Creating the Building Blocks for Health
By Tyler Norris
From Trustee, the Magazine for Community-Based Governance, April 1995

Community leaders in the Detroit metropolitan area were concerned when they learned that spending on health care was $18 billion and growing. Even more upsetting, though, was knowing that this investment wasn't buying better health care for Detroit-area residents. In fact, as spending climbed, some health outcomes-such as the rate of low-birth-weight infants and violence against youths-were actually getting worse.

Meanwhile, across the country in rural North Carolina, the Concerned Citizens of Tillery significantly lowered their rates of heart disease and cancer, with almost no financial resources. Working together, they taught themselves about nutrition, helped one another change their diets, and learned how to exercise. They also took on the area's big commercial stock farms, which were polluting the water supply, and converted a potato shack into a health clinic. In the process, the citizens of Tillery also strengthened the fabric of the community, creating a mechanism for tackling challenges.

The Tillery initiative is part of the larger, worldwide healthy communities movement-a movement embraced by communities throughout the United States-from Orlando to Oakland to rural Colorado. Even urban Detroit has since hopped on the bandwagon; its Healthy Detroit initiative has gotten citizens and leaders from health care, government, business and neighborhood groups to work together to improve people's quality of life, and thereby improve health outcomes.

A basic premise of the healthy communities movement is that well-informed people, working together in an effective process, can make a profound difference in the health and quality of people's lives within communities. While federal and state lawmakers, health care providers, employers and insurers wrestle with how to supply people with needed medical care without going bankrupt, the healthy communities movement primarily targets demand for health care, asking: How can we keep people healthier in the first place?

Nationwide, people concerned with their community's health have found that the essential building blocks of good health-such as strong families, good jobs and education, to name a few-lie largely outside the health care system.

But why should a health care organization get involved with community initiatives that don't involve the provision of health services? "'It's our mission and our community responsibility," says Carl Ellison, vice president of community affairs for Memorial Hospital, South Bend, IN. Memorial takes this responsibility seriously: The hospital was a catalyst in starting the St. Joseph County Healthy Communities Initiative, which comprises roughly a dozen community development projects, ranging from business and youth development to the establishment of an electronic network that allows providers, the health department and social service agencies to share patient information.

The hospital believes that these projects, which will help people take better care of themselves, will ultimately reduce the number of people who develop serious medical problems. And that, says Ellison, will help the hospital's bottom line as well as the community.

Orlando (FL) Regional Healthcare System also sees improving community health as fundamental to its mission-so much so that it designated Sharon McLearn as vice president of community partnerships. McLearn's mandate: to invest her time and resources in projects that significantly improve community health. In fact, she has recently been "loaned" to the Greater Orlando Healthy Communities Initiative, a collaborative community action project involving Orlando Regional, several local agencies, and Orlando's Florida Hospital Medical Center-which has long competed with Orlando Regional for patients.

So how did the Orlando system move from competition to partnership? McLearn says her guiding principle for that and other projects is: "Will the projects and partnerships we're investing in fundamentally improve long-term health outcomes in our community?"

Getting beyond competition is only the first thorny issue for health care leaders; if healthy communities projects are truly successful in reducing the incidence of disease and injury, hospitals would ideally see far fewer patients. The aim of the healthy communities movement, in fact, is to spend more time and more resources developing a community infrastructure that encourages health, so that fewer resources will need to be spent on such community services as police protection and health care, which fix the problems resulting from a weak infrastructure.

The cornerstone of the healthy communities movement is its broad, nontraditional definition of health. By now, it's well-accepted that health is more than just the absence of disease. But what else does health entail?

Within the healthy communities movement, health is defined as the product of both genetic factors and factors related to people's living and working environments. The building blocks that create health thus include: quality education; adequate housing; availability of meaningful employment; access to job skills training and retraining; access to efficient public transportation; availability of recreational opportunities; healthy and clean physical environments; and access to health education and preventive services.

Moreover, health is not a commodity or the result of an intervention; it's a state of being that occurs when other things are working.

In healthy communities, the health status of community residents is not seen as the sole responsibility of providers. That's why providers need to work in partnership with all sectors of the community - from government to business to not-for-profit organizations to ordinary citizens. But how do such partnerships start? One way is for health care leaders to reach out to others in the community and say: "We have no idea how to create health alone, and we want to be a better neighbor. Can you tell us what you need?"

This question is the beginning of an important conversation. As this conversation expands over time to include the voices of business leaders, government officials, community organizers, and private citizens as well as providers, those involved will ideally begin to recognize common community needs and values. And if these conversational relationships are properly nurtured, the newly formed chorus of community voices can eventually develop a harmonious vision of what a healthier community would look like and a plan for how to create it.

But beware of quick fixes. Community members need to ask themselves what kind of community and health care system they want, not just how they can tinker with what they've got. To be effective, your approach needs to be holistic; your initiative's vision of a healthier community must take into account human, environmental, economic, physical and design factors. It also needs to involve systems change, looking at the way services are delivered, how information is shared, how local governments operate, and the way in which business is conducted in the community.

One health care organization heavily involved in this kind of systems change is Greater Southeast Hospital in Washington, DC. To improve the health of residents of its economically depressed service area, the hospital has redefined what it means to be a health care provider. Its business now extends from providing medical care to building housing and fueling the local economy. Working with local organizations, businesses and residents, the hospital has made tremendous strides.

Most American cities and towns have many community groups striving to improve quality of life in some way. Unfortunately, these groups often don't work together effectively; they may even squabble over turf issues or feel they must compete for resources. In the end, the community loses because these groups come up with fragmented solutions.

To most effectively build healthy communities, groups need to develop a way to link these groups' information streams. priorities and resources. In Columbus. OH, for example, the Together 2000 Healthy Communities Initiative had to initially meld more than 30 community-based planning initiatives addressing a spectrum of local and regional issues. As Mayor Greg Lashutka told the group at an early meeting: "I go to 20 meetings a week, all for different organizations, yet we talk about many of the same issues. Let's find a way to tie these efforts together with one vision. We can highlight the overlaps and look for better ways to use our resources, then we can address the gaps where existing efforts are not meeting the need."

Notably, it's important to involve local government leaders like Lashutka in this kind of initiative right from the start; healthy community initiatives often involve policy changes, so make sure to coordinate your initiative's efforts with the workings of government early on.

Decisions on the kinds of policy changes and programs needed, however, should be the consensus of representatives of all sectors of the community. A hallmark of the healthy communities movement is its consensus-based planning process. The diverse members of healthy communities initiatives start with a common commitment to collaboration and to reaching consensus whenever possible. When the majority rules, the minority loses, and members of that minority may be left angry or dissatisfied. So leaders of healthy communities initiatives try to find common ground among their participants on all issues, so that everyone feels a sense of ownership in the group's process and decisions.

Those involved in healthy communities initiatives will need road signs to tell them how far they've come and how far they need to go toward their common vision. Performance measures-such as baselines and benchmarks-are good road signs because they show the impact of policy changes, investments and improvements. This information, in turn, should be shared with community residents.

Indicators for measuring community performance with respect to education, air and water quality, population density, design issues, economic performance, and green spaces will also prove helpful. Initiatives that can measure performance over time in these areas have a definite edge; they can both define their target and know when they've hit it.

Several major healthy community initiatives-most notably those in Jacksonville, FL, and Pasadena, CA-have developed quality of life indexes that measure changes affecting the community. These indexes vary greatly, depending on the initiative's focus and the needs of its community. In Seattle, a draft set of "sustainability" indicators tracks everything from population shifts to the number of salmon spawning in their native beds. Indexes may also take a more narrow focus. Riverside Hospital in Columbus, OH, for example, has developed a menu of over 150 diverse indicators for measuring overall health; the six communities served by the hospital can now choose these indicators.

While most initiatives eventually develop an index that's tailored to their own unique needs, the Denver-based National Civic League's Civic Index-a general index that can be applied to all communities-can help budding initiatives get a handle on their communities' capacity to create useful change. It's essential that healthy community groups recognize what's working, what resources are in place, and how they can build on these. Groups need to ask questions like: How can we improve communication, information sharing and intergroup relations? What would it mean to build our civic culture and pride? How do we nurture emergent leaders and develop neutral forums for dialogue?

No matter how committed and enthusiastic community members may be about their vision for the future, change takes time. A vision created in only a day may take more than a generation of hard work to bring to life. Building a healthy, sustainable community is a lifelong journey, so it's important to have fun, pay attention and celebrate along the way.

Indeed, some established healthy communities initiatives already have cause to celebrate. In Boston, the work of a healthy communities initiative combined with improved policing efforts has contributed to a 50 percent decrease in the inner-city murder rate over the past decade.

By engaging the hearts, minds and resources of the community, healthy communities initiatives succeed in doing what no health care organization or government program could accomplish alone.

What, then, is the role of health care organizations in improving community health? Now that we know that the building blocks of good health are created largely outside of the health care system, health care leaders have more reason than ever to reach out beyond their facilities' walls and act as community leaders.

Health care leaders can be the catalysts. They have a unique opportunity to help motivate the community at large to make lasting improvements in community health status.

Tyler Norris is the president of Community Initiatives, Boulder, CO, and at the time of writing, was also a Senior Associate with the National Civic League, Denver.

What creates health?*

Low crime rate 73% High environmental quality 65%
Good place to bring up children 73% Good jobs and a healthy economy 64%
Low level of child abuse


High-quality health care 61%
Not afraid to walk late at night 71% Affordable health care 60%

Good schools


Good access to health care 60%
Strong family life 70% Excellent race relations 54%

*Based on a nationally representative survey of 1,000 Americans from all socioeconomic groups Source: What creates health?, DYG Inc./Healthcare Forum, 1994