By Tyler Norris and David Lampe
National Civic Review, Summer-Fall 1994
The surest path toward improving and maintaining the health status of Americans is to empower community members to make their own decisions regarding quality of life and the factors that affect it.
Around the nation our systems and institutions are experiencing profound change. Some are in great disarray. It seems as if little works as it should, and that as a nation we are slipping on a number of strategic fronts. We speak daily of the need for education reform, criminal justice reform, health care reform, sustainable economic development, the need for mass transit, new approaches to nurturing youth, and so on.
Yet, in the face of this change - and certainly the discouraging sentiments of many who already have given up hope - there are signs of possibility. Many communities are working, both democratically and systemically, because they have found ways to engage their resources - not just material and financial, but also human - to redirect their futures in ways that build community even as they solve problems and meet challenges.
Among the striking examples of this hopeful resurgence are those communities that have adopted civic strategies for addressing social and health-related problems by considering the complex factors that contribute to wellness. In these communities, concerns over health, in effect, stimulated innovations in local governance that hold promise for fundamentally redirecting their futures.
AMERICA'S INVESTMENT IN "HEALTH"
In the United States today, we provide more medical services, at higher costs, with more physicians per capita, than any other nation in the world - but with minimal incremental improvement in our nation's health status. By comparison to other developed nations, America's overall health outcomes are mediocre at best. The U.S. infant mortality rate, for example, is higher than that of 22 other industrialized nations. In the meantime, our health care system has evolved to emphasize acute intervention and remediation rather than disease prevention and education for good health. We may have made America the best place in the world to get sick and experience very high-quality treatment, but we have not made America the best place to become and stay healthy.
With medical costs soaring past 15 percent of GDP in 1994 and growing at twice the rate of the CPI, it is becoming increasingly clear that if we are to realize any substantial improvement in our nation's health status it must come as a result of changing our individual behavior, redefining health to focus on the priority factors that contribute to good health, and reclaiming public ownership of solutions to collective, or shared, problems. For too long, "public" has meant "public sector" or "governmental." Today the measures that are most likely to work are those that emerge from people, organizations and institutions working together and investing in an array of supports in our communities.
UNHEALTHY COMMUNITIES: HOW EXPENSIVE IS THE STATUS QUO?
If health is an outcome, occurring when other things are working, what is the price of poor individual and community health in America? If we extend our health care example to another public investment, our criminal justice system, we see the pattern of America's response to our problems with "downstream," often band-aid solutions. In November of 1993, Newsweek magazine tallied the overall costs related to crime in America. The total: $427 billion spent on criminal justice, lost productivity, and private and public security. In United States, we have 455 persons per 100,000 in jail, at an annual cost of up to $25,000 per inmate. By comparison, Japan has 11 persons per 100,000 in jail. And we have scores of communities where a young person is more likely to go to jail than to college. In Washington, D.C. for example, 59 percent of young (18- to 29-year-olds) African-American males are currently in the criminal justice system: either in prison, in jail, on parole, or wanted. Further, 34 million Americans live in persistent poverty, including over 20 percent of all American children - more than at any time in recent history. These are the makings of a permanent underclass. We are paying for poor health already.
On the substance abuse front, we incur $238 billion in costs annually. "Unnecessary health care," according to a 1993 Robert Wood Johnson Foundation study, accounts for $34 billion of this sum.
There is an old Italian saying that "a toothache isn't a problem - unless it's in your mouth. This toothache is in our mouths, and much of the costs end up in health care because along with prisons, the medical care system has become central to our downstream approach to "curing" societal ills. 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 medical services will rise past an estimated $1 trillion in 1994, the health of many segments of our society continues to decline. The health and socio-economic status of African-Americans, Hispanics, Native Americans and low-income Americans continues to fall in many key indicators as reported recently by the U.S. Department of Health and Human Services. The infant mortality rate dramatizes the significant health care gap between white Americans and other segments of our population. In 1992 the infant mortality rate among African-Americans was 2.3 times that of whites, with the Native American and Hispanic populations also experiencing significantly higher rates than those of whites. Such factors as these can only compound our existing racial and ethnic tensions.
THE LIMITS OF CURRENT HEALTH REFORM
Clearly, universal health coverage, adequate access to treatment, increases in administrative efficiency, overall cost containment, and quality improvements to medical service delivery would make critical contributions to the well-being of Americans and their families. But policy measures and health care system reform alone, while essential, are not enough.
Health care reform, as it is currently being debated in the U.S., centers on the provision of insurance as the key to access. While coverage is essential, lessons from places like Hawaii (with insurance coverage for all Hawaiians) and Boston (with a surplus of physicians and facilities) illustrate that availability of services does not equal access. If access and cost are the raison d'etre of reform, we will need more than insurance and an ample supply of care givers and medical facilities, because our health problems do not flow from cost and access alone. In many respects, high cost and lack of access are both symptoms of poor health. There is a continuing need to focus on the factors that produce good health m the first place. It is time to consider more than providing insurance and good medical care. We must rum our focus toward actually creating health and healthy communities - from the ground up.
WHERE DOES HEALTH "COME FROM"?
Personal and community health is largely the product of our social environments, incomes, and the choices we make as individuals and as members of our communities. The solutions to many leading causes of sickness and premature death do not rest with our hospitals or medical service-delivery systems as currently configured. Generally speaking, chronic and acute health conditions do not arise from lack of medical technology or access to medical professionals, precisely because they are caused in the first place by behavioral choices and personal practices encouraged (or condoned) by family members, neighbors, friends, and fellow citizens. Leading health problems such as heart disease, stroke, lung cancer, and injury from accidents are to a great extent influenced by such lifestyle choices as high-fat diets and poor nutrition, lack of regular exercise, tobacco smoking, abuse of alcohol and other drugs, and failure to wear seatbelts. These are primarily issues of people taking personal responsibility for their health and well-being.
Mark Lelonde of the Canadian Health Ministry has mapped the factors that contribute to sound health (published in Health Field Conceptual Model - Influence Factors on Health Status). He has found that human health status depends 50 percent on lifestyle and behavior, 20 percent on environment and socio-economic class, 20 percent on heredity, and ten percent on medical care and access. A study published last year in the Journal of the American Medical Association supports the view that community health depends on prevention, rather than intervention, finding that half of all premature deaths (prior to age 75) in the United States flow from "external" (i.e., behavioral and life-style) factors. At the top of the list: tobacco (400,000 deaths), diet and activity patterns (300,000 deaths), and alcohol abuse (100,000 deaths). All three are "rooted in behavioral choices.'" And knowledge of risk factors is not enough to change behavioral patterns, the study concluded. Community and peer support are vital influences.
To address health in a meaningful way, we must redefine what health is and consider the relationship between wellness and key components of our living and working environments. Among these key components are quality education, adequate housing, gainful employment, job skills training and retraining, efficient public transportation, recreational opportunities, healthy and clean physical environments, and health education and preventive services. In the absence of these simple but essential community resources, individuals experience very poor health status. Health disparities among Americans may be traced directly to these and similar factors. This is where the real security threat to America resides.
CREATING HEALTHY COMMUNITIES
Fortunately, the fundamental relationship between environmental and behavioral factors and health has been recognized by communities across the United States and throughout the world. This "movement," evident in 1,500 locations worldwide, is committed to addressing the "upstream" issues that define and maintain personal and community health. The Healthy Communities/Healthy Cities movement refines the health debate by taking it to its source: the interconnected factors contributing to health and quality of life. Communities participating in this movement are achieving striking results by encouraging individuals, organizations and institutions at all levels and from all sectors to take responsibility for collectively improving the health of their communities. A holistic approach emphasizing citizen empowerment, cross-sectoral cooperation and a range of systemic factors impacting health is what more and more communities realize they truly need.
BROAD-BASED COMMUNITY INVOLVEMENT
In healthy communities, health-related issues are effectively addressed and a high health status is achieved through broad-based community involvement. 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 must work cooperatively to identify issues and find solutions to them. From Pueblo, Colorado to Detroit, Michigan, leaders from all sectors, interests and perspectives are gathering around the table to work together. Without these participants, the problem-solving capacity of a community can never be fully realized. Additionally, the most successful "healthy communities" have found that it is not enough to round up the "usual suspects;" the full diversity of the community must participate to ensure a direct linkage between decision making and the shared ownership that leads to successful implementation.
This constitutes the vital connection between civic mobilization and health promotion and maintenance. And the critical need to ensure personal and community health represents a valuable opportunity to restore and nurture a civic culture of ownership and shared responsibility throughout the nation: one that is conducive to supporting individuals in reaching their full potential and strengthening families and community.
That Americans are eager to invest in their civic "portfolio" was confirmed in a 1992 report by the Kettering Foundation entitled Citizens and Politics. It refuted the popular perception that Americans are apathetic and unwilling to take responsibility. Instead, it found that as a nation we are angry and feel pushed out of the conventional political system and decision-making process. Among the implications: leaders must frame the issues better. Citizens will no longer tolerate the "10-o'clock-news-style" of public discourse, which casts issues as symptoms; they are demanding a thoughtful development of the real causes of our challenges. We need to engage the diversity of our citizens in meaningful process - people want a direct role in governance. We need to create neutral forums for dialogue - not for partisan debate or polarized argument, but for meaningful education and exploration. And we need to develop greater collaboration among the sectors - not just public-private partnerships, but creative multi-sector collaborations in the common interest. Below, we summarize the stories of a few communities that have done precisely this:
South Bend, Indiana. For ten years, local business leaders met at the St. Joseph County Chamber of Commerce to discuss ways to curb the soaring cost of health care services. In 1993, in partnership with four major area hospitals, nonprofit service providers, the religious community, and neighborhood leaders, they launched the St. Joseph County Healthy Communities Initiative.
Convening through the leadership of the Chamber, a diverse stakeholder group of 75 area residents undertook a nine-month community-based planning process to improve the region's health and well-being. They began with a set of values and a vision of their region as a healthy community. Over the course of a year-long planning process, they worked to build the foundation for an integrated health care service-delivery system (IDS) with the four hospitals and various service providers. They have met head-on the challenge in health care by discovering what collaboration means, and have taken the first step toward realizing their vision by committing to an Integrated Health Information and Data System.
They also formed a Youth Development Initiative, involving all the youth related efforts in the area in a process which, while encouraging each to be entrepreneurial, allows them to set shared priorities and use their resources wisely. This initiative focuses on youth not as an "at-risk population to be dealt with," but as a leadership asset to be cultivated.
Contact: Steve Queior, President, St. Joseph County Chamber of Commerce, 401E.ColfaxAve., Suite 310, South Bend, Indiana 46634-1677; (219) 234-0051.
Healthy Pueblo 2000 (Pueblo, Colorado). Pueblo County is located in south-central Colorado on the eastern slope of the Rocky Mountains. The local population, 40 percent Hispanic, comprises both long-term residents of the area and many new arrivals. Pueblo County is challenged by high rates of diabetes, poverty and unemployment, homelessness, school drop-outs, teen pregnancies, and domestic violence, as well as increasing gang activity and rising numbers of frail elderly.
Pueblo believes that families want to be competent and independent, and that caring neighborhoods and caring families go hand in hand. To this end, Healthy Pueblo 2000 is strengthening families through a Family Nurturing Initiative. They plan to build family strengths as well as community support for children and families through a neighborhood-based outreach and home-visitation model.
Currently, the only health referral guide in Pueblo is an annual Human Services Resource Directory that is published by the County Department of Social Services. The Department announced that as of 1992 it would not publish future editions. To fill the gap, Healthy Pueblo 2000 is establishing a centralized Information Clearinghouse for health and human service information that will be available for both walk-in and dial-in use. The clearinghouse will provide a directory of social services and medical information provided by the Information Access Company's on-line Health Reference Center. The project will be housed in a local library to ensure convenient community access.
Pueblo County is recognized as having the highest rate of Type II Diabetes among its Hispanic population of any county in the nation. With its ethnic mix of Hispanics having three to four times higher incidence of Type II Diabetes than non-Hispanic whites, the community has decided to track the prevalence and incidence of diabetes and invest more resources in this health issue.
Healthy Pueblo 2000 is one of a dozen collaborative initiatives in the area working to improve Pueblo's health and well-being. In late 1993, Healthy Pueblo 2000 leaders were instrumental in helping their community to link and coordinate the various area planning processes and projects that had, up to that point, proceeded without effective cooperation. Pueblo has worked hard to develop a set of shared priorities across its many institutions by pulling its leaders together to eliminate duplication and organizational turf wars through a "collaboration among the collaboratives." This has permitted and area-wide targeting of resources by local businesses and philanthropic entities who are now working closely together to meet shared needs.
Contact: Dr. Christine Nevin-Woods, Director, Pueblo Health Department, 151 Central Main, Pueblo, CO 81003; (719) 544-8376.
Healthy Boston (Boston, Massachusetts). Increasingly serious issues of poverty, homelessness, unemployment, and AIDS - combined with a decrease in public and private resources to deal with such challenges - prompted the Healthy Boston initiative. Healthy Boston uses community coalitions to help neighborhoods find solutions to their problems, and coordinates the activities and resources of city departments to meet those coalitions' needs.
Healthy Boston supports coalitions in 21 neighborhoods representing the breadth of Boston's cultural and ethnic diversity. Each coalition conducts a community health assessment, reaching tens of thousands through multi-lingual surveys and focus groups. Common priority issues include youth, public safety, economic development and job training, family support, diversity, and coordinating services. While the fact that Boston has cut its inner-city murder rate in half in recent years cannot be attributed to Healthy Boston alone, the community has worked hard through community policing and scores of other initiatives in the spirit of Healthy Boston to renew the city.
Healthy Boston was started in the late 1980s by Boston's Department of Health and Hospitals. The city was able to set aside $5.0 million, consisting of Medicaid "disproportionate share" funds, for coalition building and project implementation "seed money." To gradually ween themselves from city support, all the participating community coalitions now are developing their own strategies for self-sufficiency.
Contact: Ted Landsmark, Director, Healthy Boston, Room 60S, Boston City Hall, Boston, MA 02201; (617) 635-3140.
Central Oklahoma 2020 (Oklahoma City, Oklahoma). The more than 30 cities and four counties in the Oklahoma City metropolitan area often had planned for their own needs, but in the early 1990s it became clear that the region's communities needed to work together as one to address the complex issues they share - most of which don't start and end at their municipal lines.
Citizens in Central Oklahoma recently completed a regional planning and priority-setting project called "Central Oklahoma 2020 - Restaking the Claim." This effort served as a framework for setting goals and developing action strategies to improve the Oklahoma City area's quality of life.
The leadership for this comprehensive effort came from over 90 diverse citizen "stakeholders" drawn from throughout the region. This group included educators, youth and elderly, elected officials, small business owners, corporate leaders, clergy, nonprofit and community activists, immigrants, and many others. The Association of Central Oklahoma Governments, Leadership Oklahoma City, the Oklahoma City Community Foundation, and the Kirkpatrick Foundation initiated the effort. The National Civic League was asked to design and facilitate the planning process.
The process began with an assessment of past community initiatives: what had worked, and what had failed. What were the factors that would ensure success in this new project? Among them, the participants determined, was inclusiveness and diversity. They elected to proceed through a comprehensive strategic planning process that expanded upon a vision, an assessment of regional assets and the efforts of existing collaborations from all sectors. But Central Oklahoma 2020 decided it would not promote any initiative lacking a clear strategy for action - including necessary partners and implementers.
After developing a set of shared values and a bold vision for the future of their region, the stakeholders reviewed a set of indicators illustrating current performance. Based on this assessment, they set six priority areas and turned their attention to a set of initiatives.
One such initiative is "Families First!," which is modeled after The Atlanta Project, founded by Former President Jimmy Carter. The metro area is now being organized into 50 clusters that contain geographical areas ranging in population from 10,000 to 17,000. Families First! proposes to strengthen families through neighborhood-based support systems. With applications for funding now being developed and a steering committee in formation, current efforts center on developing a training model, with January, 1995 the target date to launch one of the first three clusters.
Another initiative focuses on quality day care for children before and after school, on Saturdays, and during the summer months. Churches, schools and existing centers are working on this initiative. Grants totaling $50,000 from the Oklahoma City Community Foundation and the Kirkpatrick Foundation have been received. The effort will provide a support system, training and an information network to identify and coordinate existing resources.
Contact: Karen Luke, Director, Central Oklahoma 2020, Oklahoma City, OK 73102; (405) 235-5155. (A copy of their final report is available for $1.00.)
So, what do these initiatives have to do with health care? In communities across America, citizens are finding their power - and exerting it. They are improving the health and hastening the renewal of their communities by building on the foundation of people taking local responsibility. They know that no one else can do that for them. From what sectors do these community leaders come? They are leaders from the health care industry, business, government, non-profit and community-based organizations - and just folks. They are recognizing that improved community and personal health begins with each of us in our families, schools, workplaces and communities.
We have a profound challenge before us. We must begin to address what is expected and needed of people, and hold each other accountable to a standard of personal and community responsibility. We have cultivated a highly developed concept of our rights and privileges as Americans. We must be equally sophisticated about our responsibilities. In many communities, this implies a change in the civic culture. There is no replacement for a shared sense of mutual accountability.
Further, we must recognize that our organizations, schools, churches and hospitals are not really separate institutions, pursuing separate agendas. Instead they are one, called a community. Schools must offer classes on community-based organizations and critical contributions to community well-being. The health care system must establish facilities in the schools. The resources of our libraries must be available at home, work, and school to make every environment a learning environment. In short, if we are to better our communities, we must stop behaving as separate institutions competing for limited resources. Indeed, it is the relationships built among these diverse components of our communities that serve as the fibers from which our social fabric is woven. America's problems are not resource problems. We are a fabulously wealthy country in every way. Abundant natural resources, human resources, scientific and educational institutions, innovative businesses, and service organizations grace us. Whatever economic and political problems we have are merely reflections of a larger problem of our priorities and our compassion.
Reprints of this article are available at http://www.wiley.com/about/permissions/