progress on any number of areas. This, again, is significantly different than the common approach of identifying and measuring only community needs and deficits.

    One of the main features of the healthy communities movement is the emphasis placed on systemic thinking. In most cases, communities have problems or unmet needs because of systems that aren't working. Hospitals and medical intervention can only go so far in improving the health of a community without deep systemic change. For example, the best trauma care center in the world cannot improve individual or community health when widespread unemployment, little access to educational resources, and an unclean environment are at the root of health problems. To really foster healthier individuals and communities, action must be taken to create the conditions in which health in the broadest sense can thrive -- conditions which ensure essentials such as safe, clean living environments, meaningful employment and accessibility to education.

    To sustain systemic change means that the community itself has to become a "learning community." In other words, it must create the capacity for the whole community to learn to work together in new ways. Building healthier communities is an ongoing process, not a finite set of unconnected projects. A healthy communities initiative can stimulate that kind of community-wide learning by bringing together groups and individuals that may not have worked together in the past. The underlying assumption is that community change will not be lasting or deep unless there is really a meaningful level of grassroots buy-in. That explains why a healthy community initiative can sometimes seem to be more about grassroots democracy and citizen-based decision-making than about health itself.

    In conclusion, the growth of the healthy communities movement is the result of two important recent trends -- the need for health care institutions to respond to changing realities by developing a broader definition of health and collaborating with citizens and other institutions within the community, and the need (or desire) for citizens to have a deeper conversation about the future of their communities, a conversation that is linked to responsibility and action. Whether viewed as a metaphor or a desired outcome, the "healthy communities" idea has proved to be a valuable impetus for positive community change.

    While many of the premises and ideas embraced by the healthy communities movement are not new ones, the action taken based on these ideas is unprecedented. But if fresh initiatives and approaches can continue to demonstrate results, the movement will be credited with a profound change in the way all of us think and act on behalf of our communities and a profound change in the way we understand the term "health."

Authors' Note: Because of their tremendous resources--fiscal, intellectual and volunteer--institutions of higher education, like health care institutions, need to find new and creative ways to contribute to the health of their respective communities. Academic institutions have a history, credibility, and a wealth of resources that cannot be found in any other institution. When these institutions are fully committed to community partnerships and the spirit of healthy communities thinking, extraordinary results are sure to follow.


Monte Roulier is the Senior Community Advisor for the National Civic League. In this capacity, he delivers technical assistance in the areas of strategic planning, conflict resolution, leadership development and performance measurement for communities, non-profit organizations and local government. He also directs NCL's Healthy Communities' Program. Monte is also a board member of Community-Campus Partnerships for Health.

Michael McGrath is Director of National Civic League Press in Denver, CO. He is also editor of the National Civic Review, a quarterly journal on civic affairs. Before joining the National Civic League, he worked as a reporter and editor for newspapers in Colorado and California.