by Tyler Norris, American Journal of Community Psychology, Vo/. 29, No.2, 2001
Published in American Journal of Community Psychology, Vo/. 29, No.2, 2001 and reprinted electronically with permission from Kluwer Academic/Plenum Publishers
Healthy," "Sustainable," "Livable," "Safe," "Walkable," "Whole," "Successful," "Resilient," even "Lovable" precede the word "Community" in the name of hundreds of multisectoral coalitions across America. Although these descriptors each imply special meanings and relationships in a larger sense, they are but locally determined facets of an emergent and powerful American phenomenon: the communities movement. The future of this movement may well be to serve as a primary underpinning of our nation's ability to address its most vexing issues. Our ability to eliminate health disparities, revitalize deeply struggling inner city neighborhoods and rural towns, and manage the impact of fast growth in other locales, will in great part rest on the capacity of these coalitions.
To date, the breadth and impact of this movement to improve the vitality of America's communities has not been widely understood or documented. It falls below the radar screen of most national media. The rare political leader knows how to tap its power. Essays on the historic decline of civic institutions miss the connection with their twenty-first century successors. Academics struggle to embrace their new metrics and track their social-capital building results. Traditional institutions are only recently warming to these nontraditional entities' unique ability to get important work done. Civic power brokers are intrigued by the prospect of forming partnerships with resourceful grassroots leaders who understand how to tap local assets, and demonstrate that new ways of working together are essential to addressing the complex issues facing their communities.
Across the country, this widespread and diverse array of collaborative local and regional partnerships creatively bridges sector, race, and class division to create measurable impact. They target top community challenges such as public safety and crime, youth development, quality jobs that pay a livable wage, mobility and access, ecosystem protection, affordable and well-designed housing, strengthening families and redesigning local systems of care. They are tackling the vexing issues that no single sector, institution, program or grant can address alone. And they are producing measurable improvements in the quality of human lives. Indeed, in a 1997 report, the Centers for Disease Control and Prevention credited community partnerships with important contribution to "broad gains in the nations health" (Stolberg, 1997).
Broad-based community coalitions comprise the operational foundation of the communities movement. These coalitions typically embrace citizen, institutional and elected partners. Some initially form around key issues or crises, whereas others convene geographically to improve "quality of life" generally - allowing strategic priorities to emerge from dialogue and shared commitment. Coalition leadership tends to be shared between multiple players, and most often reflect a highly diverse cross-section of society. Participation typically includes business, nonprofit, government, health care, religious, media, education, and citizen leaders. Although well-known national and international leaders and institutions have influenced the movement, its roots are firmly planted in communities-from rural region to suburb to downtown neighborhood.
Fundamentally, the communities movement is a local phenomenon, mobilizing innate creativity and underutilized (or misallocated) resources to initiate and sustain positive change. As with any long-sustained social movement, there is no one centralized leadership group or single operational hub. Rather the nationwide movement finds spontaneous expression in hundreds of locales and forms.
HEALTHY CITIES AND CO MMUNITIES- THE FUTURE FOR EVERY COMMUNITY?
Among the most successful and widespread examples of the broader communities movement are the many hundred local, regional, and statewide initiatives that affiliate around the theme of "healthy communities" or "healthy cities." Despite their aligned goal of improving health outcomes, healthy communities do not simply focus on health and medical care. They also focus on jobs, education, public safety, housing, transportation, civic participation, and other components of community life-issues that underpin the health and vitality of people and places.
he healthy communities movement uses health as a metaphor for a broader approach to building community. Health is a common denominator that cuts powerfully across lines of race, class, culture, and sector. In recent years, this 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. Community coalitions across the nation use an array of change models and planning processes to work together to achieve their vision of improved quality of life. Regardless of the approaches taken to meet challenges, the following principles are guiding the most successful initiatives:
In past decades, efforts to rally whole communities around issues such as economic development or better education have met with mixed results, and tended to attract narrow involvement. The healthy communities approach has proven itself highly effective in uniting disparate groups of people. Almost anyone can see an enlightened self-interest in working to create a healthier people in a healthier community. Citizens see the prospect of safer neighborhoods and better living conditions. Businesses see the potential for improved productivity, a more developed workforce, and lower social dysfunction costs. Governmental leaders see the development of community priorities and the cultivation of civic will. Health and social service providers see expanded partnership on issues they cannot solve alone.
Healthy communities engage people meaningfully in the work of their communities in ways that allow them to experience success and see tangible results. In the most effective partnerships, "what's in it for me" is explicitly linked with benefit to the commons. 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 a clear relationship between their work and tangible results on issues they care about. Indeed, this is one reason that asset-based human and community development (Benson, 1997) has become a powerful feature of so many coalitions.
To support this growing nationwide movement (over 1,000 locales strong), the U.S. Coalition for Healthy Cities and Communities (CHCC) was formed in 1996 to serve as a link to resources, a voice for policy and action, and a force for creating and sustaining community partnerships. The CHCC is also the U.S. link to similar networks in dozens of other nations (over 5,000 initiatives are believed to exist globally)-many spurred by the World Health Organization, an early developer of the healthy communities approach. Based in Chicago at the Health Research and Education Trust of the American Hospital Association, the CHCC itself is a broad-based coalition of national and regional organizations acting in service to local coalitions. The CHCC has in recent years also developed a states' network with liaisons sharing promising practices and results between leaders at the community and national level.
THE DETERMINANTS OF HEALTH AND WELL-BEING
As a nation, we are learning that growing a healthy community is a lifelong process-one that requires our constant nurturing and vigilance. Healthy communities result from healthy choices and environments that support shared responsibility. And everyone has a role to play in building a healthier, more vibrant community.
The choices we make at home, work, school, play, and worship determine most of what creates personal health and community vitality. To a great extent it's about how we spend our time, dollars, and talents. But it's also about how we create settings in our communities, which result in healthier, indeed wealthier communities.
Healthy communities recognize that many of the factors society has traditionally tracked as "health " are more about "disease," and only partially inform us as to the overall well-being of populations. Indeed a "medical care" focus can distract leaders from the issues that can actually make a measurable impact in health performance. A renewed emphasis on the relationships between economic, social, and political factors and health status is transforming local leaders' perspectives on identifying the most leveraged loci of change in health improvement.
An estimate from the U.S. Department of Health and Human Services states that perhaps 50% of what creates health is lifestyle and behavior related, with another 20% determined by the socioeconomic and political environment. Genetic endowment comprises the next 20%, with medical care services contributing only 10% to population health performance (McGinnis & Foege, 1993).
BARRIERS TO FUTURE RESULTS
The challenge to coalitions however, is in transforming that knowledge on the determinants of health into meaningful groundwork in communities. This is compounded by a series of factors:
- Collaboration is tough work. Participant attrition rates are high, short and medium term outcomes are hard to measure, and organizations are sometimes unwilling to "do business differently";
- Categorical funding streams (both from governments and foundations) in practice limit community-building work that spans issues and sectors,
- Communities seeking comprehensive solutions are stuck with grants that fragment their efforts;
- Incentives for health care systems to actually benefit from improved health status are few-beyond hospital "community benefit" requirements and mission statements defining the goal of operating with a sense of value to the larger community. Most medical care providers make more money the more treatment they perform, not necessarily by improving health;
- The very medical care and public health leaders (as well as law enforcement leaders) who understand the need to better address the issues that present themselves daily on the steps of their institutions find that priority action is required outside of their sector or domain. Just as prisons and law enforcement are only partial contributors to reducing crime, so is health care only a partial contributor to improving health. Both typically serve at the end of the pipeline.
Hence the call for broad-based coalitions to support inspired cross-sectoral leadership, innovative root-cause solutions, better allocation of resources, and more reinforcing services and strategies in attainment of shared goals.
Reconnecting Citizens with Civic Life-ultimately, the strength of our democracy depends on it.
Today, many Americans experience a gulf between heartfelt conversations around their kitchen table and the formal decision-making processes in their communities. We read and hear constantly about the disaffection of citizens from the process of governance. We observe the institutional turf battles and fragmentation of well-intended efforts. We too often see our resources spent more as fixes to the symptoms of deeper problems, and less on what generates health in the first place. In building communities and regions for this new century, many of our nation's community partnerships need to move beyond the symptom-oriented, "fix the problem" responses.
A larger challenge for coalitions is to serve as policy and investment advisors for what creates healthy people in healthy communities in the first place. To do this we must redefine wealth to simultaneously include a healthy natural environment, a vital economy, full participation in a rich civic life, and the well-being of all people and their families-physically, mentally, and spiritually. This role includes advancing policies and practices that create return on investment to all these forms of wealth and capital. The diminishment of anyone of these forms of wealth, eventually contributes to the depletion of the others (AtKisson, et al., 1997).
|Table I. Design Principles for Creating and Sustaining Positive Change|
|A broad definition of "health" - Health is more than the absence of disease, and must be defined broadly to include the full range of quality of life issues. Health is an optimum state of well-being: physical, mental, emotional and spiritual. It recognizes that half of what creates health is lifestyle and behavior related. Other major factors are genetic endowment, and the socio-economic, cultural and physical environment. Health is a by-product of a wide array of choices and factors-not the simply the result of a medical care intervention.|
|A broad definition of "community" - By using as broad a definition as possible of what makes up a community, individuals and partnerships can address their shared issues at the right level, in the most fruitful way possible. Communities are based on faith, perspective, profession, as well as being determined by geographic lines.|
|Shared vision of community values - A community's vision is the story of its desired future. To be powerful and inspiring, a community's vision should reflect the core values of its diverse members. A vision is not bullet points on the wall - it is a living expression of shared accountability to priorities.|
|Address quality of life for everyone - Healthy communities strive to ensure that the basic emotional, physical, and spiritual needs of everyone in the community are attended to.|
|Diverse citizen participation and widespread community ownership - In healthy communities, all people take active and ongoing responsibility for themselves, their families, their property, and their community. A leader's work is to find common ground among participants, so that everyone is empowered to take direct action for health and influence community directions.|
|Focus on "systems change" - This is about changing the way people live and work together. It is about how community services are delivered, how information is shared, how local government operates, and how business is conducted. It's about resource allocation and decision-making, not just nice projects.|
|Build capacity using local assets and resources - This means starting from existing community strengths and successes and then investing in the enhancement of a community's civic infrastructure. By developing an infrastructure that encourages health, fewer resources will need to be spent on "back end" services that attempt to fix the problems resulting from a weak infrastructure.|
|Benchmark and measure progress and outcomes - Healthy communities use performance measures and community indicators to help expand the flow of information and accountability to all citizens, as well as revealing whether residents are heading toward or away from their stated goals. Timely, accurate information is vital to sustaining long-term community.|
|Source: Ayre, D., Clough, G., & Norris, T. (2000). Facilitating Community Change. Boulder: Community Initiatives|
A CALL TO ACTION
The challenge before Americans and their coalitions today is how to apply the learning from decades of community-building experience to the choices we make everyday in the settings where we live, work, play, and worship. Healthy communities call for inspired leadership and action from every corner of our neighborhoods and regions.
There is an increased and welcome call across the land for new levels of institutional accountability for results. This requires tracking outputs more than inputs; assuring deliverables, not simply activity; and promoting new types of knowledge exchange that broadly informs citizenry-not serving only to justify the practices of the institutions issuing the data. The rapidly growing number of community indicator sets and local report cards (Norris, 2000) tracking performance on progress toward shared vision attests to the need for new metrics, an outcomes orientation and shared responsibility by business, nonprofits, philanthropies, and governments.
But it also is about each of us as an actor in community. Aristotle defined a citizen as "one who participates in power"-the power to shape civic purposes and act in alignment with values. Acting upon a shared vision for the future is the foundation upon which a healthier community is built. This is the practice of local democracy and an investment in the civic landscape.
AtKisson, A., Norris, T. et al. (1997). Community indicators handbook. San Francisco: Redefining Progress.
Benson, P. (1998). The asset approach: Giving kids what they need to succeed. Minneapolis, MN: Search Institute.
Kretzmann, J., & McKnight, J. (1993). Building communities from the inside out: A path toward finding and mobilizing a community's assets. Chicago, IL: ACTA Publications.
Mc Ginnis, J. M., & Foege, W. H. (1993) Actual causes of death in the United States. Journal of American Medical Association, 270(18), 2207-2212.
Norris, T. (2000). On practicing community capitalism/healthy, wealthy, communities. 220.127.116.11/~tyler
Stolberg, C. G. (1997, September 12). US life expectancy hits new high. New York Times. U.S. Coalition for Healthy Cities and Communities. www.healthycommunities.org