America's Best Kept Secret: The Healthy Communities Movement
by Tyler Norris, President, Community Initiatives, Boulder, CO
(from the introduction to the Spring 1997 edition of the National Civic Review)

All revolutions begin in the mind before they begin in the streets. -John Adams

From Anchorage to Burlington and from Columbus to Dallas a quiet movement is growing in this country. The goal is ambitious: to achieve radical, measurable improvement in the health and long-term quality of life in America's communities. The leadership of this movement is dispersed throughout society - among thousands of business, non-profit, government, health care, religious, and citizen leaders working together to systemically meet their communities' toughest challenges.

The movement goes by many names and has many different facets. The local focus is always defined by the local context. Some call their initiatives "sustainable communities" or "livable communities." Others use terms like "good communities," "safe communities," or "caring communities." Some focus on health care. Others focus on the relationship among the economy, the environment, and social equity. Still other efforts focus on youth and family issues or increased civic participation.

Collaborative local and regional partnerships bridge sector, race, and class divisions. They are developing innovative strategies to address complex issues. They target top community challenges like public safety and crime, youth development, quality jobs, mobility and access, ecosystem protection, affordable and well-designed housing, strengthening families, and redesigning local systems of care. They tackle the vexing issues that no single sector, institution, program, or grant can handle alone. And they are producing measurable improvements in the quality of human lives.

These efforts thrive in urban neighborhoods, metropolitan regions, rural towns, and institutions. This movement has been influenced by well-known national and international leaders and institutions, but its roots are planted firmly in each individual community. Fundamentally, this is a local phenomenon, mobilizing local creativity and resources to spark and sustain positive change. And like any successful social movement, it has no centralized leadership or hub, but instead finds spontaneous expression in thousands of forms. It emerges from community but cannot be laid upon a community.

Among the most effective examples of this broader community movement are the many hundred local, regional, and statewide initiatives that go under the title of "healthy communities" or "healthy cities." Citizen-led in nature, healthy communities mobilize the creativity and resources of their communities to create positive change. But these initiatives do not simply focus on health and medical care. They also focus on jobs, education, public safety, housing, civic participation, and other components of community life. For example:

  • In Hilton Head, South Carolina, retired physicians and nurses volunteer one day a week to meet the entire primary care needs of thousands of area residents with no insurance or access to the medical care delivery system.
  • In Boston, thousands of adults, many of them seniors, are mentoring students in the after-school hours of 2:00-6:00 p.m. This "trouble time" before parents come home from work is now used to pass on skills, behaviors, and attitudes that prepare healthier futures and build community in the process.
  • Also in Boston, the inner-city murder rate has been cut in half thanks to the work of community policing, Healthy Boston, and other neighborhood-based strategies.
  • In Central Oklahoma, over thirty mayors in the Oklahoma City region meet monthly to develop strategies for regional economic development, transportation, air quality, crime prevention, and other cross-cutting topics that extend beyond municipal boundaries. The Regional Leadership Institute educates area leaders on regional issues.
  • In South Bend, Indiana, Memorial Hospital gives 10 percent of its net revenues to community initiatives that benefit the quality of life in the community. One such initiative is a health coverage partnership that provides full care to the working poor who earn too much to qualify for Medicaid but cannot afford commercial insurance.
  • In the Chicago community of Lawndale, the teen pregnancy rate, once over 30 percent for high school girls, has been reduced by nearly 100 percent in just over a year via a mentoring initiative of area hospitals, churches, and schools - essentially connecting young people with ideas, jobs, and a brighter future.
  • In Detroit, scores of lots where burned-out homes once stood are being converted into neighborhood "pocket parks," playgrounds, ball fields, and community gardens. In some areas, the fire department even comes by with trucks to hose down the gardens in the summer, taking a little extra time while there to connect with area children. Former gang-bangers are leaders in the effort.

Healthy Communities Metaphor

The healthy communities movement uses health as a metaphor for a broader approach to building community. Health 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 reengagement in community renewal. To begin with, the question "What is a healthy community?" usually elicits a clear and relevant answer, whether asked of a business executive, a homemaker, or a child. In past decades, efforts to rally whole communities around issues such as economic development or better education have met with mixed results, but the healthy communities approach has proved very effective in uniting disparate groups of people. Almost anyone can see an enlightened self-interest in working to create a healthy community.

Healthy communities engage people meaningfully in the work of their communities in ways that allow them to experience success and see tangible results. Only through this kind of meaningful engagement can communities fully mobilize the willingness and capacity of citizens to create positive change. Although many Americans are ready to connect with community more fully, most need to see an explicit link between their work and tangible results.

Who Leads the Movement?

Visionaries in the health care field were among the first to respond to this emerging movement, seeing their roles in a larger context than simply the provision of medical services. Consequently, the mission of health care providers is expanding beyond professional confines to focus on improving the health and well-being of entire communities. This approach is based on a simple premise: Health is only minimally the result of medical intervention and is powerfully affected by other forces. In fact, health is affected by a mix of human behaviors, practices and socioeconomic and physical factors. This recognition is causing many health care leaders to
change their priorities and to address community realities that determine health. And as health care leaders look to a future of institutions sharing financial risk in integrated systems of care, they see their ultimate self-interest in relating to the broader community context.

Other important catalysts in this movement are business leaders looking for ways to cut health care costs at their source. They also recognize that community factors affect the productivity of their employees. Healthier communities spend less money on the costs of poor health status and are more likely to retain existing jobs and attract new ones. Finally, they know that they spend plenty through taxes and insurance on the costs of crime and other symptoms of an unhealthy community - and they want to change the status quo.

One key to community success is institutions using their organizational skills, relationships, in-kind resources, and credibility to engage the rest of the community in mobilizing the creativity and resources necessary to tackle tough challenges. Healthy communities initiatives require a new role for civic leaders, that of community catalyst and convener. These efforts require a large measure of humility and a deep commitment to partnership. Further, they require a conversational relationship with the entire community and a willingness to recognize that every institution's resources are part of its community's sum of assets, which must be wisely invested for the benefit of the whole community, not just the benefit of any single institution.

Much of what ails this country can only be solved at the community level by changing the choices that groups and individuals make. On most community issues we can no longer abdicate or delegate responsibility upward. Community is where the conscience of a people and a nation resides. Community provides a moral center and a sense of place. The best place to look for positive change is in the mirror. Life-styles, everyday habits, buying decisions, relationships, choices to participate - these are the things that determine a community's performance. If, every year, thousands of teenagers' lives are challenged or cut short by substance abuse, early pregnancy, suicide, violence, and disconnection with their families, we can only see this as a reflection of the priorities and choices that we make.

Not only do communities that work possess a profound faith in the wisdom, creativity, and leadership capacities of citizens, but they also recognize that without shared leadership and responsibility no community or society is sustainable. A growing number of local leaders is recognizing that few of their communities' most pressing issues will be solved in Washington, D.C., or state capitols. To be sure, there have been community partnerships all along, but only recently have so many leaders from virtually every sector made collaborative community-based partnerships their preferred tool for creating positive change.

Yet, a significant challenge for the country is to couple the lessons of local collaboration with healthier public policies. In an era of devolution of federal power to states and communities, how can we explicitly link effective approaches and lessons learned locally with policies and resource allocation decisions made at the state and federal levels? To start, we will need the active engagement of elected leaders at every level to engage with citizens in their mutual work. The role of community-based initiatives is not to replace representative democracy but instead to inform and enrich it.

Community collaborations can improve the way policy decisions are made at higher levels of government. For example, a community initiative in Los Angeles led to the adoption of an integrated strategy for the delivery of city and county social services to young people and their families. In pursuing this strategy, however, local government had to obtain permission from the state of California to waive categorical funding rules to provide funds from a mix of sources, with a focus on outcomes, not on whose pockets the money comes from. We need to develop policies that provide incentives for communities to undertake coordinated and comprehensive service delivery.

Community initiatives also promote the kind of serious cross-cutting thinking that is beyond partisan polarization which only serves to divide communities and frustrate consensus. At the community level, concerns about family, crime, health care, and job development are not as likely to be viewed as Republican or Democratic issues. The work of government can most often be directly related to the work of people at the community level. Community initiatives can serve as a bridge between local demonstration projects and larger efforts, taking pilot initiatives to scale. For example, in attempting to meet the local challenges arising from federal welfare reform, communities could develop mutual responsibility pacts and partnerships with families, helping former recipients find and get to work while the community provides access to health and child care.

The current state of America's health care and criminal justice systems points to the need for linking local efforts with state, federal, and institutional policies and practices. The U.S. health care system provides more medical services at higher costs with more physicians per capita than any other nation in the world. Yet, in comparison to other developed countries, our health outcomes do not reflect that greater level of expense. We have significantly more health care in the form of facilities and specialists than we need, yet we ration care by income and the workplace. Our infant mortality rates, for example, are shamefully high for a developed country, while our level of medical technology, emergency care, and acute intervention is second to none. In short, we have made America the best place in the world to get sick, but not to be and stay healthy.

We possess the largest number of citizens per capita in the criminal justice system of any country. Our solution to people's and society's ills has been to criminalize and medicalize them, as if building more prisons and hospitals and transferring more assets away from education and other "upstream" investments is likely to give us less crime and a healthier population. But what are the costs of a society that does not work well? The financial cost of crime to our country is estimated at half a trillion dollars a year. Medical costs as a percentage of our gross domestic product have soared in the past two decades. Obviously, we cannot afford these quantifiable costs, but the greatest loss, perhaps, is the loss of unfulfilled possibility. We cannot afford the cost of a society that does not focus on helping young people realize their potential and older people live full and useful lives in
their later years. We need the experience, resources, and mentoring ability of the elderly for the next generation. The loss of human capital is a major contributor to poor physical, social, and economic health and the deterioration of our communities.

Signs of Success

One of America's best-kept secrets is the sheer number of active, successful, community-based efforts which achieve everything from reducing the rates of crime and teen pregnancy to creating quality jobs and building affordable housing. While many of these efforts are new and are only now being evaluated and rigorously documented, they are clearly part of the answer. Unfortunately, many collaborative, community-based initiatives are treated as "nice efforts" that are tangential to the places where real decisions are made. Few reporters know how to cover them, and these efforts rarely make the morning paper or the evening news. Many elected leaders do not comprehend how these local initiatives work or what tremendous potential they hold.

But as an increasing number of promising local initiatives unfold across rural, urban, and suburban America, it is helpful to focus on how and why these change processes work. What actually leads to improved health status and the engagement of young people in their future? What builds vibrant economies and livable neighborhoods while protecting the health of ecosystems? Where, or with whom, does change start? What does change mean for leadership and the roles of our institutions? Experience suggests that what works best to create and sustain positive community change can ultimately only be defined in a local context. At the same time, common characteristics and qualities have emerged:

First, successful communities recognize that the health and sustainability of a community are products of the whole community working, not a result of isolated interventions in any single sector. A community is an ecosystem; it is more than the sum of its parts. In considering business strategies, public policies, buying decisions, and other issues, we need to ask how a given approach will simultaneously build and maximize economic, ecological, social, and human capital. Rather than investing in narrow "fix-it" projects, successful communities orient themselves toward the allocation of resources and the equitable distribution of decision making and power.

Second, successful communities engage everybody and build ownership across all lines. A commitment must be made to developing widespread community ownership and civic engagement. Through effective collaborations, we recognize that mobilization of all parts of the community is essential in getting upstream from the typical "react to the problem" and "fight the enemy" approaches. Successful communities embrace processes that mobilize all citizens and the institutions of civil society for continued improvement.

Third, successful communities take both a regional and a neighborhood-by-neighborhood approach. We need to embrace multiple definitions of community and to deal with challenges that need to be solved at different levels simultaneously.

Fourth, successful communities know how they are performing. Citizens are yearning for, indeed demanding, accountability. Performance information is needed to create baseline data and to measure any progress toward or away from a community's desired future. Performance information is needed, more specifically, to track the impact of various community initiatives and policy choices. Continuous quality improvement is becoming a standard objective, and effective measurement is the key to its success. Strained budgets and limited public resources have exacerbated the need to maximize our return on social investment. Effective community indicators provide clear, understandable information on the status of the community system.

They serve as gauges that can assist communities in making well-informed choices. Beyond mere data compiled and delivered by professionals, community indicators are developed by diverse segments of the community so that leveraged action can be taken simultaneously by businesses, individuals, organizations, and government agencies in working toward common goals.

Fifth, successful communities start with shared values and a shared vision. In recent decades, many community efforts have started with needs assessments chronicling a litany of problems to be solved. While these efforts can uncover and quantify the problems, they often do little to mobilize action and achieve desired results. Values provide the thread for the fabric of our communities. A vision - basically, a statement of values projected as reality into the future - can articulate where a community wants to go and what ideal performance it desires. Effective communities identify their values and generate shared visions of the ideal future of their communities. They follow this visioning with a specific action plan and implementation strategy.

Sixth, successful communities build on existing resources. Rather than decrying deficiencies and shortcomings, effective collaborations generate local power by clearly articulating how each person, group, organization, company, or agency can be part of the solution. They make explicit links between the work that needs to get done and those who can do it. They look at how they can do better with what they have rather than wait for another program, grant, or other bailout.

Finally, successful communities move beyond quick fixes and look at systemic change. They look at doing more with what they have. They look at ways of reallocating assets and resources to more productive ends. Veterans of community mobilization efforts know from experience that complex issues cannot be solved with categorical programs, single-sector initiatives, and dollars alone. They know that the only true locus of fundamental change is people's choices grounded in their cultures, not in dollars and programs.

Mobilizing Communities

The challenges facing our country are formidable, but we have the technological capabilities and resources to address them successfully. We are in many ways a rich nation with expansive capacities. The real challenge lies in developing the community and political will to act together coherently. To cite one example, we must stop seeing our non-profit organizations - such as churches, schools, and health care facilities - as fragmented units competing for resources, each with its own strategic plan, domain, and agenda.

We need schools to form partnerships with community-based organizations, and we need health care providers to deliver services on-site in churches, schools, and neighborhood centers. We need the resources of our libraries and civic institutions to be available at home, work, and school in order to make every environment a learning environment. While social entrepreneurship and civic innovation are essential, our communities can no longer afford duplication, disconnection, and institutional arrogance.

The larger opportunity before us is to mobilize and engage people of all ages and from all walks of life to produce results that are tangible, visible, and value-added. Only when people directly participate in the public work of our society and help to create measurable success can we hope to build the shared civic ownership and social capital on which our democracy and, indeed, our ultimate well-being, rest.

The growing healthy communities movement provides a vehicle for such engagement as we renew our country, house by house and neighborhood by neighborhood. The movement is a sign of hope that provides a foundation for the work ahead. This approach requires a new mind-set about where change is created and what sustains the well-being of communities. It implies an active form of community-oriented governance, not government by the experts. It grows where people, not just institutions, see themselves as public actors. It forces people to define how communities work and to recognize what money can and cannot do. The healthy communities movement has profound implications for leadership and will change the job description of everyone of us who wishes to create positive and sustainable community change.

"Peter Lee Recommends..."

Healthy Communities Web Sites to Explore

The Benton Foundation - seeks to shape the emerging communications environment and demonstrate the value of communications for solving social programs.

Non-profit Conference Calendar search engine, national and by state.

Amherst A. Wilder Foundation - An excellent resource.

The Search Institute - youth assets, excellent resource.

Healthy Cities International - numerous connections, excellent information.

Empowerment Zone - funding information.

Healthy Valley Connecticut - a healthy communities initiative.

National Federation of Interfaith Volunteer Caregivers - grant information on faith-based caregiving.

National Rural Development Partnership - working to improve America's rural communities.

The Community Toolbox - community building and community health.

The Civic Practice Network - public problem solving.

W. W. Kellogg Collection of Rural Community Development Resources -

National Community Building Network -

Community Solutions Toolbox -

The National Coalition for Healthier Cities and Communities -

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