Empowering communities may be the best way to improve health
by Tyler Norris, In Context, #39, Summer 1994
There is an old Italian saying that "a toothache isn't a problem ... unless it's in your own mouth." In the case of the health care system, the toothache is in all of our mouths because along with prisons, the medical care system has become central to our downstream fix for the ills of society. No matter where we live there is no getting away from the moral implications and high costs of poor health in our communities.
While spending on health care services will exceed an estimated $1 trillion in 1994, the health of many segments of our society continues to decline. The US Department of Health and Human Services reports that the health and socioeconomic status of African Americans, Hispanics, Native Americans, and low-income Americans continues to fall, contributing to continuing racial and ethnic tensions.
We need to focus on the factors that produce good health in the first place - creating healthy communities from the ground up.
The Origins of Health
The health of individuals and their communities is largely the product of our social environments, incomes, and the choices we make as individuals and as members of our communities.
Mark Lelonde of the Canadian Health Ministry has developed a Health Field Conceptual Model - Influence Factors on Health Status. He has found health is 50 percent lifestyle and behavior, 20 percent environment and socioeconomic factors, 20 percent human biology, and 10 percent medical care and access.
A study published last year in the Journal of the American Medical Association supports findings that show we need to address the root causes of preventable illness in the community. "Half of all deaths in the United States" before age 75 may be attributed to "external nongenetic factors." At the top of the list: tobacco (400,000 deaths); diet and activity patterns (300,000); and alcohol (100,000). All three are "rooted in behavioral choices." The article goes on to say that behavior is not changed by knowledge alone, but instead by "a supportive environment and the availability of facilitative services."
Creating Healthy Communities
A welcome movement is afoot in America and around the world to improve our health and quality of life. Now 1,500 locations strong worldwide, "Healthy Communities Initiatives" address the "upstream" issues of how we get and stay healthy as people and as a society. The initiatives begin at the health care discussion's roots by considering the interconnected factors contributing to health and quality of life.
Healthy communities focus on the total community - social, economic, geographic, and political - as the ideal context for health promotion. For this reason, private citizens and the business, nonprofit, and governmental sectors work cooperatively to identify issues and find solutions to them.
The Concerned Citizens of Tillery, North Carolina, for example, working with almost no financial resources, converted a potato shack into a health clinic, helping each other to screen for diabetes and learn about nutrition. Because they needed to cut back on fried foods, they relearned how to cook. They taught themselves to walk and exercise more. They took on the big commercial stock farms that were polluting their water supply and poisoning their children. As a result, they have dramatically lowered their heart disease and cancer rates, and are dealing with diabetes.
This process began with a community making explicit its shared values and developing a shared vision. This is a unifying process that provides a basis for making hard choices. Healthy communities then develop a specific action plan and implementation strategy to bring their plan to life. This commitment to the future supports the development of long-term, leveraged initiatives instead of Band-aid projects.
Creating healthy communities inevitably involves systems change, not just developing "another project." Communities need to look at how services are delivered, information is shared, local governments operate, and business is conducted.
In Fort Wayne, Indiana, for example, this approach led to the recognition that crime peaked between the hours of 5 a.m. and 7 a.m., a time when garbage trucks are out in force. The citizens bought their garbage haulers two-way radios to connect with police. These public servants have cut the morning crime rate.
Ultimately, the most substantial cost-saver is helping people realize their potential - physically, intellectually, professionally, emotionally and spiritually.
Boston's Allston-Brighton neighborhood residents are experiencing a greater sense of community, increased safety on the streets, and an ability to directly impact the quality of their lives through the efforts of Healthy Boston. One long-time resident said, "I've been here for 27 years and until the Healthy Boston project, I had never felt heard. Until now I never felt that I could be a part of something important for my community."
America's problems are not resource problems. Our economic and political problems are derivatives of a larger issue concerning our compassion and priorities. Bring people together, in a constructive process with good information, and they will create good results and take responsibility for them.
A New Role for Hospitals
Ninety percent of what we need to generate good health is found outside the health care system. For hospitals and health care systems to do their job in the future, they will need to build partnerships with everyone.
They can start by saying to the community, "We have no idea how to create health alone. We want to be a better neighbor. Do you need anything?" Here are some approaches to try:
- Get the trustees, CEO and staff directly involved in the health of the community. Move beyond going to the community only when you want a new wing or parking lot.
- Consider tithing a percent of net revenues to community-based initiatives.
- Tie a percentage of CEO raises to improvement in community health outcomes.
- Create a position of Community Outreach on the staff - not to do all the community work, but to support the effective engagement of other staff in the effort.
- Encourage programs in which nurses, physicians and other staff work outside the hospital. Perhaps some can adopt a school.
- Create centers for child development and for creative aging
- Involve retired physicians; a donation of one half-day each week could meet the entire US demand for primary care.
As we move towards integrated delivery systems or community care networks, these ideas will become more motivated by the bottom line. But why wait a couple of years - why not make it part of our hospital strategies now? What is the cost to society of not doing it?
From January 1986, when the World Health Organization organized the first meeting of the Healthy Cities planning group in Europe, until 1994, the movement has grown to include 1,500 communities in more than 50 countries on every continent.
In 1989, the Denver-based National Civic League was asked by the United States Department of Health and Human Services, Office of Health Promotion and Disease Prevention to help launch a nation-wide effort in the United States. Their work now takes
the form of the United States Healthy Communities Initiative, with partners and practitioners in more than 150 communities and 25 states nationwide. The National Civic League provides training and technical assistance to communities around the nation working to improve health and quality of life. It also publishes the Healthy Communities Handbook, directory, and resource guide.
For more information contact the National Civic League, 1445 Market Street, Suite 300, Denver, CO 80202; (303) 571-4343; fax: (303) 571- 4404.