Place-Based Practices Shape the Healthy Communities Movement

Place-Based Practices Shape the Healthy Communities

Movement BY MONTE ROULIER

In 1995, a group of Scranton, Pennsylvania, civic ine that an obesity epidemic and lifestyle-induced leaders concluded it was time for a new way to chronic diseases would eventually dominate the approach the region’s future. Inspired by several focus of the vast majority of Healthy Communities other communities using a Healthy Communities efforts across the country. A new landscape of chal- process, they launched Forging the Future. At the lenges and opportunities has forced new ways of ad- time, this long-term, vision-driven, holistic, partic- dressing community change. These new approaches ipative, asset-oriented, and upstream model was a are commonly referred to as place-based strategies, radical departure from the status quo. an emergent transformative force within the larger Healthy Communities movement. Over a period of about fourteen months, nearly four hundred stakeholders came together regularly Place-based approaches recognize that where we to develop a plan that would bend negative trends spend most of our time—neighborhoods, work- and realize untapped potential. The planning pro- places, schools, and places of worship—has enor- cess birthed an ambitious fifteen-year vision, and mous influence on the choices we make each day. seven key performance work teams focused on areas An overarching theme is making the healthy choice such as economy and jobs and art and culture. Even the easy choice. The many community change ef- though Scranton was experiencing one of the highest forts that comprise this place-based movement often downtown business vacancy rates in the country, the place a strong emphasis on healthy eating and ac- group implemented a number of strategies to revital- tive living (HEAL); policy making and environmen- ize the downtown through a coordinated approach tal changes to shift behavior and norms and health to arts, culture, and tourism. The plan took advan- equity; or acting to address the growing health dis- tage of local talent and of aging, although once won- parities, particularly with low-income and minority derful, music and theater venues. The initiators saw community members, that are largely rooted in fac- the overall process as a means to foster a greater tors related to place. sense of community, a prime motivation of other healthy community efforts at the time. Although there are no exact formulas for place- based approaches, there are clear essential practices Technological and social changes of the last twenty that lead to its enhanced benefits and results. Five to twenty-five years have profoundly influenced the emerging essential practices are discussed next. ways communities approach the work of health and quality-of-life improvements. Few communities today would be willing or able to pull off a fourteen- Weave Mutual Interests into a Common Vision month planning process with over three hundred Working with a shared vision as starting point has stakeholders on a broad range of focus areas. Forg- been a staple practice for most healthy community ing the Future leaders used snail mail and the tele- efforts and entails much more than simply crafting phone as the primary mode of communication. Hav- a nice vision statement. It requires a critical mass of ing never experienced meetings where stakeholders community members and partners sharing a vision possessed smart phones (and the competing inter- or common understanding of both the benefits to be ests of real-time texts/e-mail/Facebook), they could derived and the nature of underlying challenges. not imagine the level and depth of access to information and data made possible through a Google Individuals and organizations alike need to see how search or Web-based apps. Nor could they imag- fundamental needs and interests will be met through

C⃝2014 Wiley Periodicals, Inc. Published online in Wiley Online Library (wileyonlinelibrary.com) 4 National Civic Review ● DOI: 10.1002/ncr.21164 ● Spring 2014 A Publication of the National Civic League this common vision. LiveWell Greenville (LWG) in Make Wise Use of Data and Technology South Carolina was able to do just that when it en- The need to save time and resources has prompted visioned a more walkable/bikeable community and collaboratives to rethink strategies for data col- made the case for investing substantial resources lection, analysis, and management. New tech- in trailheads (one being central to downtown trail nologies for securing, visualizing, and managing networks). The local Chamber of Commerce recog- data are improving assessment, case making, and nized how this strategy could contribute to qual- performance. ity of life and to recruitment of new business. The school district viewed trails and related street en- A place-based collaborative in the Quad Cities re- hancements as creating safer and more healthful gion on the border of Illinois and Iowa is finding new ways for children to get to school (and potentially ways to use data and technology. Access to healthy to save money on busing). Greenville’s two pri- foods is a growing concern for regional leaders and mary hospitals found walking trails to be an as- community members, prompting the Quad Cities set in chronic disease prevention and management. collaborative to move toward creating a regional As LWG coordinator Eleanor Dunlap said, “Our food system with a sustainable food access plan. As partners may use slightly different words to make a starting point, an accurate map was developed of the case for active transportation—bikeable, walk- the region’s food deserts, a term used to describe able, and connected to public transportation—in places where it would be difficult, if not impossi- Greenville, but we all recognize we are describing ble, to find fresh, affordable fruits and vegetables. the same desired future.” A Web-based mapping utility secured by the United Way allowed coalition members to combine and cor- The shared vision for active transportation allowed relate locally collected data (from grocery stores and the LWG partners to build a broad constituency food pantries) with other relevant publicly avail- and to persevere through legal challenges and also able data on a broad range of focal areas, such as through early but vocal citizen opposition, regula- schools, poverty, and the retail food environment. tory roadblocks, and financial setbacks. The part- The result is a Web-based map that allows the entire ners knew they had a good chance of shifting the community to identify neighborhoods and areas in way community members got around by providing greatest need of healthy and affordable food outlets. the choice of easily accessible trails connecting to Maps enable the coalition to engage the tacit wis- practical and compelling destinations. The Swamp dom of a broader set of community stakeholders— Rabbit, a 17.5-mile multi-use trail system running adding insight into the specific challenges and gener- along the Reedy River connecting Greenville County ating solutions. The maps are easily updated to show with schools, parks, and local businesses, opened in new assets and progress toward shrinking the food 2010 and has seen extraordinary increases in usage deserts. each year since—more than meeting the mutual interest of the partners. It has become a prized asset The Quad Cities coalition recognized the need to and has led to a chain of additional actions. be utilization focused in its data and assessment for the place-based efforts. Although former com- LWG is using this same formula for four other goal munity health needs assessments offered some con- areas: text, subcounty-level data are needed to pinpoint challenges and opportunities. Securing data at zip 1. To help different sectors and community partner- code level (e.g., for schools and fast food loca- ships discover mutual interests tions) and/or at block level has become essen- 2. To act in concert on big policy or environmental tial for place-based strategies. More communities changes (e.g., the trail system and funding mech- like Quad Cities are also utilizing tools geared to anisms) HEAL assessments—such as the YMCA’s Com- 3. To support coordination among various initia- munity Healthy Living Index or doing walkability tives (e.g., outreach or installation of bike racks) and/or food access audits—to collect meaningful ob- 4. To tether vision to measurable strategies and servational data in and around settings where people outcomes live, work, attend school, or play.

National Civic Review DOI: 10.1002/ncr Spring 2014 5 Many communities are drowning in a sea of data social media, recognition efforts, and creative adver- and often have duplicate assessment and data col- tising. According to David Campbell of the Metro lection efforts. The LiveWell Omaha partnership in Nashville Health Department, “Nashvitality is now Douglas County, Nebraska, is evolving a Web-based a brand that means something to the residents of system and processes to ensure that its commu- Nashville; it means we are striving to live out values nity improvement efforts share reliable health and of a healthier and greener city. We make sure to con- quality-of-life indicators. The business, nonprofit, nect our many place-based projects—our new bike and government leaders who share governance for share program, our workplace wellness initiatives, LiveWell Omaha have come to realize that a shared and our greenway and food access initiatives—to a measurement system with common measures serves brand that represents a new way of working and liv- an important role in community discussion, commu- ing together.” Plans are under way to encourage and nity education, and collective action. ensure that whenever businesses, schools, and workplaces use the brand, they also adhere to a high level of healthy eating/active living policies and practices. Artfully Blend Policies, Programs, and Promotion Policy and environmental strategies are essential for deep and sustained change, but the greatest impact Policy and environmental strategies are essential for generally comes when these are combined with pro- deep and sustained change, but the greatest impact grams and creative promotion. generally comes when these are combined with programs and creative promotion. For example, the PedNet Coalition in Columbia, Missouri, found that policies and environmental improvements—street improvements involving sidewalks, crosswalks, bike lanes, and crossing guards— Adopt an Opportunistic and Experimental Mind-set alone would not lead to long-term behavior changes. Long-range action plans become static and are prone It would take a combination of these improvements to irrelevance when operating in a dynamic politi- plus programs—in particular, Columbia’s nationally cal, social, and fiscal environment. Given today’s ra- recognized “walking school bus” and bicycle safety pidity of change, the nature of place-based strategies courses—to tip behavior change so that children and requires a highly adaptable approach. No cookbook families would begin walking or bicycling to school. exists for executing place-based strategies; rather, effective place-based change leaders increasingly think Each year PedNet and scores of partners sponsor and behave like social entrepreneurs, testing small “Bike, Walk & Wheel Week,” a highly visible and changes and scaling what works. When anchored popular week of music in the parks, bike giveaways with a strong vision, place-based coalitions can af- (recycling bikes for lower-income families), break- ford to be highly adaptable, even opportunistic, fast stations at schools and workplaces promoting while maintaining fidelity to their long-term goals. biking/walking, and a local celebrity car versus bike challenge. This event is strategically aimed at re- Investing in complete street policies and strategies cruiting families to participate in walking school bus (e.g., making it easy to cross the streets, walk to programs (a walking school bus is a group of chil- shops, and bicycle to work) was an aspiration, dren walking to school with one or more adults) though not initially a top priority, for Birmingham and at growing support for future infrastructure Alabama’s Health Action Partnership (HAP), pri- investments—building a constituency for change. marily because of the perceived political and fiscal climate. Things changed when the mayor and Place-based coalitions across the country are turn- City of Birmingham decided to move forward with ing to full-blown branding strategies and campaigns a sizable repaving project to be completed prior to to help cement and grow communitywide support Birmingham’s hosting the international Davis Cup for place-based changes. For example, a Nashville, Tennis Tournament. HAP members seized the op- Tennessee–based coalition called Nashvitality has portunity to educate city leaders about the bene- been very intentional about branding, coordinating fits of complete streets. They convinced leaders to

6 National Civic Review DOI: 10.1002/ncr Spring 2014 make slight adjustments to the paving project, such more like movement mobilization than program as striping bike lanes and adding signage (which management. would have been much more costly to do later). HAP was able to capitalize on the opportunity because the No single model exists for leading and organizing a members were flexible. place-based collaborative. Some communities house them within existing organizations, such as health Effective coalitions constantly scan for assets and departments or YMCAs, and some incorporate them opportunities. Such opportunities often arise unex- as separate nonprofit organizations, while others pectedly. HAP was also working to link healthy rely on a variety of collaborative partners to fulfill eating and physical activity with smoke-free en- these core leadership and support functions. What- vironments. After a poll showed stronger-than- ever model is used, the effective ones usually have anticipated community support for tobacco-free these characteristics: environments, HAP learned of an interest in smoke- free ordinances on the part of two influential bar ● Engage the right mix of individuals. At the core owners and seized on another opportunity. Its ap- they have a strong leadership team with a mix of proach of combining a pilot program of smoke-free individuals representing different sectors and per- nights at the most popular bars along with a coor- spectives and willing to contribute their influence, dinated media effort presenting data from polls to skills, and/or networks for the greater good of justify public support became instrumental in ad- the community. They also have action teams/work vancing smoke-free policies. Highlighting a pressing groups that include an appropriate mix of part- problem that needs a solution and building on ex- ners, content experts, and stakeholders (including isting assets are great ways to generate momentum. those who shoulder the greatest burden of health Assets may include willing volunteers or school or disparities) who can implement targeted strategies civic leaders who like to be early adopters. effectively. ● Build team and team skills. A group working A network of youth-serving organizations banded together needs solid relationships and a sense together in Nashville to test organizational poli- of being part of a team to perform well. Ann- cies and practices that lead to healthful eating and marie Medina of Activate Tucson said, “Making more active environments for youth. They came time for our respective team relationships out- together over a six-month period to experiment side of a traditional meeting format—doing site with evidence-based strategies. They looked at what visits, watching movies, and eating together— worked, what did not work, and effective ways to as well as attending relevant learning events, scale strategies in an effort to create healthier “youth has helped us build trust and stick together zones” across the metro area. A group of participat- when things get tough.” Endeavoring to im- ing organizations that included the YMCA, United plement policy and environmental strategies is Way, and Boys & Girls Club entered the collabo- new territory for many team members; provid- rative experiment with the attitude that failures are ing them with education and capacity building to be expected and provide good opportunities for allows them to contribute fully. Building team learning and adapting, a powerful approach that is skills and capacity often includes helping people bearing results and often snowballs into other viable find their voices as effective advocates and under- opportunities and even greater results. stand effective ways to influence policy-making processes. ● Provide collaborative infrastructure. Collabora- Distribute Leadership and Spread the Movement tion within and across coalition teams requires Most of these initiatives have ambitious aims, lim- substantial support: facilitation; communication ited staffing, and strong reliance on volunteers. through meetings, notes, notices, and updated ac- Place-based initiatives are often complex—involving tion plans; research to determine proven strate- many organizations and partners—and do not rely gies; evaluation to establish the baseline and iden- on hierarchy or individual organizations to mandate tify gaps; and convening meetings. The HAP of performance. This coordinated work effort looks Jefferson County, Alabama, leaned on its United

National Civic Review DOI: 10.1002/ncr Spring 2014 7 Way partner to help cultivate action team facil- sources like the Centers for Disease Control and itators and to support communication between Prevention, the Robert Wood Johnson Foundation, action teams. This support has been crucial to the W.K. Kellogg Foundation, and/or Kaiser Per- HAP’s successful implementation of place-based manente, along with several larger statewide foun- solutions. dations. Clearly, the increased public focus on the obesity epidemic and issues of physical inactivity One key to spreading the movement is to help lo- and unhealthful nutrition has garnered an unprece- cal organizations adopt their own policies and prac- dented level of collaboration among funders and tices. Because so many of the policy/environmental researchers as well as state and local networks of improvements are also specific to settings, numer- place-based coalitions. ous opportunities exist for local organizations to adopt and implement place-unique improvements, As place-based approaches mature, there is a grow- for example, helping local nonprofit organizations, ing recognition that the potential impact of these small and large workplaces, and places of wor- strategies to combat obesity extends well beyond ship to customize and implement their own healthy- benefits of community members’ physical health. eating, active-living policies and practices. Another These same strategies have the added benefit of cre- improvement might be helping government agen- ating physical spaces that are conducive to a greater cies adopt procurement policies that support healthy sense of belonging and social cohesion—a power- eating for employees and contribute to the local ful antidote to suburban sprawl and the car-centric food system. These are powerful and sometimes easy landscape of strip malls and fast food joints. They ways to reach and engage a broad number of com- are proving to be a powerful way to reestablish, or munity members and to contribute to core strategies. create for the first time, places worth caring about. This returns us to the vision and promise of early Of course, helping community members take basic health community efforts like Forging the Future: meaningful daily actions, such as biking to work and To create and sustain health, people need, and are supporting the local farmers’ market, is also at the naturally wired to thrive in, places where there is heart of changing community norms and spreading an authentic sense of community and connection to the movement. place.

Conclusion Monte Roulier is the cofounder and president of Community Today hundreds of community collaboratives are Initiatives, an organization dedicated to building healthy and employing place-based strategies. Many of these whole communities. have received funding and technical assistance from

8 National Civic Review DOI: 10.1002/ncr Spring 2014 Community Commons A Unifying Public Good Web Site for Healthy, Sustainable, and

Livable Communities BY CHRISTOPHER L. FULCHER

In the spring of 2010, a distributed network of leaders of their initiative cohort to a community-centric who were collaborating on policy, systems, and en- view of funded activities across funders. A broad vironmental change approaches for improving pop- landscape perspective of people, places, partner- ulation health and community vitality initiated a ships, and impacts is needed to accelerate learning national conversation in Indianapolis, Indiana. The and advance the field. purpose of this conversation was to increase and sustain the impact of local, state, and regional initiatives working for the vision of healthy people in What Are the Essential Features of Community healthy places, toward a more equitable and pros- Commons? perous United States of America. Community Commons adopts a user-centric design approach that provides users with individual profiles From this conversation emerged Community Com- and a coherent navigation structure to access social mons, an online interactive mapping, network- media, stories, tools and functionality. Specifically, ing, and learning utility for the broad-based Community Commons offers free access to: healthy, sustainable, livable communities’ movement (www.communitycommons.org). This na- ● Individual customizable profiles. Each user has an tional public good Web site provides easy-to-use, individual profile that can be customized with an free–to–end-user, democratized access to collabora- image and description. The user profile can hold tion tools, data, maps, reports, and stories that sup- saved maps, reports, documents, files, and inspir- ports collective impact for the health of people and ing articles read on the Commons. Users can also places. The primary audiences include communities access a list of all groups they belong to in their (civic leaders, municipalities/agencies, and multisec- individual profile. tor collaborations), funders (public and private), ● Interactive mapping and data engine. The Com- and intermediary organizations (policy, technical as- mons’ mapping tools include thousands of inter- sistance, and evaluation organizations). active mapping layers covering a variety of topics that include health, education, poverty, food systems, socioeconomic, demographic, and other Why Is Community Commons Important? community context data layers that may be visu- Community Commons serves as a network of net- alized at the state, county, zip code, tract, block works to help communities learn who is doing what group, or point levels for all communities in the and where around the country that might be re- United States. Users can create unlimited maps to lated to their work, focus areas, and strategies. To share via e-mail and hyperlinks as well as create this end, an interactive, searchable “Map of the maps to print and save as images. Users can take Movement” of the broad-based Healthy Communi- advantage of the variety of selection and query ties movement features the locations and content of tools in the interactive mapping environment and place-based, evidence-informed initiatives. All con- customize maps to their own community. tent contributed or saved by users (maps, stories, ● Reporting tools. The Commons’ reporting tool al- videos, images, etc.) can be filtered by type of con- lows users to create a variety of reports for their tent and initiative(s). The “Map of the Movement” county or region. Users can compare their county changes the conversation from a funder-centric view or region to the state and the nation. The reports

C⃝2014 Wiley Periodicals, Inc. Published online in Wiley Online Library (wileyonlinelibrary.com) A Publication of the National Civic League National Civic Review ● DOI: 10.1002/ncr.21165 ● Spring 2014 9 include charts, graphs, data descriptions, and in- wise be marginalized in their former disconnected teractive maps. The reports can be saved, shared, Web sites that have smaller audiences and/or num- or downloaded as PDF or Word files. One re- bers of Web site visitors. porting tool, the Community Health Needs As- sessment (CHNA), is designed to assist hospi- All Commons group spaces have private-public ar- tals (with particular attention to critical access eas where the private space is reserved for an orga- and other smaller facilities), nonprofit organiza- nization or network to upload and check local data, tions, state and local health departments, finan- pull content together, and generate stories; the pub- cial institutions, and other organizations seeking lic space is reserved for the organization’s or net- to better understand the needs and assets of their work’s dissemination of content to the broader pub- communities and to collaborate to make mea- lic. The funder or community collaborative for that surable improvements in community health and group space decides what content is made publicly well-being. available. User roles allow only those with the nec- ● Public group spaces and request-to-join private essary credentials to see and access additional tools group spaces. The Commons includes a number and functionality. of topic-based public groups that provide an opportunity for collaboration and dialogue among There are several distinguishing features of the Com- the Commons community. Users can visit these mons model. First, when funding ends for grantees groups and then join a group of interest. There or organizations no longer have funding to main- are also private group spaces on the Commons tain their subscription for advanced access, they will that users can visit and request to join. Within the continue to have access to all existing content gen- groups, users can discuss maps, reports, shared erated as part of their funded group engagement; files and documents; collaborate around aco- however, they will not have access to the full suite editable document; and discuss topics via forums of custom tools. For example, a national network and discussion threads. of grantees that sunsets when funding ends will con- ● Contextualized resources. Resources include tinue to have access to their individual profile and starter maps, social media tools, widgets, data group space without interruption in service (e.g., apps, case stories, news feeds, compelling videos, they do not need to migrate to Community Com- hot-off-the-press features of communities and mons from a disconnected custom Web site with a leaders having an impact, tutorials, and other different navigation structure) because they are al- useful resources that are added on an ongoing ready embedded in the Commons. Although fund- basis. ing ends for grantees, a community may elect to subscribe for continued access at a nominal cost to the full suite of custom tools uninterrupted. All How Is Community Commons Different from communities, including those that never receive na- Comparable Efforts? tional funding, have public access to the Commons. To further accelerate this network of networks, ma- In addition, any community has the opportunity jor investments once made toward disconnected cus- to create a customized group space by subscribing tom Web sites are now being aligned in the Com- to additional tools and functionality at a nominal mons as “group” spaces to provide coherency across cost. place-based funded activities. A Commons group space is a customized Web site, linked to the Com- Second, with a user-centric design in place, all users, mons, that provides a home page for an organization regardless of their level of access, have a consistent, or network that includes collaboration spaces, con- coherent navigation structure in place and will be tent, logo, customized tools, and subgroup spaces able to directly benefit from new tools and function- if needed. The level and complexity of customiza- ality generated from other public good grants and tion varies across each group space based on funder contracts. A most recent example of this direct ben- needs and level of funding. Organizations are able to efit is the launching of the Community Health Needs amplify their respective online activities to the larger Assessment (CHNA) tool that is now embedded in Community Commons audience that would other- Community Commons.

10 National Civic Review DOI: 10.1002/ncr Spring 2014 Third, the Commons provides a larger and growing points to perform big data analytics. We have many audience base to share stories, policies, maps, and data sparks but no networked intelligence fire. related content that would not otherwise be available via disconnected systems with smaller, content- specific audiences. The traffic generated through the Although the Community Commons Web site cur- Commons can be directed to external organization rently is more health focused with stories, data, re- Web sites through the stories and related content ports, and group spaces, the longer-term vision of generated via their individual profile or group space. the Commons will transcend health to include other This growing audience base, supported in part by aligned investments, advances the Healthy Commu- sectors, such as environment, natural resources, nities movement. agriculture, education, and public policy.

A Vision for Community Commons Although the Community Commons Web site cur- An example of a prosumer activity might be commu- rently is more health focused with stories, data, re- nity sourcing playground conditions in communi- ports, and group spaces, the longer-term vision of ties across the country. Community sourcing coordi- the Commons will transcend health to include other nated by trusted anchor organizations—rather than sectors, such as environment, natural resources, crowdsourcing by individuals—may improve data agriculture, education, and public policy. For many quality and ensure protocols are adhered to, which years, the organizers of Community Commons have in turn provides the basis for comparative analyses focused our discrete project activities in these mul- that may inform public policy. Place-based nonprof- tiple sectors from a geographic information system its, grantees, and volunteer organizations can visit (GIS) and data perspective. Our holistic or “ecolog- local playgrounds and use their smartphones to take ical” systems perspective and related project work photos and answer a very simple survey related to for engaging communities has not yet manifested it- playground conditions and the surrounding envi- self in the Commons; however, given the broader ronment. This survey should be simple, short, and definition of health as it relates to the Healthy Com- fun rather than overwhelmingly detailed. Submit- munities movement, these sectors also will align in ted surveys and associated photos are automatically the Commons. geotagged with their locations and added to servers along with thousands of other responses, which will Prosumer Data provide the broadest reach to capture the level of Web sites are increasingly being built to accommo- prosumer data necessary for analyses. These data date two types of people: consumers and prosumers. can be mined based on the attributes collected and Consumers go to Web sites to browse and con- overlaid with other GIS data layers to better under- sume information (Web page content, images, au- stand spatial, socioeconomic, and built environment dio, videos, documents, articles, etc.) that currently characteristics that may inform playground use (or reside there. Prosumers, in contrast, go to Web sites underuse) and steps that might be taken to improve to produce or contribute information (data, content, conditions. images, audio, videos, documents, articles, etc.). The ability of companies to mine large databases (think This example is technically quite doable, and several big data) rests on the thousands, if not millions, of efforts currently are under way; however, the sparks prosumers who willingly provide data as part of the generated from these innovative activities may not terms and conditions for accessing Web sites. One be generating the needed fire. The challenge is align- prosumer activity—crowdsourcing—offers a wealth ing organizations with a commitment to a coher- of data for companies to further understand pref- ent communications channel for messaging that may erences and behaviors. Public sector organizations lead to coherent data collection and analyses and also collect basic prosumer data; however, given the meaningful change. For example, national organi- disconnected nature of data collection efforts and zations might commit to coordinated dissemination lack of protocols around types of primary data to of a monthly community source survey where the collect, there are not a sufficient number of data month of March might be “Community Source Your

National Civic Review DOI: 10.1002/ncr Spring 2014 11 Playgrounds!” Now, imagine the volume of pro- Conclusion sumer data generated by a VSS topic each month, We believe that a nation full of healthy, thriving containing three to five questions only (plus captur- communities is closer than you think. To get there, ing images or videos). we will need to work and learn together. This effort is about creating a collective impact. It is about What are we doing in the public sector (nonprof- building communities where everyone can thrive. It its, foundations, institutions of higher education, is for this reason that Community Commons was and government agencies) around big data to better created—to bring change makers together to con- understand community or aggregated population- nect with thought leaders and peers, share stories level characteristics? Where is a transparent, col- and strategies, and use the latest technology and laborative, networked-intelligence capacity to help tools to make lasting change. us make more informed decisions on improving the health of our communities across the country? The answer is, in part, organizational alignment and Christopher L. Fulcher is codirector of the Center for Applied commitment and, in part, technology-based plat- Research and Environmental Systems, located at the Univer- forms such as Community Commons that leverage sity of Missouri, Columbia. public good big data.

12 National Civic Review DOI: 10.1002/ncr Spring 2014 Promising Strategies for Building

Healthy Communities for All BY MARY M. LEE

Where you live shapes your health. If you live in a the infants of white high school dropouts. People community with access to good jobs, quality of color also suffer disproportionately from many schools, health care, and social services, you are health conditions that shorten or compromise the likely to thrive. But if your neighborhood lacks these quality of their lives: Infant mortality, asthma, di- essential elements, you are more likely to suffer from abetes, and heart disease top the list of chronic, pre- obesity, asthma, diabetes, heart disease, or other ventable diseases that are all too common among chronic conditions. Failing schools, low wages, and people of color. the absence of jobs severely restrict opportunities, raising the likelihood that you will be the victim of Public policies and the discriminatory practices and a crime. customs that followed caused and perpetuated the deplorable conditions that have excluded and weak- ened communities of color. Although there are suc- Place and Race Matter cess stories as well, the obstacles to prosperity Place and race are intimately connected in Amer- remain deep, ingrained, and difficult to overcome ica, where neighborhoods remain highly segregated in a sustainable and equitable manner. Policies are due to both historic and recent discriminatory pub- statements of the values—such as equity—that we lic policies in housing, zoning, land use, and ur- want to see fostered widely and deeply; therefore, ban planning. Racialized policy and practice have concerted action in crafting and implementing pol- shaped every system within our communities, from icy is a critical strategy. Policy makers in both the education to employment, from transportation to private and the public sectors must adopt strategies commerce. This legacy of institutional racism has re- to eliminate barriers to success and advance healthy, sulted in communities that have been disadvantaged equitable outcomes. The time is now, especially be- by design. People of color disproportionately live in cause the country is undergoing a profound demo- neighborhoods that lack access to health care, qual- graphic transformation as the population of Ameri- ity education, employment opportunities, healthy cans of color grows very rapidly. food, transportation, quality housing, clean air and water, services, and amenities; these same neighborhoods have the most entrenched obstacles to social America’s Tomorrow and economic opportunity. Given demographic trends, reducing racial and class inequity is not only the right thing to do, it is fun- Race alone is a powerful determinative of health, damental to the economic future of the nation as a even after controlling for factors such as income or whole. In 2012, for the first time, more than half of education. Although higher levels of education typ- all babies born in this country were of color, a trend ically correlate with higher life expectancies, race that is expected to continue. America will soon pass still trumps education for people of color. For ex- many more demographic milestones. By 2018, the ample, according to Murphy and to Braverman and majority of American youth will be youth of color. coauthors, African American college graduates have By 2030, the majority of the young workforce will shorter life expectancies than whites with only a be of color. Our country is projected to become ma- high school education. As reported in 2008 in Life jority people of color by the year 2042; California and Death from Unnatural Causes: Health and So- passed this milestone more than a decade ago. cial Inequity in Alameda County, another troubling example is that babies born to college-educated Consequently, there is a growing racial genera- black women in that California county have a higher tion gap between America’s oldest and youngest. risk of dying before their first birthday than do Eighty percent of seniors are white, compared with

C⃝2014 Wiley Periodicals, Inc. Published online in Wiley Online Library (wileyonlinelibrary.com) A Publication of the National Civic League National Civic Review ● DOI: 10.1002/ncr.21166 ● Spring 2014 13 54 percent of those under age 18. Too many elders strategies and policies that consider both race and and decision makers do not see themselves reflected place. in the faces of the next generation, and they are not investing in the educational systems and community infrastructure of the future in ways that en- An equitable society is one in which all have the op- abled their own success. This racial generation gap portunity to reach their full potential. not only puts youth of color at risk, it threatens the well-being of the entire nation. This is not a zero-sum game—an equity agenda As the country rapidly transitions to a majority would not eliminate or transfer existing opportuni- people-of-color nation, it is even more imperative ties from some communities to others. The goal is that communities of color have opportunities to con- to end practices that are harmful to people of color tribute to our economy. We need a new economic and replace them with approaches that enhance both growth model that is driven by equity. their opportunities and their life outcomes, thereby expanding prosperity for all. Equity is the opposite of one size fits all; it is right- sizing approaches to overcome the challenges of to- Target Strategic Places day to reach a better tomorrow for all. An equitable The challenges facing people of color often can be society is one in which all have the opportunity to addressed by targeting specific places. The work of reach their full potential. An equity-driven economic the Harlem Children’s Zone in New York City is growth model assesses every community’s situation a prime example. The initiative identified a clearly and develops the specific policies and strategies nec- marked geographic area with significant needs to essary for everyone to thrive, including the creation provide comprehensive services to the predomi- of real pathways for low-income people and peo- nantly black population that resides within the zone. ple of color to contribute to growth and democ- The initiative was the inspiration for the federal racy. The Conversation on Regional Equity, an ef- Promise Neighborhoods program, which takes a fort that brought together early leaders and thinkers similar place-based approach to address the needs in what has become an emerging field of research of communities of color. and community practice (2006) considers equity in a community to be achieved when “all neighborhoods Place-Based Strategies are supported to be vibrant places with choices for Place-based strategies can transform distressed affordable housing, good schools, access to open neighborhoods into opportunity-rich areas with space, decent transit that connects people to good high-quality housing and schools, public transporta- jobs, and healthy and sustainable environments” tion, thriving businesses and retail stores, walkable (p. 5). and safe streets, and essential services. Federal place- based initiatives such as the Promise Neighborhoods Neglecting communities of color for so long has re- (and the soon-to-be-launched Promise Zones), the sulted in gross inequity and an unsustainable future Sustainable Communities Initiative, the Healthy where America cannot compete on a global level. An Food Financing Initiative, and Choice Neighbor- equity-driven growth model, resulting in policy ac- hoods are helping hundreds of communities across tions that consider both race and place, is integral to the country implement place-based strategies to the elimination of health disparities and the creation improve neighborhoods and connect people to of robust, safe, and opportunity-rich communities. opportunity.

Public Infrastructure Investments Promising Strategies Public infrastructure investments can connect work- Understanding the connections among race, place, ers to jobs and educational opportunities, increase and health is necessary to build healthy communi- business productivity, and foster growth and com- ties. To create effective solutions that build on the as- petitiveness. Infrastructure renewal is a promising sets of a community, we must employ equity-driven strategy that creates opportunities to transition to

14 National Civic Review DOI: 10.1002/ncr Spring 2014 the clean energy economy of the future, starting proach could be adapted to any number of business first by increasing energy efficiency and improving sectors. environments in low-income communities of color. We support equity-driven policies that target areas Adopt Comprehensive Strategies where the need is greatest and employ local residents, particularly those from communities of color To achieve an improved health outlook for all in the and other historically underrepresented groups. Ex- places where people live, the next more comprehen- amples of such programs include Portland’s Clean sive strategies are also needed. Energy Works project, the national Emerald Cities Collaborative working in ten cities across the coun- Enhance Political Power try, Hire Houston First, and community workforce Civic engagement among people who are tradition- agreements being utilized by the Los Angeles De- ally underserved, especially people of color and im- partment of Public Works, Los Angeles Unified migrants, is critical to enacting policies that advance School District, and Los Angeles Community Col- equity. In California, for example, the electorate is lege District. disproportionately older and whiter than the general population. As a result, the state’s politics often ig- Cradle-to-Career Pipelines nore the needs of underrepresented, nonvoting com- Cradle-to-career pipelines expand education and munities within the larger population. Increasing the employment opportunities for vulnerable youth. civic engagement of diverse communities can lead to Early childhood education is one of the most cost- dramatic results. For example, with critical support effective investments in existence, particularly for from low-income communities of color, California low-income children of color. Researchers from passed an increase in upper income and sales taxes prominent institutions such as Harvard and the Uni- last year to reverse painful cutbacks and enhance versity of Chicago have documented the positive funding for education, health, and other critical state impacts resulting from expanding early childhood services. education, including an increased likelihood of academic success, college graduation, or career training Organize and Engage Residents of Vulnerable and acquiring quality jobs. Another example is the Communities federal Promise Neighborhoods program, described People of color and immigrants must also have the earlier. power to help set and implement an action agenda. Community residents have crucial insight into their Innovative Financing Mechanisms most pressing needs, their community strengths, and Innovative financing mechanisms can attract and the solutions that will be likely to succeed and en- sustain small business development in underserved dure. Struggling communities must be supported communities. Public/private initiatives that assist and provided with access to detailed information entrepreneurs in developing grocery stores, farm- and analysis about root causes of barriers to op- ers’ markets, and other food retail options in low- portunity and the possibilities to remove them in income neighborhoods without access to healthy formats that are relevant, accessible, and in ap- food are prime examples of the effectiveness of propriate languages. In Oakland, California, Urban this strategy. The pioneering Pennsylvania Fresh Habitat—a grassroots organization that focuses on Food Financing Initiative, launched in 2004, was the environmental, economic, and social justice—has model for programs that have now been launched undertaken this strategy by launching the Boards in California, Illinois, New Jersey, Colorado, New and Commission Leadership Institute. Since 2009, York, and New Orleans, Louisiana. In 2010, the the institute has recruited and trained low-income federal government launched the Healthy Food Fi- residents and people of color to serve on pub- nancing Initiative, taking the program to a national lic boards of agencies that make decisions about scale. As a result, more than a hundred new and up- the issues that affect their lives, particularly agen- graded stores are making healthy food available to cies that address core equity issues of transporta- hundreds of thousands of low-income consumers, tion, public planning, land use, housing, health, and and thousands of jobs have been created. This ap- jobs.

National Civic Review DOI: 10.1002/ncr Spring 2014 15 Enforce Existing Laws That Prohibit Discrimination . . . positive behavior supports [and] report reduc- Practitioners and advocates must pursue rigorous tions in problem behavior, a more positive school cli- enforcement of existing antidiscrimination laws. mate, greater safety, and improvements in academic Successful enforcement can reduce disparities while achievement. Studies have also shown reductions in increasing awareness of available legal protections office discipline referrals of up to 50 percent per and the consequences of violating these laws. Peo- year. Secondary benefits include improved academic ple who know their rights are less likely to be vic- achievement, reduced dropout rates, higher teacher timized, and potential violators are put on notice retention, and a more positive school culture.” that they cannot act with impunity. The nation’s network of fair housing laws provides a powerful Shift Public Perceptions example. The Federal Fair Housing Act is a com- Powerful imagery hardwires our brains with biases. prehensive statue that prohibits discrimination in All too often, television, newspapers, magazines, housing transactions based on an array of factors, and social media primarily present negative images including race, national origin, sex, and religion. of people of color. The mainstream must be held Combined with fair housing protections adopted by accountable for coverage that reflects the diversity several states, these laws have expanded protections and the strengths of our increasingly multiracial and to those renting or buying homes or applying for multiethnic communities. Advocates and commu- mortgages or insurance. Yet evidence of discrimi- nity stakeholders must also maximize opportunities nation persists. Vigorous enforcement plus educa- to utilize new technology and media tools to tell tion is essential to make the goal of fair housing a their own stories and disseminate authentic images. reality. A compelling example of shifting perceptions was the 2012 effort to gain support for the DREAM Act, Eliminate Discriminatory Polices a federal proposal to grant conditional permanent Not only must we enforce existing laws; it also is residency to the children of undocumented immi- necessary to ensure that current policies do not inad- grants. This multifaceted, broad campaign incorpo- vertently deepen racial inequities. At times, policies rated video and social media to create a movement may seem to be crafted to benefit everyone or to help that transformed attitudes toward immigrants on a vulnerable populations, yet they often accomplish national scale. the opposite. For example, zero-tolerance policies in schools may not appear to be biased; presumably Winning support for and implementing a compre- they were implemented to curb disruptive behavior hensive national policy agenda is difficult under the in schools. But data show these policies do not make best of circumstances. Given the current climate of schools safer or support learning; furthermore, be- divisiveness and gridlock, as well as mean-spirited cause of the biased way they have been applied, cuts to basic programs for access to food and health such policies disproportionately punish students of care under the banner of austerity, the undertaking color, pushing them out of school, increasing their is daunting. The only viable option is determined, risk of incarceration, and diminishing their life sustained, collective action to advance equity: action chances. that will achieve just and fair outcomes in education, employment, wealth, and by extension, health. Policy goals can and must be accomplished without disproportionately burdening vulnerable groups— Together, we can create a productive nation that there are better ways to make schools safer than to honors and supports the extraordinary diversity and summarily expel students. Student court, commu- energy of its residents by making sure that every nity service, counseling at-risk students, and other community is a healthy, vibrant, opportunity-rich demonstrated alternative measures are much fairer place to work, study, and play: the kind of place than summary expulsion and vastly more effective at where we all want to live. creating an atmosphere that supports learning. Ac- cording to the Fix School Discipline organization at References http://www.fixschooldiscipline.org/solutions, “Over Alameda County Public Health Department. 2008. Life and 13,300 schools across the country are implementing Death from Unnatural Causes: Health and Social Inequity in

16 National Civic Review DOI: 10.1002/ncr Spring 2014 Alameda County. Oakland, CA: Author. http://www.acphd Quamie, Lexer. 2011. “Transportation Equity a Key .org/media/53628/unnatcs2008.pdf. to Winning Full Civil Rights.” Race, Poverty and the Environment 18(2). http://www.urbanhabitat.org/node/ Conversation on Regional Equity. 2006. Edging To- 6701. ward Equity: Creating Shared Opportunity in America’s Regions. Santa Cruz: Center for Justice, Tolerance & World Health Organization. 1946. “WHO Definition Community, University of California. http://cjtc.ucsc.edu/ of Health.” http://www.who.int/about/definition/en/print docs/r CORE Edging Toward Equity summary.pdf. .html. Hernandez, Jesus. 2008. “Connecting Segregation to Con- temporary Housing Credit Practices and Foreclosures: A Case Study of Sacramento.” Written Testimony Submitted to Mary M. Lee is a deputy director at PolicyLink, a national ad- the National Commission on Fair Housing and Equal Oppor- vocacy organization working to advance equity and social jus- tunity. Los Angeles Hearing, September 9. http://www.prrac tice, where she helps guide the PolicyLink Center for Health .org/projects/fair housing commission/los angeles/hernandez Equity and Place. .pdf.

National Civic Review DOI: 10.1002/ncr Spring 2014 17 Building Healthy Communities over the Long Run Lessons from the Colorado

Healthy Communities Initiative BY DOUG EASTERLING

The World Health Organization in 1986 formulated the ties throughout Colorado participated in various concept of healthy cities around two key prin- aspects of the initiative. These communities varied ciples: (1) health planning and health promotion tremendously in terms of geographic size (from 2 should incorporate a broad definition of “health,” square miles to 9,247 square miles) and population and (2) community members need to participate (from 2,700 residents to 249,000 residents). fully in determining which health issues are addressed and how they will be addressed. Communi- Like most other foundation-sponsored approaches ties around the world have experimented with var- to healthy communities, CHCI required each partic- ious approaches to carrying out these principles. ipating community to convene a broad set of stake- Some of these efforts are incremental augmenta- holders to engage in a comprehensive strategic plan- tions to conventional health planning while oth- ning process. The CHCI approach to planning was ers are radical overhauls of community decision- mapped out initially by John Parr, who was then making structures and processes. NCL president. Parr hired Tyler Norris to flesh out a more specific process. Norris’s model spelled out In the United States, foundations such as Kel- a step-by-step process of visioning, data collection, logg, Robert Wood Johnson, California Wellness, deliberation, goal setting, and action planning, all California Endowment, the Colorado Trust, and carried out in an inclusive, consensus-oriented man- Sierra Health have funded Healthy Communities ner. Each CHCI community was expected to com- initiatives in which multiple communities pursue a plete the prescribed planning process over twelve to prescribed model of planning and implementation. fifteen months. Evaluations of these initiatives demonstrate mixed success, with some models being more effective than Of the twenty-nine stakeholder groups that began others and the same model working better in some the planning process, all but one completed all the communities than in others. It turns out to be ex- specified steps, ending with the creation of anac- ceedingly challenging to bring diverse stakeholders tion plan. Most of these planning efforts had high together around a common agenda and to generate levels of participation from a broad cross section of meaningful action that actually improves health, es- stakeholders. In the average community, forty-nine pecially at a communitywide level. stakeholders participated in at least three meetings. The largest stakeholder group had 130 active participants while the smallest group had fourteen. Colorado Healthy Communities Initiative One of the more successful of these multi-site initia- Each of the twenty-eight stakeholder groups that tives was the Colorado Healthy Communities Ini- successfully completed the planning phase received tiative (CHCI), which was jointly launched by the an implementation grant of $100,000 to be ex- Colorado Trust and the National Civic League pended over two years (although most were ex- (NCL) in 1992. Originally conceived as a five-year, tended). These grants were intended to cover key $4.5 million initiative, CHCI eventually spanned elements of each community’s action plan. The an eight-year period with a total investment of Colorado Trust initially restricted the implementa- $8.8 million on the part of the trust. A total of tion grants to projects that specifically advanced twenty-nine urban, rural, and suburban communi- Healthy People 2000 objectives but eased these

C⃝2014 Wiley Periodicals, Inc. Published online in Wiley Online Library (wileyonlinelibrary.com) 18 National Civic Review ● DOI: 10.1002/ncr.21167 ● Spring 2014 A Publication of the National Civic League restrictions based on concerns raised by the first It is important to note that many of the most im- round of communities. pactful projects resulting from CHCI were not included in the original action plans. Instead, they The action plans consisted of anywhere between two were developed by the local CHCI organizations and ten projects aimed at a broad range of quality- that emerged following the planning phase. By of-life issues, including health, recreation, envi- 1999, a total of twenty-one communities had set ronmental quality, education, housing, economic up a new organization to implement the CHCI development, youth, families, older adults, civic en- action plan and/or to facilitate ongoing commu- gagement, communication, and leadership. Roughly nity problem solving. These organizations became one-third of the action plans also called for the cre- vehicles for growing the work and for learning ation of a new organization that would institution- how to do healthy communities over the long run. alize the “healthy communities” process beyond the A statewide organization, the Colorado Healthy planning process. Communities Council, was created in 1995 to facilitate networking and peer learning among these local groups. The Colorado Trust supported Beyond developing their own projects and programs, the operations of CHCC and also provided it the local CHCI organizations facilitated planning with a pool of challenge grant funds that CHCC and problem-solving processes that set the stage awarded on a competitive basis to local CHCI organizations. for system-level strategies to improve community health and well-being. Beyond developing their own projects and programs, the local CHCI organizations facilitated planning and problem-solving processes that set the stage for system-level strategies to improve commu- Outcomes and Impacts nity health and well-being. Some of these big-ticket Over the years following the planning process, payoffs are listed next. CHCI communities launched a host of important projects, programs, and initiatives, including health ● Healthy Mountain Communities convened an clinics, family resource centers, recreation facilities, economic sustainability task force that developed a mobile van, leadership training programs, com- a community-supported agriculture project and munity indicators projects, master plans, civic fo- also facilitated regional transportation partner- rums, and even a new community foundation. For ships that set the stage for the Roaring Fork Trans- instance: portation Authority, which now operates the second largest bus system in Colorado. ● The High-Five Plains project created the Strasburg ● Mesa County Civic Forum engaged in planning ef- Clinic (for urgent care) and established a satel- forts that led to the creation of Grand Valley Tran- lite campus of Morgan Community College in sit System, which provides bus service to eight Bennett. Kit Carson County created Frontier hundred low-income, disabled, and elderly citi- Health Network to oversee the development of a zens. countywide health insurance program. ● Kit Carson County established Healthy Living ● Pinon˜ Project (Cortez County) opened three Fam- Systems through the CHCI implementation grant ily Resource Centers that provide parent edu- and built twenty units of low-income housing cation, literacy training, and life skills and also in four sites across the county (Country Roads developed a training program for civic leaders Housing) as well as two assisted-living facilities (Montezuma Leadership) that attracted twenty (the Beehive and the Legacy). participants per year. ● Prowers County created High Plains Health Cen- ● Pueblo County established within a local school ter (HPHC), which opened in Lamar in 1995 the Eastside Health Center (La Familia Puerta), through the efforts of Health Resources, Inc., a which provides parenting classes, immunizations, group of county volunteers who were actively en- and health resource education. gaged in the CHCI planning process. Over the

National Civic Review DOI: 10.1002/ncr Spring 2014 19 next sixteen years, HPHC grew to be one of the Looking back at CHCI from a 2013 vantage point, dominant health care providers in southeastern it becomes clear that the planning process was Colorado, with eighty-one staff members and an not a mechanism for getting to definitive solu- annual budget of $5 million. tions but rather an initial step in an ongoing journey. Stakeholder groups generated ambitious ac- In addition to generating high-impact projects and tion plans as part of their planning work, but programs, CHCI also benefited the civic infrastruc- these turned out to be first approximations of the ture of the participating communities. For example, work that actually occurred over subsequent years. Ross Conner’s evaluation in 1999 found that over The action plans were valuable not because they three-fourths of the stakeholders participating in the were strategic and comprehensive but because they planning process increased their ability to analyze specified an initial round of work that setthe community problems and to work collaboratively. stage for more interesting, creative, and powerful A majority developed at least some new leadership projects. skills. Beyond building the capacity of stakeholders, the planning process set in motion a shift in how Over time, the actors involved in the work got communities go about making decisions and solving smarter about the health of their communities, problems. Stakeholders came to realize the value of the underlying factors that influence public health, civic engagement, visionary planning, and collabo- and how to intervene effectively on those factors. ration, which led to the creation of new organiza- They also strengthened their networks and deep- tions to continue the CHCI process. Although many ened their ability to work together toward shared of these organizations were unable to sustain them- goals. In other words, they built their collaborative selves over the long run, their work continues to intelligence. show a lasting impact on community capacity and civic culture across Colorado. This shift in how communities identify and solve problems is arguably CHCI’s most profound and Implications for Community-Based Health Initiatives lasting impact. Over the past twenty years, the culture of problem solving in Colorado has come to CHCI generated broader and deeper levels of com- emphasize civic engagement, collaboration, systems munity impact than can be claimed by nearly any thinking, and inclusive decision making. CHCI was other multisite HCC initiative. In many respects, not the only impetus for Coloradans to begin think- it is a best practice. But it is crucial to qualify ing and acting this way, but it was one of the first that assessment with a recognition of how CHCI initiatives to clearly spell out and promote the defin- actually achieved its impacts. CHCI was initially ing principles. The planning process played an essen- viewed—at least by the board and staff of the tial role in exposing residents from across the state Colorado Trust—as a planning-based approach to a new way of working together and a new way that would allow local stakeholders to identify of thinking about the health of their communities. and implement high-leverage strategies to improve That intelligence ripened and matured over subse- health. A community would presumably complete quent years as local residents practiced the princi- its CHCI process in three and a half years. However, ples of CHCI and experimented with new processes the path to impact was not nearly so linear and for collaborative problem solving. Any attempt to ordered. Many of the most impressive projects that replicate CHCI should support participants during took shape as a result of CHCI (e.g., the High Plains all phases of the work. Health Center, the Strasburg Clinic, the Frontier Health Network, the Roaring Fork Transportation Authority) were not even mentioned in the action plans. Instead, they were formulated through planning processes facilitated by the new organizations Doug Easterling is chair of the Department of Social Sciences that formed in various CHCI communities during and Health Policy at Wake Forest School of Medicine. the implementation phase.

20 National Civic Review DOI: 10.1002/ncr Spring 2014 Healthy Polk 2000 to Healthy Polk 2020 What a Long, Strange Trip BY BECKY MILES-POLKA, CHRIS FRANTSVOG, It Has Been AND RICK KOZIN

In March 1993, the Polk County, Iowa, Board of expert, for assistance in developing the Healthy Polk Supervisors created the Polk County Health Plan- 2010 plan. ning Committee, charged with “developing a Polk County community health plan.” With leadership More important, local funders (Polk County Em- provided by the director of the Polk County Health powerment and the Mid Iowa Health Foundation) Department (PCHD) and the county manager, the began to align their own investments with the pri- initial planning committee developed a mission orities identified by the community through the statement: Healthy Polk planning processes.

Healthy Polk is a movement of individual citizens and community organizations with a mis- Community Engagement sion to improve health status, longevity and From the project’s inception, Healthy Polk leaders quality of life for persons of all age groups, so- intended to create more than a plan or a new coali- cioeconomic levels and ethnic backgrounds liv- tion. It was to be a movement with a strong emphasis ing in Polk County, Iowa. on community input, community engagement, and community ownership. With minor modifications, this remains the mission twenty years later. As the italic words indicate, the The PCHD provided early leadership for the move- intent of the mission was to have a direct impact ment. This was critical in recruiting the necessary on health conditions in our community. Although senior-level decision makers from key partner insti- much progress has been made on health outcomes, tutions (e.g., United Way and the hospitals) to estab- the movement has impacted our community in other lish Healthy Polk’s credibility. In turn, these leaders ways as well. successfully recruited, from within their own organizations, the next tier of leaders who were necessary, and willing, to get actual work done. Investments The Polk County Board of Supervisors made a con- These people became the work group leaders and siderable investment of county resources in getting recruited their work group participants. In general, the initiative off the ground. Significant staff sup- these people were high-middle level management. port was provided by both the health department They had the necessary flexibility and autonomy and the county manager’s office. This in-kind invest- within their job descriptions to play this additional ment was complemented by annual direct cash in- convener role. They were also able to play a liaison vestments in projects advancing the work to impact role between their own organization’s senior lead- community-identified priorities. All told this invest- ers and the movement leaders. However, these high- ment probably exceeded $500,000 to date. middle level, highly committed change agents were caught between community priorities and organiza- Financial commitments by the county helped to tional priorities. Over time, we learned how difficult leverage additional dollars. Based on the early suc- it was to replace these leaders when they moved on cess and energy generated by the work around the to other things. original Healthy Polk 2000 plan, the Annie E. Casey Foundation committed resources for local leaders to With the adoption of the healthy community engage Tyler Norris, national Healthy Communities model for the development of Healthy Polk 2010,

C⃝2014 Wiley Periodicals, Inc. Published online in Wiley Online Library (wileyonlinelibrary.com) A Publication of the National Civic League National Civic Review ● DOI: 10.1002/ncr.21168 ● Spring 2014 21 movement leaders recognized the importance of the distinction between community-level results and more participation and involvement from residents. program-level performance measures. In developing the plan, five town hall meetings were convened throughout the community for public in- And there is now a clearer recognition of the dis- put. Using a community dialogue process, over 650 tinction between measuring how much we did com- county residents shared what they thought were the pared to how well did we do it and is anyone better most pressing concerns. From this input Healthy off? Polk leaders identified the six community “trend benders” to guide the work between 2001 and 2010. In retrospect, many of the outcomes from the work of Healthy Polk 2000 would be considered “how much we did.” However, the work accomplished Community health plan writers often fail to listen to by Healthy Polk 2010 did make people better what is really important to people’s vision of suc- off. cess, with the result that initiatives to change the ● health of a community sometimes put forward goals More children enrolled in the State Children’s Health Insurance Program—from 19 percent in using language that residents find difficult to relate 2001 to over 95 percent 2010 to in their day-to-day lives. ● Oral Health/Des Moines Smile squad. Reduction in preschool children with untreated caries from 24 percent in 2008 to 18 percent in 2012 This level of engagement was deepened even fur- ● Reduction in children with elevated lead levels ther for the Healthy Polk 2020 plan. Through from 4.7 percent in 2000 to 2.3 percent in 2008 participation in an online survey, responding to (a 51.1 percent reduction) a telephone interview, or attending a community ● Reduction in teen smoking and drinking by 38 conversation, over 2,300 people identified potential percent/27 percent respectively from 2000 to community priorities. After this list was narrowed to 2008 “measurable” priorities, 150 Polk County residents ● Infant mortality down from 7.4 per thousand to convened on a midwinter Saturday morning for a 5.7 per thousand from 2000 to 2011 traditional Iowa-style community caucus to choose ● Mothers initiating breastfeeding at birth increased the final ten priorities that serve as our current from 67.15 percent to 76.6 percent from 2000 to agenda. 2010

It is important to note that as the level of commu- Measuring success is important. But consider for nity engagement increased, the scope of the Healthy a moment whether community residents will res- Polk agenda broadened. Compared to the more tra- onate more with an outcome they can actually see as ditional chapters on alcohol, mental health, can- opposed to numerical success measurements. Com- cer, and diabetes in the 2000 plan, the new plans munity health plan writers often fail to listen to included “community engagement” and “spiritual- what is really important to people’s vision of suc- ity” (2010 plan); and affordable housing, affordable cess, with the result that initiatives to change the transportation, and access to healthy food (2020 health of a community sometimes put forward goals agenda). These new inclusions were a direct prod- using language that residents find difficult to relate uct of community dialogues. to in their day-to-day lives. Here is an actual example of one indicator from a community health plan: Impact on Conditions “Limit the upward prevalence trend of diabetes to Shortly after the release of the Healthy Polk 2010 0.2 percent per year.” Question: Are residents likely plan, many community leaders were introduced to to hop on board a community campaign to impact results-based accountability (RBA). This framework “prevalence”? has been instrumental in how we think about our impact on the health conditions in our commu- There is absolutely nothing wrong with the numer- nity. We now have a clearer understanding about ical measurement just given. Our experience has

22 National Civic Review DOI: 10.1002/ncr Spring 2014 been that some community partners may require the After the director retired, his next two successors proof of hard data before they will get involved. As did not assume a movement leadership role. Addi- Paul Mattessich and Ela Rausch conclude in Collab- tional planners were hired in the community orga- oration to Build Healthier Communities (2013), cre- nizer model, which strengthened the PCHD’s sup- ating healthy communities will require metrics that port role. appeal both to community members and to experts from multiple sectors in the community. What about the Data? But if you intend to maximize the number of indi- Both the 2000 and 2010 plans included clear, mea- viduals, groups, and institutions hopping on board surable goals. Yet it has not been a high priority of (or perhaps joining together to push is a better either the Healthy Polk movement in general or the metaphor) to change health outcomes, then you will PCHD specifically to collect the necessary data and need to speak their language. You need to give voice report on progress to the community. to their visions of what a healthy community could be. The Healthy Polk movement is working to identify The Healthy Polk movement, especially in its 2010 and promote opportunities for community members and 2020 versions, has tried to encapsulate the com- to turn their visions into action that can change the munity’s vision by asking questions like this one: “If everyone in Polk County were healthy, what would health of our community. it look like?” The replies that came back were ones like these: affordable, healthy food; accessible, affordable transportation; equal access to health care As mentioned, this is not due to the lack of data for all and youth who are more physically active ev- indicating progress. Part of the reason for this way ery day. of prioritizing can be explained by certain ambivalence with statistics as the best indicator of suc- The decision to capture a vision-based community cess (compared to stories and experiences). But it agenda was intentional. We think that people who also can be explained by a lack of capacity at the live, work, and play in Polk County will be energized PCHD to do the necessary collection, reporting, and by a goal they can understand, one they can see. The analysis. Healthy Polk movement is working to identify and promote opportunities for community members to turn their visions into action that can change the Taking It to the Next Level health of our community. The product emerging from our evolving definitions of the terms “investment,” “leadership,” “engagement,” and “impact” is a new model for community initiatives. It stands in marked contrast to ear- Role of PCHD lier models that emphasized: As stated, the PCHD director played a critical leadership role in conveying visibility and credibility for ● Decentralized investments in a broad blanket of Healthy Polk in the beginning. Although that senior programs leadership commitment was crucial, the Health De- ● Distributed leadership around programmatic partment lacked the capacity to provide the neces- elements sary support services that are now associated with ● Recruitment of individuals to fill the programs being a backbone organization. ● Impact measured through program results

This deficit was addressed when the department The new model, instead, focuses on: hired a full-time public health planner with strong community organizing skills at the time of the re- ● Concentrating community investments of dollars lease of the 2010 plan. and efforts in order to double-down on one or

National Civic Review DOI: 10.1002/ncr Spring 2014 23 two narrowly focused initiatives with high impact ● Numbers of individuals to be engaged and target potential populations (if any) ● PCHD asked by Healthy Polk leaders to be a deci- ● Purpose and frequency of mobilizing events sive leader in identifying and guiding community ● Targeted institutions and organizations to be or- initiatives ganized ● Mobilization of community residents to advance key initiatives Several key Healthy Polk leading partners will raise ● Impact measured by a combination of statistics the necessary funds for the initiative. Proposals and observable experiences will be accepted from individuals and firms with demonstrated expertise in achieving successful cam- How does the new model work? First, Healthy Polk paign outcomes. One firm will be awarded a con- leaders facilitate a dialogue among community part- tract to conduct the project (subcontracts will be ners with unique knowledge of the priority area allowed). (e.g., food, health access) and others who are famil- iar with community change. PCHD provides a list The first two phases of the kickoff of this new model of initiative outcomes drawn from existing strategic were under way as this article was being written. plans that have been created by Healthy Polk stake- In early June 2013, a group of thirteen community holders over the past one to two years. The goal is partners met to consider four different outcomes to identify one or two narrowly focused initiatives, to increase access to affordable, healthy food. Af- each with a high likelihood of resident engagement ter rich discussion, they selected an outcome titled and success in moving the needle within the priority “Closer Food,” which focuses on every neighbor- area. hood having “fresh fruits and vegetables available, or options for food delivery for sale at least weekly.” Second, PCHD selects one initiative (if more than A Healthy Polk leadership team has set a funding one has been specified) from the list that has the level of $200,000, and ideas are being considered for highest potential for impact based on these charac- the initiative, which could begin as soon as January teristics: 2014.

● It will involve/engage thousands of individuals. Reference ● The concepts, actions, and desired behaviors Mattessich, Paul W., and Ela J. Rausch. June 2013. Col- are broadly understandable to individuals and laboration to Build Healthier Communities: A Report for organizations. the Robert Wood Johnson Foundation Commission to Build a Healthier America. St. Paul/Minneapolis, MN: Wilder ● The effort has a clearly defined beginning, end, Rearch/Federal Reserve Bank of Minneapolis. and outcomes. ● Sufficient support and investment can be garnered among key stakeholders and partners. Becky Miles-Polka is owner of Within Reach Consulting Ser- Third, PCHD will write a scope of work for the ini- vices LLC. tiative that will include a budget, themes for promo- tional efforts, and measures of success. It will also Chris Frantsvog is public health planner for the Polk County Health Department. include key deliverables, such as: Rick Kozin is director of the Polk County Health Department. ● Overall outcomes for the initiative

24 National Civic Review DOI: 10.1002/ncr Spring 2014 Memphis

Faith in Healthy Communities BY GARY GUNDERSON

The Healthy Communities movement of the 1990s was tion to suffering and privilege rather than toward imported from Europe but adapted well to the so- transformation. cial ecology of the United States. It had no natural enemies (who could be against a healthier commu- Although Dr. Martin Luther King Jr. was killed nity?) and was blessed with many enthusiasts work- in Memphis, his dream did not die with him. To- ing in a striking array of professional settings. Per- day in Memphis 529 congregations, mostly, but haps the movement was too easy to accept, too easy not entirely, African American, work in a relation- to agree with. Now, twenty years on, there are signs ship called covenants that makes possible the prac- that its basic ideas are becoming part of the opera- tical movement toward what Dr. King called the tional mind system of some institutions that would “Beloved Community.” This is more radical than seem to be its greatest beneficiaries: health care orga- “healthy community,” more resonant in Memphis’s nizations and networks of religious congregations. mud and blood than European ideals. Today these congregations, one faith-based health system, and The first, hospitals, are still barely breaking asweat a plethora of community partners are the heart of when it comes to community health, the primary tes- what is now widely known as the Memphis model. tament to which is the remarkable attention they are Hospitals and public health leaders from around the paying to the recent and very minor requirements of country are interested because the large-scale part- current “community benefit” legislation (the essence nerships have shown evidence of moving patient of which merely requires them to do some kind of as- data in directions that matter to them: lower costs sessment of community needs and report how they and higher participation in trust-sensitive secondary are going to align their community activities with services, such as hospice, rehabilitation, and home at least some of those needs). This feels more like a care. Even more striking is evidence of 39 percent first step twenty years late than a mature grasp ofthe longer time out of the hospital after treatment and promise of healthy communities. Healthy Commu- a decline in gross charity care cost in the zip code nities was and is still a movement, not a plan. People where the covenant partners are concentrated. who measure success at the scale of populations and organizational culture learn to value increments and The ideas underlying the work in Memphis, which surprises but also go deeper. One surprise involves are now spreading to many other communities, trace the second obvious partner—religious networks— back to the Interfaith Health Program at the Carter which finally seem to be embracing community as Center (IHP), which was a small but visible part mission. of the Healthy Communities movement at its inception. The IHP was created after the Closing the Memphis is among the last places one would look Gaps collaboration in 1986 by the Centers for Dis- to find a population with which to scale healthy ease Control and the Carter Center that exhaus- hope. The city is at the wrong end of every list, tively documented that roughly two-thirds of deaths which is predictable given its economic logic. Mem- before age sixty-five are due to preventable causes. phis is to cotton as Johannesburg is to gold, spin- President Jimmy Carter, Dr. Bill Foege, and the Park ning a similar tapestry of inevitable, if not inten- Ridge Center for the Study of Health, Faith, and tional, pathologies visible in patterns of race and Ethics called a meeting in 1989 of religious leaders to gender and every way of measuring health. These see if they could grasp the moral opportunity to ad- are twisty, wickedly complex, self-replicating pat- dress these issues (which they could, of course). This terns that every next generation quickly accepts as stream of moral energy converged with the Healthy normal. Even the religious dynamic, as in South Communities movement. Both rested on the obvi- Africa, tends toward complicity and accommoda- ous, but radical, notion that “community” is not the

C⃝2014 Wiley Periodicals, Inc. Published online in Wiley Online Library (wileyonlinelibrary.com) A Publication of the National Civic League National Civic Review ● DOI: 10.1002/ncr.21169 ● Spring 2014 25 name of a patient but the critical partner. Commu- mands an ensemble of activities sustained over time nity people are not “boots on the ground” to be used that resonates with healthy communities insights of by medical experts but brains on the ground with in- long ago: telligence to be blended. 1. Move toward the socially complex (the most challenging) patients by engaging them in their Health systems—and their beloved communities— neighborhoods, with their families and social net- can move toward the health that both science and works. Those places are where you find the so- faith envision. cially complex assets relevant to the socially complex problems. 2. Move with large-scale, load-bearing partnerships Well beyond Memphis, the work of healthy com- aligned with those other socially mediating communities is visible in the wide instinct among faith- munity structures relevant to the neighborhoods. based health systems and governmental partners to Many of those partners will be surprised to find adopt the model. When staff from the Department themselves relevant to health outcomes. In fact, of Health and Human Services and the White House they will be surprised to see you in their neighbor- Center for Faith-based and Neighborhood Part- hoods at all! And they will be surprised to hear nerships visited Memphis in February 2011, they you want a partnership, not a deal, project, pilot, recognized the (then) four hundred covenant con- symbol, highly targeted measurable data-driven gregations working with Methodist Le Bonheur outcome, certain evidence-based blah blah blah. Healthcare not just as a good project but as a whole Do real work with real partners who have a stake new class of assets relevant to healthier communi- in the future. ties. The early Healthy Communities era had many 3. Move with your own money first. The largest sin- faith-driven individuals and organizations as mem- gle line item in any hospital’s annual budget is the bers, even some leaders. But it did not have a real projection of charity care, which in most decent model of functional networks with any obvious po- systems ranges from 5 to 10 percent. While it is tential to move data at the community scale. Mara very difficult to predict exactly which individual Vanderslice-Kelly (then the acting head of the White will need that kind of care, it is extremely pre- House center), then Alexia Kelley, followed by Aca- dictable what neighborhoods, even streets, they cia Salatti, used the Congregational Health Network will come from. The trick is to turn what is now in Memphis as a foil for the imagination for dozens seen as an unmanageable liability into a funding of health care systems and their regional governmen- stream. It is obvious that proactive mercy should tal partners to find in their communities the seeds of be cheaper than reactive charity—but only if one covenants of similar scale. commits to “a” and “b,” to work in places and partnerships. Two White House conferences formed the bookends for a very large amount of learning that is being A movement is the thing that moves you, not the adapted to San Bernardino County, Brooklyn, Mi- thing you think you are doing to move others. The ami, Chicago, and many small left-behind towns of spirit that moved in a relative handful of hopeful North Carolina. Like the early Healthy Communi- people twenty years ago turned into the Healthy ties movement, it is easy to agree with these new Communities ideas and structures that morphed ideas too quickly and overlook the fact that it turns and are still morphing, moved and are still mov- health care systems inside out and upside down. This ing. The Memphis model spawned the Health Sys- is why this approach is for the faith at heart, not the tems Learning Group, which is now moving (sort faint of heart. of like a movement) as Stakeholder Health (stake- holderhealth.org). Like any movement, it blends The learning has an edge to it that is close to un- and jumbles the ideas and experiences, wounds comfortable. It says that health systems—and their and dreams of those in the movement. It has al- beloved communities—can move toward the health ready spread to the tobacco and furniture towns of that both science and faith envision. To do so de- North Carolina with different kinds of assets to be

26 National Civic Review DOI: 10.1002/ncr Spring 2014 aligned, including thousands of Baptist congrega- shared future by building the relationships that turn tions and an academic medical center. The barbe- into connections that turn into committees that turn cue has a different sauce here, and people do not into agreements and policies and practices that over want the red stuff from the delta on their pig. The the arc of time channel the energy toward healing, idea of moving toward the broken but potentially even health. Dr. King was not surprised to be killed healthy complexity in large partnerships resonates by a stupid bullet fired at a dreamer. And he would deeply with small-town communities. The move- not be surprised that the bullet that killed him did ment here is called FaithHealthNC (faithhealthnc not kill the dream. .org).

What is a movement of faith and health? It is when Gary Gunderson is vice president for faith and health, professor of public health science at Wake Forest University Baptist people sense they do not have to be afraid of each Medical Center, and professor of faith and the health of the other or afraid of the future. And it is when they be- public at the Wake Forest University School of Divinity. gin to move toward each other in trust and toward a

National Civic Review DOI: 10.1002/ncr Spring 2014 27 BY KERRI PETERSON The Live Well Omaha Story AND MARY BALLUFF

It started as a vision in 1995. Omaha had a new tional infrastructure matured, an independent entity mayor who envisioned a new character and image emerged as its own 501(c)(3). A volunteer board, for the city, features that would give it world-class consisting of elected representatives of the member status. The mayor’s vision would prove to be con- organizations, began the crucial work of creating a tagious as health officials took a similar view and strategic vision. The first five years had seen plans decided that the public and private organizations of develop and key strategies assumed by issue-specific Douglas County must set aside agendas, work to- organizations. With so many effective organizations gether, and improve the health status of the county. involved, the question arose: Was the task group What was happening locally was also being echoed work making the most of the resources? Answering at the national level. Leland R. Kaiser, Ph.D., a futur- this question was a tipping point for the direction in ist and expert on the changing American health care which LWO would head after 2001. system, was visiting hospitals and their partners, encouraging them to strive not only to help the patients To begin with, LWO wanted to recount and truly who walk through their doors but also to improve measure its success. LWO’s Annual Report Card on the health of the community in which their hospi- Health for Douglas County combined vital statistics tals resided. It became the time for a meaningful data and key informant interviews to track three to conversation. four key indicators in each strategic health area and to show the changes in those indicators over time. The report card featured a section that discussed The Birth of Live Well Omaha: 1995 to 2000 community assets and action, using the voice of a In that year, seventeen partners, including all the ma- community expert to describe needed policy, collab- jor hospitals, insurance companies, the local health orative actions, and successes experienced. In itself, department, and public and private agencies, came the report card gave the community a marker of together to create a vision and a plan for improv- progress and a starting point for health dialogues. ing the health of the community. Each organization LWO’s board of directors distributed the document provided funding to initiate the effort. With a bud- to member organizations and local foundations so get of just under $300,000, Live Well Omaha (LWO; that the report card would serve as a blueprint both known at that time as Our Healthy Community within organizations and across the community’s in- Partnership) was launched. Hundreds of community vestments to improve the health status in the fo- members helped to determine the four areas of focus areas. The release of the report card, which has cus by participating in a health assessment process. trended data over a decade, has created a communi- Task groups of community experts were formed to tywide agenda. The partnership between LWO and determine root causes and action plans, and an exec- the Douglas County Health Department enhanced utive director was hired. Over a period of five years, its credibility. community health baseline data were collected, task groups were launched to develop action plans, the By highlighting key health issues and bringing to- membership grew from the original seventeen mem- gether interested entities that normally have little, bers to thirty-five to form the Collaborating Council, if any, association with, or vested interests in, health and LWO was on its way to creating health indica- care, LWO serves as a catalyst and agenda setter. Ev- tors, priorities, and a health agenda. ery year in October, LWO holds an annual health summit where keynote speakers address a catalytic health topic and time is spent focusing on the com- From Organizational Infancy to Adolescence: 2000 munity’s health priorities. The quarterly Collaborat- to 2006 ing Council meetings present timely, relevant health Originally, LWO was under the umbrella of the topics and significant community actions. Coun- county health department, but as the organiza- cil members also share successes in these meetings.

C⃝2014 Wiley Periodicals, Inc. Published online in Wiley Online Library (wileyonlinelibrary.com) 28 National Civic Review ● DOI: 10.1002/ncr.21170 ● Spring 2014 A Publication of the National Civic League Each step facilitates a community dialogue that goes lifestyles. This pinnacle grant laid the foundation for beyond the question of “Why?” to ask “How?” and the next phase of work and LWO’s third role of be- “By when?” this community would make change. ing an umbrella for efforts that targeted any of the Member organizations are challenged to look within report card areas. their own structures to become a part of a movement. Intensive investment and focus went into creating a solid partnership on the issue of obesity. Promo- tional efforts encouraged Omaha residents to be ac- Although there is no concrete way to point specifi- tive at any place, anywhere, and anytime. Physical cally to the work of LWO, Douglas County residents environments were planned to support active trans- are eating more vegetables and moving more. portation, and policy work laid the groundwork for other grants and initiatives that have changed the community forever. LWO set the strategic vision of As LWO grew, the annual report allowed it to look at a community that was active and had the capacity its health priorities on a consistent basis. It became to encourage healthy eating; this became the back- clear that reversing the negative health trends would bone for three separately funded initiatives moving require more than just the hospitals and human toward that one strategic vision. These three sepa- service organizations. In a community grounded in rate initiatives, all focusing on healthy eating and businesses, the business community had to be an ac- active design, used LWO to ensure common brand- tive participant. Key partners, such as the Chamber ing, complementary fund development, and robust of Commerce, Union Pacific, Con Agra, and RDG evaluation. Live Well Omaha Kids, Activate Omaha, Planning and Design, were recruited. LWO could and Douglas County: Communities Putting Preven- help to create a vision of improved health status; tion to Work all work collectively toward the same a business case was made for why it was impera- goals. tive to invest in this Healthy Communities initiative. Business demanded that LWO strengthen its infras- Although there is no concrete way to point specif- tructure and identity, which has positioned LWO to ically to the work of LWO, Douglas County resi- act not only as the community catalyst but also now dents are eating more vegetables and moving more. as a trusted convener. LWO’s work became focused In 2001, 22.3 percent of adults achieved physical on facilitating collaborative efforts and creating a activity requirements, and that percentage rose to strategic direction. This was the next stage of growth 49.6 percent in 2011. In 2002, 12.5 percent of Dou- in LWO’s evolution. glas County adults consumed five servings of fruits and vegetables per day, and that number increased to 35.3 percent in 2011. In addition, the com- Adolescence to Adulthood: 2006 to the Present munity boasts many examples of corporate well- (from Catalyst to Convener) ness and innovative community-based projects de- Historically, LWO had proven it could be a cata- signed to make a difference in individual lives. The lyst and build the social capital needed to take its trends are moving in the right direction. Omaha next growth phase—that is, to be the convener and can boast over thirty miles of new bicycle lanes, to lead health interventions. As early as the release a balanced transportation coordinator in the city of the 2001 Report Card, the impact of obesity on government, bicycle racks on all city buses, a bicy- the community became readily apparent. Through a cle commuter map, a Ride Your Bike to Work an- strategic planning process, the Collaborative Coun- nual challenge, a B-Cycle bike rental system, Safe cil launched an effort to reverse the impact of obe- Routes to School programs, eight healthy neigh- sity. An application was submitted in response to the borhood stores, farm-to-school efforts, and a vis- request for proposal issued by Robert Wood John- ible increase in community gardens and farmers son’s Active Living by Design. There were over eight markets. hundred applications, and LWO was one of forty- four communities funded for a four-year period to All of these examples of successes can be attributed focus on creating environments that support active to the collective vision and work of LWO and its

National Civic Review DOI: 10.1002/ncr Spring 2014 29 partners. Ownership lies within the partnerships. Organizationally, the funding structure has been Over $6 million in funding has been brought in and diversified to incorporate membership dues, grant distributed to the engaged partners to do the work funds, event income, and sponsorships that will en- they do best, but that work is guided by the vision sure the financial health of the organization. Because LWO holds and stimulates. of its efforts around communication and the formation of a media bureau, LWO is receiving five to Most recently, LWO and the Douglas County ten media hits a month and has a constant presence Health Department shifted from paper documents through social marketing. This communication ef- to launch a Web-based indicator application. The fort is targeted at keeping health at the forefront of Web site has helped to move the blueprint be- the citizens. yond the fifty-five-member organization to area citizens. Anyone in the community can access over Into the Future one hundred various indicators, trends, and best LWO is making the case for the value of a collective practices regarding Douglas County. Five sepa- impact organization. Surviving several evolutions, rate funders have joined together to make this keeping flexible, being responsive to the commu- possible. nity’s needs, and making the business case all have enabled LWO to survive over time. The foundational As new health priorities are identified, LWO and blocks have been laid, and LWO is an organiza- its partners serve as the convener for commu- tion poised to make a difference in the health of the nity dialogue. Interested parties can come un- Douglas County community. der the LWO umbrella; use the 501(c)(3) status, board of directors, and committee structure; Kerri Peterson is director of Urban Initiatives at The and join the momentum of collective impact LWO Sherwood Foundation and a former director of Live Well is providing. This convening role is unique in Omaha.

the community and has created sustainability and Mary Balluff is the chief of community health and nutrition flexibility to adjust to issues as needed inthe services for the Douglas County Health Department. community.

30 National Civic Review DOI: 10.1002/ncr Spring 2014 Policy and Systems Change to Build Healthy Communities in King County, Washington BY JAMES KRIEGER

The Epidemic of Chronic Disease and Health minants of health has led to a new paradigm of Inequity chronic disease prevention. The new paradigm rec- Communities across the nation are mobilizing to face ognizes that policy and systems changes are needed the intertwined challenges of the epidemic of chronic to modify environments so that they promote health diseases and persistent health inequities. Dramatic by making the healthy choice the easy choice. Poli- increases in obesity and diabetes may make the cies that affect land use decisions, marketing and current generation of children the first to have a advertising, the relative prices of healthy and less shorter life expectancy than their parents in US his- healthy products, and food availability in schools tory. Growing rates of chronic lung diseases such as and child care (to name a few) shape environments. asthma and COPD lessen quality of life. The costs of Systems changes that link organizations in ways that treating chronic diseases are the major driver of es- promote health, such as building food systems that calating health care costs. And chronic diseases are distribute locally grown produce to community in- also the greatest contributor to the health inequities stitutions (e.g., hospitals, schools, child care sites) that limit quality of life for people with low socio- or connect schools to transportation departments to economic status and people of color. The gap in life develop Safe Routes to Schools also create healthier expectancy between those with a college education environments. and those with fewer than twelve years of education is increasing. For example, according to a study pub- In King County, Washington, whose largest city is lished in the journal Health Affairs, among white Seattle, our local health department and its part- males, the gap in life expectancy at age twenty-five ners have adopted this policy, systems, and environ- increased from 5.1 years in 1990 to 13.2 years in ment change (PSE) paradigm. With support from 2008. the US Centers for Disease Control and Prevention (CDC) and national foundations (Kellogg, Robert Wood Johnson), over the past decade we have led A New Approach to Improving Health—Policy, and supported partnerships that have created mean- Systems, and Environment Change ingful changes to prevent chronic diseases in com- The increases in chronic diseases suggest that old munities most affected by health inequities. (See ways of preventing them are not sufficient. Tradi- Table 1 to learn of some of our successes, and find tionally, prevention has taken place through deliv- more at http://www.kingcounty.gov/healthservices/ ery to individuals of services such as health edu- health/partnerships.aspx.) cation and medical care. This approach was based on the recognition that a limited number of health As part of our Communities Putting Prevention risks (poor nutrition, physical inactivity, and to- to Work (CPPW) initiative, funded by CDC with bacco exposure) is the largest contributor to the de- stimulus revenues, we partnered with public hous- velopment of chronic diseases and that screening ing agencies to ensure that low-income residents and education could modify health-related behav- could live in smoke-free homes. As a result, 13,546 iors. However, health behaviors do not take place units at twelve housing agencies are covered by in a vacuum—they are shaped by the environments smoke-free policies. To support full policy imple- in which people live, work, learn, and play. mentation, grantee agencies engaged administrators, property managers, and residents in the pol- The growing realization of the importance of icy development process by educating them about environments—built, social, media, food—as deter- the impact of tobacco on health and increasing

C⃝2014 Wiley Periodicals, Inc. Published online in Wiley Online Library (wileyonlinelibrary.com) A Publication of the National Civic League National Civic Review ● DOI: 10.1002/ncr.21171 ● Spring 2014 31 Table 1. Examples of Policy, Systems, and Environment Changes in King County, Washington Faith-based Churches remove vending machines, serve healthier food, adopt tobacco-free policies. Hospitals/Health care Hospitals implement tobacco-free campuses, reduce sales of sugar drinks. Clinics support access to pools, improve quality of asthma and diabetes care using chronic care model. Mental health sites go tobacco free and offer cessation support. Medicaid health plans begin payment for community health workers. Schools Schools implement high-quality nutrition and physical education standards, school wellness policies, Safe Routes to School programs, recess before lunch, Farm to School arrangements. Child care Providers implement Farm to Table arrangements and healthy eating, physical activity, and TV screen time reduction policies. Food system Farmers’ markets increase access for Supplemental Nutrition Assistance Program and Special Supplemental Nutrition Program for Women, Infants, and Children customers; Community Supported Agriculture farm makes deliveries to low-income housing sites. Food retail Board of health implements menu labeling regulations for chain restaurants. Neighborhood restaurants increase healthy menu items. Pharmacy chain increases availability of fruits and vegetables. Local governments Cities adopt bike and pedestrian master plans, include healthy eating/active living elements in comprehensive plan updates, adopt healthy vending and meeting policies, implement pedestrian safety street improvements to support walking. Parks City and county parks implement tobacco-free policies, switch to healthy vending machines, offer women-only swim sessions. Public housing Agencies implement smoke-free policies, increase access to physical activity programs, develop housing sites as healthy communities, develop asthma-friendly public housing, install playground and outdoor exercise equipment.

support for people who wanted to quit using to- with forty-seven mental health and substance treat- bacco. Housing providers have many fears about the ment agencies to change this culture, implement impact of smoke-free policy changes—for example, tobacco-free policies, and offer tobacco cessation that vulnerable residents who cannot comply will programs. Glen, a Vietnam War vet, suffered from be evicted. Few actual incidents resulted from the schizophrenia and had tried to quit smoking at least policy change, and eventually people adjusted to it. seventeen times without success. After his treatment “The sky has not fallen,” one project staff member site implemented a client-centered cessation pro- pointed out. gram and became tobacco free, he quit smoking and has remained abstinent for the past year. CPPW also helped the Reverend Aaron Williams, the senior pastor of the Mount Zion Baptist church The Seattle Housing Authority has redeveloped the in Seattle, improve the health of his congregation. High Point public housing site over the past decade, Mount Zion, along with five other churches, intro- and our health department has provided techni- duced more healthy food and beverage options at cal assistance and project development support. church events, planted church gardens, encouraged The old High Point consisted of 716 older hous- group walking, and introduced limits on time spent ing units in varying states of deterioration laid out in front of computers and televisions at child and in a suburban-style street plan with cul-de-sacs. teen church programs. It is now a health-promoting, mixed-income, sustainable community with 1,600 new housing units, Historically, a culture of ambivalence regarding to- open spaces and trails, wider sidewalks, traffic- bacco has been common at mental health and sub- calming structures, a grid street layout, and asthma- stance abuse treatment sites, with providers believ- friendly homes. A pro-walking campaign secured ing that nicotine was less of a health concern than street crossing and path improvements, created and other drugs and had some value for helping clients distributed walking maps, and organized walking cope with stress and mental illness. We partnered groups. A group of Muslim women identified the

32 National Civic Review DOI: 10.1002/ncr Spring 2014 need for exercise and swim programs that are partments, sought to cut funding for the Preven- women only to respect cultural norms. Their efforts tion and Public Health Fund that is the largest led first to a women’s-only swim time at the nearby source of federal funding for healthy community community pool and then expansion to additional work, and lobbied for legislation preempting lo- pools across the city. cal and state government authority to regulate the food retail sector. Government must assert its le- gitimate role to protect and promote the health The PSE approach to making communities healthier of communities through encouragement of volun- is already producing results. tary actions by other organizations and by regulation when needed. Regulation is not a dirty word but rather one of several tools to correct market failures. Lessons Learned ● Community engagement is both valuable and The PSE approach to making communities healthier presents unique challenges when using a PSE is already producing results. Cities across the coun- change model. Community members and try are beginning to see plateaus and even declines community-based organizations (CBOs) are in childhood obesity rates. However, rates remain experts about community needs and assets. They too high, and disparities persist across race/ethnic contribute innovative approaches to addressing groups and socioeconomic strata. Some of the community health issues. They rally support lessons we have learned about PSE change work for making PSE changes. However, many CBOs over the past decade are listed next. focus primarily on provision of direct services and have limited experience with or interest in PSE ● Engaging with the multiple sectors that influence approaches. Community leaders may view other the health of the community is essential. Engage- issues as more important than chronic disease ment occurs more readily if: there is a founda- prevention or support strategies that differ from tion of trusting relationships, funding is available those proposed by public health experts. Finding to support partners, champions from each sector common ground, supporting community lead- promote PSE change from within, and the changes ership, and balancing experiential and scientific both help the partner realize its specific goals and knowledge are important challenges. promote community health. ● Creating PSE change may require advocacy and ● Coalitions are sometimes, but not always, the best lobbying. Yet the bulk of funding comes from gov- method of partner engagement. In some cases, a ernment and foundation sources with attendant simple partnership between a public health agency restrictions on use for advocacy and lobbying. and a sector is sufficient to create change. In other ● The PSE approach is new for many local health cases, more complex coalitions that include multi- departments. They need to develop capacity and ple sectors are needed. Coalition development and skills to be successful. Resources are constrained maintenance are resource intensive—this method in the current climate of fiscal austerity, pre- of partner engagement should be used judiciously. senting tough choices to the local health depart- ● Government is not always the best change agent. ments about how to support PSE work focused Public health and other government officials are on chronic disease prevention while maintaining constrained by the views of elected leaders. They important traditional activities, such as infectious are susceptible to the nanny-state label by propo- disease control and maternal and child health. nents of a smaller role for government. Commu- ● Measuring success presents challenges. The ulti- nity advocates have more freedom to take on chal- mate goals are changes in health behaviors and lenging PSE change efforts, and public health can prevention of chronic diseases, outcomes that provide technical support in the background. can take years to achieve. Intermediate measures ● Conservative political advocates will challenge the of policy, systems, and environment changes are PSE approach and the role of government in valid metrics. contributing to healthy communities. They have ● Evidence of the effectiveness of PSE strate- threatened legal action against local health de- gies is just emerging. Many potentially valuable

National Civic Review DOI: 10.1002/ncr Spring 2014 33 strategies have not yet been evaluated. Decid- Reference ing what to do in the absence of clear-cut evi- Olshansky, S. J., T. Antonucci, L. Berkman, R. H. Binstock, dence of effectiveness is a challenge. Implement- A. Boersch-Supan, J. T. Cacioppo, B. A. Carnes, et al. 2012. ing evidence-based strategies as well as promising “Differences in Life Expectancy Due to Race and Educational ones and conducting robust evaluations are ways Differences Are Widening, and Many May Not Catch Up.” Health Affairs 31 (8): 1803–13. forward.

Making policy, systems, and environment changes to improve health is already transforming our commu- James Krieger is chief of chronic disease and injury prevention at Public Health–Seattle & King County and clinical profes- nities into healthier places. Bringing these changes to sor of medicine and health services at the University of Wash- more communities has great potential for preventing ington in Seattle, Washington. chronic disease and reducing health inequities.

34 National Civic Review DOI: 10.1002/ncr Spring 2014 Community-Level Obesity Prevention Initiatives BY ALLEN CHEADLE, SUZANNE RAUZON, Impact and Lessons Learned AND PAMELA M. SCHWARTZ

In the last decade, many US cities, counties, and flected in major consensus reviews by the Centers neighborhoods began implementing community- for Disease Control and Prevention (CDC) and the level initiatives to prevent obesity, systematic efforts Institute of Medicine (IOM). Of the eleven recom- targeting a specific geographic area with a port- mended nutrition-related strategies proposed in the folio of strategies at multiple levels (e.g., individ- CDC review by Dana Keener and coauthors, four ual, family, community) and across multiple sectors target the availability and accessibility of healthier (e.g., school, worksite, neighborhood). Typically, food choices in the community food environment: these efforts have focused on implementing policy and environmental changes related to food and 1. Increasing the availability and affordability of physical activity focusing on specific populations, healthier food and beverage choices in public ser- complemented by supporting programs and promo- vice venues tions. Examples of policy changes implemented by 2. Increasing the geographic availability of super- community-level initiatives include sugar-sweetened markets in underserved areas beverage taxes and school policies limiting the avail- 3. Providing incentives to food retailers to locate in ability of unhealthy food in vending machines and and/or offer healthier food and beverage choices cafeterias. Examples of environmental changes in- in underserved areas clude increasing the availability and affordability 4. Restricting the availability of less healthy foods of healthier food and beverage choices in public and beverages in public service venues venues, increasing the geographic availability of su- permarkets in underserved areas, and enhancing the The consensus reviews also recommend a number community infrastructure to support bicycling and of environmental approaches to promoting physi- walking. cal activity, in particular, changes to the built environment in communities. Five of the nine CDC- A number of large-scale government and foundation recommended strategies call for these changes to efforts aimed at preventing obesity have adopted the environment: improving access to outdoor recre- the community-level initiative as a strategy. These ational facilities; enhancing the infrastructure to include the W.K. Kellogg Foundation’s Food and support bicycling and walking; locating schools Fitness Initiative; the Robert Wood Johnson Foun- within easy walking distance of residential areas; im- dation’s Health Kids/Healthy Communities Initia- proving access to public transportation; and zoning tive; the Kaiser Permanente Community Health for mixed-use development. Initiative; the Department of Health and Human Services Communities Putting Prevention to Work The 2005 Institute of Medicine (IOM) Commit- Initiative, funded under the American Relief and tee on Prevention of Obesity in Children and Reinvestment Act of 2009; First Lady Michelle Youth created a national action plan that identi- Obama’s Let’s Move Campaign; and the White fied several immediate steps to address the obesity House Task Force on Obesity. The 2009 Affordable epidemic, including improving school food environ- Care Act also includes prevention funding that is ments, promoting more active physical activity dur- supporting place-based initiatives. ing the school day, expanding access to healthier foods in the marketplace, and expanding and pro- Strong support among public health researchers and moting opportunities for physical activity across the practitioners for community-level policy and envi- community. More recently, the 2012 IOM report ronmental approaches to obesity prevention is re- Accelerating Progress in Obesity Prevention took a

C⃝2014 Wiley Periodicals, Inc. Published online in Wiley Online Library (wileyonlinelibrary.com) A Publication of the National Civic League National Civic Review ● DOI: 10.1002/ncr.21172 ● Spring 2014 35 step further by: calling for increasing access to places collection strategies that can be sensitive enough and opportunities for physical activity; reducing un- to detect the relatively small expected changes healthy food and beverage options and increasing across a community population and attribute them healthier food and beverage options at affordable to the initiative. Second, the field is relatively prices; transforming messages in the environment new, and some of the largest and potentially use- about physical activity, food, and nutrition; expand- ful evaluations are currently in progress and re- ing the role of health care and employers in obesity sults will not be known for several years. A third prevention; and increasing attention on schools as a constraint is publication bias. The accumulation focal point for obesity prevention. of initiative-level evidence requires that negative studies be published, but reviews consistently find But questions remain: Do community-level initia- almost all positive studies in the peer-reviewed tives work? Have they been successful in changing literature. Some of this bias is likely due to self- health behaviors that cause obesity and/or obesity selection by researcher/evaluators—if a community- rates themselves? This article reviews the evidence level initiative evaluation shows negative findings, to date on the impact of community-level initiatives there is little incentive for either the funder or to prevent obesity and offers suggestions for both fu- the evaluator to undertake the effort to publish ture intervention and evaluation design for this type these findings in the peer-reviewed literature. Finally, of community initiative. conducting primary data collection at the population level can be cost prohibitive for a community intervention. Do community-level initiatives work? Have they been successful in changing health behaviors that cause obesity and/or obesity rates themselves? Evidence of Impact Given the caveat that information about community-level obesity prevention effectiveness is limited, the studies that have been published Evaluation Goals and Challenges indicate that the approach can be effective and In assessing the contribution of community-level ini- give us road maps for replication. We conducted tiatives to the overall obesity prevention effort, it is a review of the published and gray literature (e.g., important to consider their impact on intermediate- unpublished evaluation studies and online initiative term outcomes, such as food and physical activity descriptions) to identify examples of initiatives that behaviors, as well as their impact on more long- have been or are currently being evaluated. The term outcomes, such as obesity rates and obesity- search was conducted in December 2012 for years related chronic illnesses (e.g., diabetes, heart dis- 2000 to 2012 using bibliographic databases. A ease). Substantial investments are being made in total of thirty-six community-level initiatives that these initiatives, and there is considerable interest in included sufficient detail concerning their interven- understanding long-term impacts and the value of tion and evaluation methods were identified. These the investments. included sixteen initiatives that were completed and included population-level outcome results. Another Unfortunately, there are a number of challenges twenty initiatives are either in process or not mea- to collecting definitive information about the long- suring population-level behavior change. Some of term impact of community-level initiatives. First, the largest and potentially most useful evaluations it is challenging to conduct credible evaluations of are in progress. In particular, many independent these initiatives, particularly evaluations that in- evaluations of the CDC’s Communities Putting clude an assessment of their impact on population- Prevention to Work initiatives are currently being level behaviors and health outcomes. The key conducted, and a large-scale, retrospective National longer-term outcomes, especially food and physi- Institute of Health–funded Healthy Communities cal activity behaviors, are difficult to measure ac- Study is using chart reviews to track changes in curately at a population level, and there are a obesity rates in 268 communities across the United number of challenges to creating designs and data States.

36 National Civic Review DOI: 10.1002/ncr Spring 2014 Of the sixteen community-level initiatives for which lished in the journal Obesity by Christina Economos results were available, thirteen showed positive im- and coauthors. pacts on health behaviors or obesity rates. Three- quarters of these positive studies were focused on Kaiser Permanente HEAL-CHI Initiative children, typically combining school-based inter- The Healthy Eating Active Living—Community ventions with surrounding community-level policy Health Initiative (HEAL-CHI) was a five-year ini- and environmental changes (e.g., park improve- tiative (2006–2011) funded by Kaiser Permanente’s ments, increasing healthfulness of offerings in gro- Northern California Community Benefit program. cery stores and restaurants). Two of the initiatives Three neighborhoods within larger cities in North- (one positive and one negative) were state level; the ern California were selected through a request for rest targeted smaller geographic communities such proposal process for five years of funding: Modesto as cities or neighborhoods. (population 38,400, 54 percent Latino), Richmond (52,900, 45 percent Latino, 29 percent African Two examples of youth-focused initiatives targeting American), and Santa Rosa (37,960, 41 percent smaller cities and neighborhoods will help illustrate Latino). The emphasis in HEAL-CHI strategies was the nature of community obesity prevention activi- on policy and environmental change strategies. Ex- ties as well as the impacts: Shape up Somerville and amples of organizational policy changes included the Kaiser Permanente HEAL-CHI initiative in three changing cafeteria policies in schools and worksites communities in Northern California. to increase the number of healthy entrees and implementing California Standards–based physical ac- Shape Up Somerville tivity curriculum during school hours in local ele- Perhaps the best-known community-level obesity mentary schools. Public policy strategies included prevention initiative is Shape Up Somerville (SUS), influencing urban planning via the city general plans a comprehensive community-level intervention in- (e.g., by adding “health elements” that require a volving children, parents, teachers, school food ser- consideration of the health consequences of new vice providers, city departments, policy makers, zoning and construction). Environmental strategies health care providers, before- and after-school pro- focused on increasing access to healthy food and grams, restaurants, and the media (Economos et al. changing the built environment to promote physi- 2007). Using a community participatory process, the cal activity (e.g., increasing purchase or distribution intervention activities were developed to influence points for fresh fruits and vegetables in the commu- every part of the community. SUS participated in nity and changing the infrastructure around schools or conducted one hundred events and four parent to promote walking and biking to schools). forums, trained fifty medical professionals on childhood obesity guidelines and current screening Across all three communities, a total of over 41,000 practices, and recruited twenty-one restaurants to people were exposed to environmental and pro- become SUS approved. A total of fourteen after- grammatic interventions in their neighborhoods, school programs implemented a new after-school worksites, and health clinics; and 17,000 school- curriculum. Various communitywide policies were age youth were exposed to interventions in their developed to promote and sustain change, including schools. The highest-impact strategies (as measured a school wellness policy, new policies and union con- by the dose or percentage of the population reached tract negotiations that led to enhancements of the and the estimated impact per person reached) tar- school food service, expanded pedestrian safety and geted physical activity and were implemented in and environmental policies, the adoption of a healthy around schools. These “high-dose” strategies were meeting and event policy, and a city employee fit- associated with significant and positive population- ness wellness benefit. The SUS interventions resulted level changes in the three HEAL-CHI commu- in a modest but significant decline in body mass in- nities. Using data from a school-based survey, dex standard deviation (BMI z-scores) in children in we found that of the nine instances where there grades 1 to 3 after one year of intensive implementa- were high-dose strategies in place, four of those were tion, an indication of a lower prevalence of obesity statistically significant and favored the interven- among young children, according to a study pub- tion. For example, a community that implemented a

National Civic Review DOI: 10.1002/ncr Spring 2014 37 high-dose combination of after-school physical ac- encourage walking and biking to school. The dose of tivities and a new physical education curriculum saw a cluster of strategies can be determined by combin- an increase in the percentage of youth performing ing the quantitative dose estimate of the individual vigorous physical activity at least 20 minutes per day strategies. from 61 to 67 percent.

The early evidence from community-level initiatives Best Practices in Evaluating Impact is that they can be effective in changing obesity- As part of our review of the literature on related behaviors at the population level. community-level initiatives, we also examined the approaches that have been used to evaluate these initiatives. Based on that review, we recommend using Dose of the strategies can then be combined logic model designs that combine estimates of po- with population-level behavioral data to examine tential impact with pre–post measures of behavioral whether higher-dose community change strategies and other longer-term outcomes. Logic model de- or clusters of strategies are associated with measured signs start with a program “theory of change”—that population-level changes in the relevant outcomes. is, the mechanism by which the comprehensive com- The first test of the dose approach was the HEAL- munity initiative is intended to achieve its long-term CHI initiative, described earlier, where there was an outcomes—and then create indicators for each step observed correlation between high-dose strategies in the logic model. In the case of community-level and behavior change. initiatives, the key steps in the logic model are intermediate outcomes (e.g., environmental and policy changes implemented in communities) and longer- Conclusions and Recommendations term population-level outcomes (e.g., physical ac- The early evidence from community-level initia- tivity behaviors, weight, and health status). If the tives is that they can be effective in changing temporal pattern of change is consistent with that obesity-related behaviors at the population level. A specified in the logic model, the intervention ismore number of initiatives, particularly youth-focused ini- likely to have been the cause of the population-level tiatives in small cities and neighborhoods, have changes. An example would be if significant built en- demonstrated increases in physical activity and vironment changes are made to facilitate safe walk- healthier eating, and in some cases reductions in ing (e.g., completing sidewalks in neighborhoods), obesity rates. However, the evidence is too limited to and residents report an increasing upward shift in say whether they can be generally successful across minutes of daily walking in the years that follow. a wide range of communities—that is, whether they are truly an “evidence-based” practice. To measure the intermediate outcomes of environmental and policy change interventions, we devel- Some recommendations emerge from a review of the oped the concept of “population dose.” It is a evidence for both community-level initiatives and in- combination of the number of people reached by dividual environment and policy change strategies: the intervention and the strength of the intervention needed to change the behavior of those reached. ● Focus on youth in schools. Most of the successful initiatives and strategies have focused on chil- The intervention strategies being implemented in dren and used school-based interventions as ma- a community can be grouped into clusters tar- jor components. Students are a captive population geting the same outcome measure (e.g., minutes in an institutional setting conducive to making the of physical activity) and population segment (e.g., healthy choice the easy choice, and many school school-age youth or adults/families). For example, environment and programmatic interventions can strategies attempting to increase minutes of physi- reach the whole student body. cal activity among school-age youth in a community ● Cluster strategies. The most successful initia- might include an enhanced physical education (PE) tives used multiple overlapping strategies target- curriculum and Safe Routes to School programs to ing the same population and health behavior. For

38 National Civic Review DOI: 10.1002/ncr Spring 2014 example, a school-based intervention might in- et al. 2012. “Kaiser Permanente’s Community Health Initia- clude a new PE curriculum, Safe Routes to School tive in Northern California: Evaluation Findings and Lessons program, after-school and recess activities, and Learned.” American Journal of Health Promotion 27 (2): playground renovations. This interlocking ap- e59–e68. proach is consistent with the systems perspec- Economos, Christina D., Raymond R. Hyatt, Jeanne P. Gold- tive recommended by the Accelerating Progress on berg, Aviva Must, Elena N. Naumova, Jessica J. Collins, and Obesity Prevention report. Miriam E. Nelson. 2007. “A Community Intervention Re- duces BMI z-score in Children: Shape Up Somerville First ● Sustainable strategies. Long-term impact will re- Year Results.” Obesity 15 (5): 1325–36. quire that the implemented policy and environmental interventions are sustained. Legacy eval- Institute of Medicine, Committee on Accelerating Progress in Obesity Prevention. 2012. Accelerating Progress in Obesity uations several years after intervention funding Prevention: Solving the Weight of the Nation. Washington, has ended should be carried out to assess both DC: National Academies Press. whether the community changes occurred and remain in place and the behavioral outcome changes Institute of Medicine, Committee on Prevention of Obesity in Children and Youth. 2005. Preventing Childhood Obesity: and reductions in obesity rates have been main- Health in the Balance. Washington, DC: National Academies tained. Press. ● Logic model evaluation designs. Evaluations that Keener, Dana, Kenneth Goodman, Amy Lowry, Susan link the theory of change to behavioral outcome Zaro, and Laura Kettel Khan. 2009. Recommended Com- measures have a greater chance of accurately as- munity Strategies and Measurements to Prevent Obe- sessing whether the initiative has had an impact. sity in the United States: Implementation and Measure- ment Guide. Atlanta, GA: US Department of Health In summary, community-level initiatives are a and Human Services, Centers for Disease Control and promising approach to preventing obesity and have Prevention. been demonstrated to be successful on a number of occasions. A focus on thorough documentation of intervention approaches, consistent monitoring Allen Cheadle is director of the Center for Community Health of their impact, and widely available reports on and Evaluation at the Group Health Research Institute in progress, including failures, is needed to better un- Seattle, Washington. derstand the conditions required for them to be successful. Suzanne Rauzon is director of strategy at UC Berkeley’s Center for Weight and Health.

References Pamela M. Schwartz is director of program evaluation for Cheadle, Allen, Suzanne Rauzon, Rebecca Spring, Pamela Kaiser Permanente’s Community Benefit Program Office. M. Schwartz, Scott Gee, Esmeralda Gonzalez, Jodi Ravel,

National Civic Review DOI: 10.1002/ncr Spring 2014 39 Transportation for the Twenty-First Century Designing Healthy Communities and Active Lifestyles with Safe

BY DEB HUBSMITH Routes to School AND MARGAUX MENNESSON

A study released in spring 2013 by the US PIRG Ed- less physical activity. School districts and families ucation Fund shows that after decades of steady spend billions on gasoline to get children to school growth, US driving rates have slowed and even while John Cawley and Chad Meyerhoefer (2012) stalled and that, in the long term, Americans are un- estimate the total cost of treating obesity at $190 bil- likely to return to driving as much as they did be- lion a year, approximately 21 percent of health costs. fore. The groundbreaking report finds that millen- These are just some of the factors that are leading nials (the generation of people born between 1983 growing numbers of Americans to walk and bicy- and 2000) drove 23 percent fewer miles on average cle more and give their children opportunities to be in 2009 than they did in 2001—a greater decline in healthier and physically active. driving than any other age group. Millennials are also more likely than previous generations to want Fortunately, Safe Routes to School programs are to live in urban and walkable neighborhoods and helping communities and people make healthy are more open to nondriving forms of transporta- choices by making walking and bicycling to school tion than older Americans. safe, convenient, and accessible. Safe Routes to School programs help communities accomplish their As millennials grow older and start having families, goals by focusing on the 5 Es: engineering, educa- how will communities evolve to serve the needs of tion, evaluation, enforcement, and encouragement. those who value dense, urban neighborhoods and More than 5 million children and 14,000 schools walkable/bikeable centers with less reliance on driv- nationwide are benefiting from more pedestrian and ing? When safety is paramount to parents, how bicycle infrastructure and education through Safe will cities and towns ensure that children can safely Routes to School programs. walk and bicycle to and from school and around the community? Safe Routes to School programs The Safe Routes to School National Partnership was will play an integral role in the way cities and founded in 2005 and works to: catalyze support for towns serve these families now and in the coming safe, active, and healthy communities; advocate for decades. policy change that supports Safe Routes to School programs and healthy community design; and leverage expertise, core knowledge, and research that The Imperative help improve the quality of life for kids and com- Today, the National Center for Safe Routes to munities. Fire Up Your Feet, a new school-based School found, only 13 percent of children walk or program of the National Partnership, encourages bicycle to school—a drastic drop from 1969, when families, students, and schools across the country to nearly 50 percent of children got to school under create active lifestyles that inspire our children to be their own power. Childhood obesity increased from healthy and physically active. 4 percent to 19.6 percent between 1969 and 2007, reported Cynthia Ogden and coauthors (2006) in the Journal of the American Medical Association, Healthy Kids, Healthy Schools, Healthy Places and nearly one in three young people are overweight As more Americans choose to live, work, and raise or obese. Families, schools, and communities are families in urban and walkable communities, com- bearing the costs associated with more driving and munities will find the next Safe Routes to School

C⃝2014 Wiley Periodicals, Inc. Published online in Wiley Online Library (wileyonlinelibrary.com) 40 National Civic Review ● DOI: 10.1002/ncr.21173 ● Spring 2014 A Publication of the National Civic League strategies critical for improving the quality of life of schools during drop-off and pickup times can dis- and saving lives and dollars. courage parents and students from walking and bicycling to school. Public Health and Obesity Prevention Studies show that children who walk and bicycle to Case Study. Nearly three-quarters of students at school are more physically active, have lower obesity Alpine Elementary School in Alpine, Utah, live close levels, and are more likely to meet the recommended enough to walk to school, but traffic congestion dis- 60 minutes a day of physical activity than children couraged many families from doing so. After re- who are driven or bused to school. ceiving two federal Safe Routes to School awards totaling $71,500, the school made improvements Case Study. Safe Routes to School programs have to reduce congestion and improve safety around shown an increase in the rate of children walking the school, including repainting crosswalks, adding and bicycling to school where interventions have school zone signs, installing speed monitor signs, been implemented. A 2013 study by Orion Stew- and creating a safe walking path to a rear entrance of art and Anne Moudon of Safe Routes to School the school. Following the intervention, the number programs in five states (Florida, Mississippi, Texas, of students who regularly walk or bicycle to school Washington, and Wisconsin) showed that where has risen from 32 percent to 50 percent, and there Safe Routes to School projects were completed, on are 60 fewer cars commuting to school each day. average walking increased by 45 percent, bicycling increased by 24 percent, and all active transporta- Financial Benefits of Walking and Bicycling to School tion increased by 37 percent. Many school districts are cutting bus service to com- pensate financially for rising fuel costs, changing Improving Safety and Preventing Injury and Crashes demographics, and decreased general funding for Safe Routes to School projects reduce pedestrian and school districts. The loss of bus service creates an op- bicyclist injuries and deaths by implementing so- portunity for school districts to promote safety for lutions that slow vehicle speeds, increase visibility children walking and bicycling. of children walking and bicycling, and make street crossings safer. Case Study. The city of Wooster, Ohio, secured a $464,000 Safe Routes to School grant to improve Case Study. The New York City Department of sidewalks and crosswalks around several schools Transportation (DOT) evaluated the crash histories in the district. After building sidewalks, improving near all of the city’s 1,471 elementary and middle school zone signage, enhancing high-visibility cross- schools to identify the schools with a high incidence walks, and adding signals, the school district will be of crashes and those most in need of infrastruc- able to eliminate one full bus route, saving the school ture improvements through Safe Routes to School. district $49,000 each year. The DOT prioritized 135 of the highest-risk schools and worked with principals, parents, and commu- Increasing Physical Activity through Changes in the Built nity members to identify short- and long-term infras- Environment tructure solutions for those schools. After making The President’s Council on Fitness, Sports & Nu- short-term improvements at all 135 schools, the rate trition Physical Activity Guidelines for Americans of pedestrian injury during school travel hours de- Midcourse Report (2012) established a connection creased by 44 percent while the rate at other schools between the built environment and improved pub- remained steady. lic health in recommending active transportation to school as a strategy to improve health and help Reducing Traffic Congestion children reach the recommended sixty minutes of During the morning commute, driving to school ac- physical activity a day. Studies show that commu- counts for an average of 5 to 7 percent of miles trav- nities that are more walkable and bikeable and have eled and 10 to 14 percent of traffic on the road and pedestrian-accessible destinations also have higher costs parents an estimated $5 billion a year in fuel. levels of physical activity. Children who live in The often-chaotic and unsafe environment in front neighborhoods with safe crosswalks and sidewalks

National Civic Review DOI: 10.1002/ncr Spring 2014 41 are more likely to be physically active than children front of engaging children, families, and schools. living in neighborhoods where it is less safe to walk. Together, we are leading the way toward designing stronger, healthier, and safer communities through- Case Study. The city of Des Plaines, Illinois, out the United States. used $304,000 in federal Safe Routes to School funding for the construction of new sidewalks, curb References extensions, raised crosswalks, and striping improve- Cawley, John, and Chad Meyerhoefer. 2012. “The Medical ments. Since making these infrastructure improve- Care Costs of Obesity: An Instrumental Variables Approach.” ments, Des Plaines has seen walking and bicycling Journal of Health Economics 31 (1): 219–30. rates among students double from 19 percent in Dutzik, Tony, and Phineas Baxandall. Spring 2013. “A 2007 to 40 percent in 2010 while traffic congestion New Direction: Our Changing Relationship with Driv- has declined. ing and the Implications for America’s Future.” Boston: US PIRG Education Fund. http://www.uspirg.org/sites/ pirg/files/reports/A%20New%20Direction%20vUS.pdf. The Future of Safe Routes to School National Center for Safe Routes to School. 2011. How As more Americans shift to living in walkable neigh- Children Get to School: School Travel Patterns from 1969 borhoods and choose nondriving forms of trans- to 2009. Chapel Hill, NC: National Center for Safe portation, communities will need to invest in new Routes to School. http://saferoutesinfo.org/program-tools/ NHTS-school-travel-1969--2009. transportation infrastructure to attract young people and their families. Ogden, Cynthia, M. Carroll, L. R. Curtin, M. A. McDowell, C. J. Tabak, and K. M. Flegal. 2006. “Prevalence of Over- weight and Obesity in the United States, 1999–2004.” Jour- We all have a role to play in designing and build- nal of the American Medical Association 295: 1549–55. ing thriving communities. Governments and municipalities can apply for Safe Routes to School and Stewart, Orion, and Anne Moudon. 2013. “Moving Transportation Alternatives Program federal grants Forward: An Assessment of Safe Routes to School Pro- grams in Five States.” Presented at the Active Living and begin to incorporate Complete Streets policies Research Conference, San Diego, February 26–28. http:// into their transportation and land use planning pro- activelivingresearch.org/moving-forward-assessment-safe- cesses. They can also explore innovative new strate- routes-school-programs-five-states. gies to increase physical activity opportunities, such US Department of Health and Human Services. 2012. as shared use agreements between a school district Physical Activity Guidelines for Americans Midcourse Re- and a city or county, to make facilities such as play- port: Strategies to Increase Physical Activity Among Youth. grounds, fields, courts, and tracks available tothe Washington, DC: Author. http://health.gov/paguidelines/ public outside of school hours. Parents and schools midcourse/pag-mid-course-report-final.pdf. can champion Safe Routes to School programs and engage directly with their community by bringing Fire Up Your Feet programs to their school. Fire Up Deb Hubsmith is the founder and director of the Safe Routes Your Feet makes it easy and fun to walk and bicy- to School National Partnership and has been a nationally re- cle to school and create opportunities for physical spected leader for Safe Routes and other active transportation advocacy efforts for more than fifteen years. activity in daily life. Margaux Mennesson serves as the communications manager The active transportation movement is growing at for the Safe Routes to School National Partnership. every level, and Safe Routes to School is at the fore-

42 National Civic Review DOI: 10.1002/ncr Spring 2014 Advancing Walkable Communities

Retro, In, and Here to Stay BY SCOTT BRICKER

Walking is one of the earliest defining human traits. It from our waning real estate crisis. A 2011 Na- evolved more than 4 million years ago, and today, tional Association of Realtors survey showed that despite decades of engineering, marketing, and de- most Americans would like to live in walkable com- velopment efforts to make walking obsolete, a new munities where shops, restaurants, and local busi- American consciousness about walking is emerging. nesses are within an easy walk from their homes This consciousness is sparking grassroots groups (as long as those communities can provide detached across the country to push for safe walking environ- single-family homes). The survey also shows that ments and to begin changing the development pat- most Americans would choose a smaller home and terns that put automobile travel at the center of our smaller lot if it would keep their commute time to lives. 20 minutes or less.

To provide a snapshot of this emerging movement, The good news for equity and affordability interests to consider some of the key forces behind the in- is that other studies have shown that although real creased interests in walking and walkability and estate prices, values, and rents are higher, walkable highlight national walking opportunities that have places actually can be more affordable because fam- the potential to significantly alter who and how ilies can cut household transportation costs by re- much we walk, it might be best to start by asking ducing auto ownership. why there is such an interest in walking, a rather primitive form of mobility, when we live in an age Other interest groups such as AARP, American where great technological and scientific advances Heart Association, and YMCA of the USA have happen almost daily. Perhaps the most important taken on the built environment and continue to fo- reason is that the human body is made to walk. cus on walking and walkability, a core need of their There is almost nothing more beneficial we can do constituents, to live healthy, active, and happy lives. for our own personal health than walking. Walking is the most accessible and widely available free in- The many benefits of walking have helped catalyze tervention to increase physical activity and baseline and shape a new walking social movement. health. And it is for these reasons that public health and health care providers have gotten so proactive In 1991 two organizers in Portland, Oregon, started in supporting built environment solutions to public the Bicycle Transportation Alliance (BTA) and health. For example: the Willamette Pedestrian Coalition (now Oregon Walks). In 1998 I joined the staff of the BTA, mak- ● Blue Cross Blue Shield of Minnesota helped lead ing it three. Each year the BTA grew, and when I left an effort to pass a series of Complete Streets poli- the alliance in 2009, we had sixteen staff members. cies in the state and communities in Minnesota. Also at that time in Portland (yes, it’s a bike town, ● The Every Body Walk! campaign by Kaiser Per- but it’s a walking town too), numerous other bike manente has helped lead the development of the groups thrived, as did the bike industry. But Oregon Every Body Walk! Collaborative. Walks was still struggling to pay for their first-ever staff person. Today, three and a half years later, Ore- Many mayors, developers, real estate agents, and gon Walks has two staff members, and the future is other economic boosters have become engaged in bright for advocating for walkability in Oregon and efforts to make their communities more walkable. elsewhere. Numerous studies are showing how the most walkable places hold the highest real estate values and When I joined America Walks in 2010, well-staffed were impacted least and are rebounding quickest walking advocacy was seemingly nonexistent in all

C⃝2014 Wiley Periodicals, Inc. Published online in Wiley Online Library (wileyonlinelibrary.com) A Publication of the National Civic League National Civic Review ● DOI: 10.1002/ncr.21174 ● Spring 2014 43 but a few select cities—Boston, San Diego, and Ways to Get Engaged Atlanta—and was the minor part of the platform ● of livability groups. But in the past three-plus Endorse the “Vision for a Walkable years I have seen an explosion in communities and America”—www.americawalks.org. ● Learn about and share tactics and case studies to states working hard to build their walking port- advance walkability—www.walksteps.org. folio; America Walks itself has grown fourfold. In ● Share stories about walking and just eight months, America Walks worked in eight walkability—www.everybodywalk.org. communities/states to help start or strengthen walk- ● Join the Every Body Walk! Collaborative—Have your ing collaborations; many more are seeking these organization participate in the collaborative— services. http://everybodywalk.org/collaborative.html.

This explosion has occurred mainly because many types of organizations, industries, and interest groups are realizing just how important walking and tive,” was formed to advance walkability and walk- walkability is to their own interests and goals, mak- inginAmerica. ing this truly budding movement of multisectoral partners. A critical outcome of the Every Body Walk! Col- laborative’s effort was the 2013 Walking Summit. Where can we go from here? Local action is spring- The summit’s goal was to increase the demand for ing up everywhere, and we are seeing national head- more walking (behavior and culture change) and the winds to spur the efforts. supply of safe places to walk (environmental, policy change) by exchanging learning and mobilizing The US Centers for Disease Control and Prevention, the diverse leadership, assets, and beneficiaries of the which put science to work in its Vital Signs on Walk- walking movement. The idea of the summit was to ing reports, calls for “improving spaces and having coalesce the current base of the walking movement, safe places to walk” to help more people become welcome new players, and strengthen partnerships physically active. On December 5, 2012, America at local, regional, state, and national levels, includ- Walks, Kaiser Permanente, Safe Routes to School ing people, organizations, and businesses whose sec- National Partnership, American College and Sports tors/interests benefit when more people walk and Medicine, and others hosted the Building Partner- when communities are more walkable. ships for Aligned Action for Walking meeting. One hundred forty leaders attended this meeting with Reference the intention of advancing walking and walkabil- Community Preference Survey. March 2011. What Amer- ity in America. US Surgeon General Regina M. Ben- icans Are Looking for When Deciding Where to Live. jamin announced the proposed Call to Action on Analysis of a Survey of 2,071 American Adults Nation- Walking—the Office of the Surgeon General’s high- ally, Conducted for the National Association of Real- est scientific-based action document—which is now tors. Washington, DC: Belden, Russonello & Stewart. http://www.realtor.org/sites/default/files/smart-growth- under way and received a record number of com- comm-survey-results-2011.pdf. ments during the public comment period. (Her suc- cessor, Acting US Surgeon General Boris D. Lush- Scott Bricker is the executive director of America Walks, a niak, has clarified his intention to move the Call to national nonprofit organization making America a great place Action forward.) As a result of this meeting, a new to walk. collective effort, the “Every Body Walk! Collabora-

44 National Civic Review DOI: 10.1002/ncr Spring 2014 Food and Community BY RENEE GUILBAULT, LARRY YEE, A Future Intertwined AND KAREN SCHMIDT

From a foodie perspective, the last twenty-five years value and serious environmental consequences. have been exhilarating, some might even say revolu- Local butchers and bakers have been replaced by tionary. There are gardens growing in many schools big-box retail superstores, four of which control and a flagship garden at the White House; celebrity over 50 percent of all retail food sales. Meanwhile, chefs abound, and even some farmers have attained families and communities have in one or two rock star status; people are doing farm-stays for va- generations lost a whole history of knowledge and cations, milking cows and helping with the harvest; expertise around growing and preparing food. and the ratings of the Food Network channel are exploding. Although local food sales have grown to an estimated $7 billion in 2012, they still are an infinites- Food has moved to center stage in our culture and imal fraction of our $1.3 trillion food economy. collective consciousness. One major positive note is And the vast majority of our food dollars, some that more and more people are equating good food 89 percent in 2011 according to the US Depart- with good health, and not just to individual health ment of Agriculture, continues to be spent on man- but the health of the larger community as well. Food ufacturing, packaging, transporting, and marketing is coming back home, seeking relationships of trust, processed food products, with only a thin sliver of well-being, and community. our food dollar paying for the production of actual whole, real foods—let alone for such foods grown Yet observers such as Herman Daly and John B. with minimal chemical inputs by well-paid workers Cobb reckon our food system remains seriously out within the communities that consume them. of balance. “If economics is reconceived in the service of community, it will begin with a concern for Food insecurity and diet-related chronic illness con- agriculture and specifically for the production of tinue to plague the nation, with disproportionate food,” they write in their book, in For the Common and reverberating impacts on minority and low- Good (1994). “This is because a healthy community income communities. In a 2012 report for the US will be a relatively self-sufficient one. A community’s Department of Agriculture, Alisha Coleman-Jensen complete dependency on outsiders for its mere sur- and coauthors found that nearly 15 percent of vival weakens it. The most fundamental requirement households in the world’s richest nation experienced for survival is food. Hence, how and where food is food insecurity in 2011, but the rate of hunger in grown is foundational to an economics for commu- black and Hispanic households was over 25 percent, nity” (p. 268). and approached 35 percent in low-income households. Obesity and type 2 diabetes have reached Food production and distribution are highly con- epidemic proportions across all age, income, and centrated in the hands of a small number of too-big- ethnicity groups, but rates are significantly higher to-fail agribusinesses and retail mega-corporations, in African American and Hispanic communities, writes Wenonah Hauter in her book Foodopoly which, not coincidentally, are more likely to be lo- (2012). The small farms, ranches, and dairies of cated in food deserts with limited access to grocery a century ago have been replaced by enormous stores selling fresh, healthy foods. agribusiness concerns, some twenty of which supply most of the food that makes its way into our food And our political leaders have thus far utterly failed chain, and massively concentrated confined an- to adapt our antiquated and dysfunctional national imal feedlot operations (CAFOs), which raise food policy (aka the Farm Bill) to these and other animals in appalling conditions to produce exigencies of the twenty-first century, including cli- chemical-laden meat with questionable health mate change, soil loss, and groundwater depletion.

C⃝2014 Wiley Periodicals, Inc. Published online in Wiley Online Library (wileyonlinelibrary.com) A Publication of the National Civic League National Civic Review ● DOI: 10.1002/ncr.21175 ● Spring 2014 45 Without a doubt, the centralized industrial food sys- aging those efforts to increase communitywide tem has achieved amazing productivity and techno- healthy food access via hospital-based farmers logical advances over the last half century. But along markets and CSA. the way, the creation of short-term shareholder ● Food policy councils giving rise to proactive poli- wealth has been decoupled from community health, cies and programs, such as the Good Food for All environmental sustainability, and justice, and com- Pledge, a comprehensive procurement program munity self-reliance has been sacrificed to the pursuit created by the Los Angeles Food Policy Council of specialization, efficiency, and scale economies. and signed onto by the Los Angeles Unified School District, highlighting a holistic approach to sourc- We believe that the current food revolution is a ing good, fair, nutritious, and sustainable food. hopeful harbinger of some remarkable community- ● Initiatives like the Food Commons seeking to level changes in our food and food system to come weave together threads of sustainable agricul- over the next twenty-five years—changes that are es- ture, new economy, local food, and innovative sential to diversify and restore balance and resilience community-based ownership and finance into a to our dangerously lopsided current system. holistic system of infrastructure to support thriving, networked regional food economies. Signs of communities retaking control of their food systems are multiplying exponentially around the All of this activity has not gone unnoticed by ma- country. Witness: jor players in the dominant large-scale food system. Some are moving proactively toward more sustain- ● The explosion of farmers markets and able ways of operating. Bon Appetit´ Management community-supported agriculture (CSA). Company, for example, is leading the charge in de- ● The growth of programs, policies, conferences, manding better practices from the largest produc- educational programs, and media on home, neigh- ers in the country. One of its current initiatives is borhood, and community-based food production, phasing out gestation crates from their pork supply from backyard chickens and neighborhood back- by 2015. As Helene York, the company’s director yard produce exchanges, to community gardens of strategic initiatives, stated in Civil Eats (2012), and gleaning programs, to local seed banks and “We are announcing a commitment—even though seed swaps, to mobile slaughterhouses and sus- the products we need aren’t produced in the quan- tainable meat “hackathons.” tities we need. Why? We’re convinced of one thing: ● Individuals rediscovering cooking skills as one of The best chance for change is to stop waiting for ev- the most valuable assets in managing personal eryone else to make the first move. We’re committed health and wellness, not to mention food costs; to shifting production practices in the marketplace and communities investing in community kitchens one way or another.” and kitchen incubators to support the growth of local food artisans and entrepreneurs. Retailers—from Costco to Walmart—are respond- ● The emergence of hundreds of local food hub ing to consumer demand by expanding their offer- projects around the country, seeking to rebuild the ings of local and organic foods, and many others are infrastructure that has been lost over the last sixty rushing to enter the fast-growing fresh and natural years to bring local products from small and mid- foods segment. size farms and food processors to local markets. ● Farm to school and school food programs en- Even policy makers are beginning to take note. In gaging parents, teachers, administrators, farmers, spite of a lack of visible progress on revamping the and communities in bringing healthy, local food Farm Bill, national dialogue about commodity crop into school cafeterias and utilizing school gardens subsidization is getting louder, the US Department and nutrition education to raise a new generation of Agriculture is putting more resources and effort that understands where food comes from and why than ever before into supporting regional food good food matters—and that has access to that systems, and First Lady Michelle Obama is shining good food every day. a spotlight on the vital connections among health, ● Hospitals not only reassessing their internal food food access, physical activity, and individual and service and procurement operations but lever- national prosperity.

46 National Civic Review DOI: 10.1002/ncr Spring 2014 That the largest food retailer in the world, Walmart, that same essay, “We cannot be free if our food is utilizing its enormous market power and highly ef- and its sources are controlled by someone else” (p. ficient global logistical systems to buy and sell more 229). Food and food production are now major con- local and organic foods is, on the whole, a good versations in both public and private sectors. As thing. we harness this incredible moment of convergence across sectors, let us celebrate our accomplishments But does the presence of “local” produce on the (preferably around a good meal) and then get back shelves at Walmart equate to a community being to the good work that needs doing to bring food able to feed itself? back home.

Is there not some real value to communities in- As Dee Hock (1999) has said, “In times such as vesting in and retaining for themselves such a core these, it is no failure to fall short of realizing all that competency as food production, particularly in the we might dream. The failure is to fall short of dream- face of increasingly volatile economic, political, and ing all that we might realize” (p. 3). physical climates? What have communities lost by ceding their self-sufficiency to remote corporations References whose primary obligations are to still more remote investors and shareholders? More important, what Berry, Wendell. 2009. “The Pleasures of Eating.” In Bringing do communities stand to gain, or regain, through the It to the Table: On Farming and Food. Berkeley, CA: Coun- terpoint. flourishing of home-grown local food movements? Coleman-Jensen, Alisha, Mark Nord, Margaret Andrews, A community-level food system will undoubtedly and Steven Carlson. September 2012. Household Food Secu- not be able deliver the same price points as Walmart. rity in the United States in 2011. ERR-141, US Department But mounting evidence suggests that, across the eco- of Agriculture, Economic Research Service. nomic scale, people are ready to pay more for local Daly, Herman E., and John B. Cobb Jr. 1994. For the Com- food that nourishes not only their bodies but their mon Good: Redirecting the Economy Toward Community, communities. the Environment, and a Sustainable Future. Boston: Beacon Press. We believe we are in the midst of a community- Hauter, Wenonah. 2012. Foodopoly: The Battle over the Fu- rooted food renaissance—the rebirth of food that ture of Food and Farming in America. New York: New Press. travels a short and known route from field to plate Hock, Dee. 1999. Birth of the Chaordic Age. San Francisco: and accomplishes these things: Berrett-Koehler. US Department of Agriculture Economic Research Ser- ● It supports local farmers and farm workers with vice. “Food Dollar Series: Industry Group Dollar 2011.” dignity. Accessed December 18, 2013. http://www.ers.usda.gov/ ● It keeps dollars circulating within the local econ- data-products/food-dollar-series/food-dollar-application. omy and creates a ripple of jobs throughout the aspx#.UrIZbY3oXbk. community. York, Helene. 2012. “Inside One Corporation’s Decision ● It is a genuine expression of local identity and her- to ‘Go Humane.’” Civil Eats, February 21. http://civileats. itage, not a cosmetically engineered imitation. com/2012/02/21/inside-one-corporation%E2%80%99s-de- ● It celebrates and enriches cultural and genetic di- cision-to-%E2%80%9Cgo-humane%E2%80%9D/. versity that fits the season and the local environment rather than fighting against them. Renee Guilbault is the director of operations and service for ● It increases the self-sufficiency of families and the Compass @ Google, Americas, and serves on the Los Angeles resilience of the community for generations to Food Policy Council’s Leadership Board. come. ● It expresses love and care for ourselves, our neigh- Larry Yee is cofounder and coordinating director of Food Commons. bors, and our planet. Karen Schmidt serves on the national Food Commons execu- The last twenty-five years have witnessed a reawak- tive team and is director of the Fresno Food Commons pro- ening of what Wendell Berry eloquently described totype project. in “The Pleasure of Eating.” But as Berry noted in

National Civic Review DOI: 10.1002/ncr Spring 2014 47 The Laboratories of Place-Based

Change BY ROBERT OGILVIE

In recent years, public health agencies all over the how built environments are planned for and devel- country have started working to create places where oped. In some rare cases, public health department people can more easily make healthy choices and live employees went to law school or planning school to healthy lives. Much of this work is modeled after develop skills and expertise. More often, they wrote the tobacco control movement, which has focused proposals to foundations and to state and federal on changing social and retail environments to help agencies that could fund them to attend conferences make smoking less socially acceptable and therefore and training seminars and to hold their own local make people less likely to start or continue smoking. meetings and training seminars with partner organizations and local elected officials. They built their In social environments, such as bars, restaurants, skills and relationships bit by bit on the job. parks, and even multi-unit housing, smoking affects everyone’s air quality. In the retail environment, Our organization, ChangeLab Solutions, has been making tobacco products less attractive and avail- at the forefront of working with public health agen- able means people—especially teenagers—are less cies trying to do this work. With support from likely to buy them and become addicted. the California Department of Public Health, the Centers for Disease Control and Prevention, the Public health agencies can take a similar approach California Endowment, the Robert Wood John- when they look at the built environment—man- son Foundation, Kaiser Permanente, and the Kresge made structures such as roads, neighborhoods, Foundation, among others, our team of attorneys, cities, and buildings in which we conduct our lives. If urban planners, and policy analysts has worked with those elements of a community are designed to pro- and for local government staff members and com- mote physical activity in daily life, the healthy choice munity advocates to help them become experts on becomes the easy choice. how to work with land use, redevelopment, economic development, and other local agencies to cre- Research was starting to show fewer people were ate and adopt policies, ordinances, agreements, and being physically active—many people live in places zoning codes to create healthier environments. designed for cars. That meant people had to make a conscious choice to be physically active. It was not normal for them to walk or use a bicycle to The ChangeLab Solutions Approach get around their community. Reversing this trend re- To do our most effective work, ChangeLab Solu- quired changing the built environment so opportu- tions has used an advocacy and policy change logic nities for active transportation—walking to school, model adapted by evaluator Nancy Frank from one work, or the grocery store, for example—became developed by Julia Coffman at the Harvard Family convenient and safe for people. In addition, neigh- Research Project. It portrays the multiple elements borhood parks and schoolyards stayed unlocked in or stages of a community-based policy change pro- the evenings and on weekends so they were accessi- cess. The key elements are as shown in Figure 1. bletoall. Although this logic model holds true from place to This is not a traditional way for public health de- place, our entry point varies from community to partments to work—they have no actual power to community, as does the pace of change and the chal- change the built environment, so they had to become lenges that arise and need to be overcome. partners with the redevelopment agencies and planning authorities that did. Public health department We have helped address different types of challenges staff members also had to develop new expertise in in two places in California: Fresno and San Diego.

C⃝2014 Wiley Periodicals, Inc. Published online in Wiley Online Library (wileyonlinelibrary.com) 48 National Civic Review ● DOI: 10.1002/ncr.21176 ● Spring 2014 A Publication of the National Civic League Figure 1. Advocacy and Policy Change Composite Logic Model

San Diego is the eighth largest city in the country, Governed by the Central California Public Health with a robust economy based in military and de- Partnership, CCROPP is a collaborative venture of fense contracting and biotechnology research, while the eight county public health department directors, much-smaller Fresno is the thirty-fourth largest in a community-based organization in each county, the country and is the center of the world’s most pro- and an obesity council. In each county, a pub- ductive agricultural region. Both had very high rates lic health department staff member was designated of obesity and related chronic disease, and in both as a lead member and charged with implementing places the county public health departments decided CCROPP activities and policies in their county. to change policy to prevent chronic disease. In Fresno County, Rosemarie Amaral was the Experience had taught them that just encouraging CCROPP lead, and we worked most directly with people to live healthier lives through education cam- her. There, as in all of the CCROPP counties, Rose- paigns was not working, and they needed to cre- marie faced resistance to some of her new ideas ate environments that were more likely to lead to from conservative elected officials, suspicion from a healthier outcome. Whereas the tobacco control disenfranchised community members, and limited movement was trying to change the environment to resources in a rural county. These challenges meant make the unhealthy choice—the choice to smoke— she and her colleagues could ill afford missteps and the hard one, this burgeoning anti-obesity move- needed to work with partners with whom she and ment was trying to change environments to make the public health department could devise and im- healthy choices—being physically active and eating plement policies to quickly achieve mutual goals. healthy food—easier. We brought the Fresno CCROPP team up to speed on the impact of the built environment on health, about health disparities, and about which types of Policy Change in Fresno policies could be changed at the local level to cre- Fresno’s catalyst for change happened in 2006, when ate healthier environments. The investments of TCE, the California Endowment (TCE) launched the Cen- the Healthy Eating Active Living (HEAL) program tral California Regional Obesity Prevention Pro- of Kaiser Permanente’s Community Benefits Depart- gram (CCROPP) “to promote safe places for phys- ment, and of the California Department of Public ical activity, increase access to fresh fruits and veg- Health allowed experts from ChangeLab Solutions etables, and support community and youth engage- and other organizations—including the Local Gov- ment in local and regional efforts to change nutrition ernment Commission (LGC), the California Center and physical activity environments for obesity pre- for Public Health Advocacy (CCPHA), the Preven- vention” in six, and later eight, counties in Central tion Institute, and PolicyLink—to come in regularly California’s San Joaquin Valley. and train the group on a range of subjects. Change- Lab Solutions staff was also on call to answer Rose- As with Healthy Eating Active Communities marie’s questions and to develop solutions to the (HEAC), TCE’s other place-based, policy-driven problems she and her colleagues wanted to over- obesity prevention program, CCROPP had two come. components: The first big action we took together was drafting 1. Engagement of community members and local in- language to rewrite a subsection of Fresno’s Munic- stitutions in environmental change ipal Code that banned farmers’ markets. The fact 2. Policy change technical assistance, and advocacy that this ban existed in the largest town of the coun- training and support try’s most productive agricultural county seemed

National Civic Review DOI: 10.1002/ncr Spring 2014 49 like an obvious policy change target. In 2008, Fresno Committee, and the Fresno Unified School Dis- adopted a municipal ordinance that amended lo- trict to open school recreational facilities to the cal zoning codes to include the new language and, community on evenings and weekends. This more at last, allowed farmers’ markets to operate. With sophisticated step would never have been successful that success behind her, Rosemarie and her partners if Rosemarie and her team had not laid that earlier turned their focus to the city’s neighborhoods. groundwork by taking simpler steps toward building more health into the Fresno community. Rose- The HEAL grants the CCROPP team received from marie herself also was appointed to be a member of Kaiser Permanente helped it build links to commu- the Fulton Corridor Specific Plan Advisory Commit- nity organizations, and Rosemarie and her team de- tee in downtown Fresno, a first for a staff member cided to develop a relationship with the Burroughs of the public health department. Neighborhood Committee. Rosemarie had given a presentation about the connection between the San Diego built environment and poor health conditions in the At the same time that HEAC and CCROPP were cat- neighborhood to parents at the Burroughs Elemen- alyzing change in Fresno, the San Diego Department tary School who subsequently comprised the com- of Public Health issued a request for proposals for an mittee. The parents identified changes they wanted organization to help write a countywide plan for re- the public health department to help make. ducing rates of childhood obesity. The idea for this plan was hatched by two county supervisors, Pam Rosemarie noted that it took awhile for the neigh- Slater-Price and Ron Roberts, who convinced the borhood to trust the public health department. San Diego County Board of Supervisors to vote in However, Rosemarie, the public health department, 2004 “to support the creation, coordination and im- and their partners started building that trust by plementation of a Childhood Obesity Master Plan to holding a Spanish-language workshop for the neigh- end childhood obesity” in San Diego County (p. 2). borhoods. This effort, which was led by LGC, won One of the organizations that was awarded that con- over many of the Spanish-speaking residents— tra- tract was the San Diego County Childhood Health ditionally they had felt excluded from the decisions Improvement Partnership. In 2006, a public-private others made about their neighborhood, but, this partnership started working on creating a compre- time, they had the rare opportunity to make deci- hensive countywide approach to dealing with child- sions themselves. hood obesity.

After the community members identified things they The first version of the plan, published in 2006, was wanted to change, some of them were invited to the state’s first comprehensive countywide plan to make a co-presentation to the city council with Dr. address obesity. As Cheryl Moder, the director of the Ed Moreno, the director of the Fresno County De- San Diego Childhood Obesity Initiative noted, this partment of Public Health. The city council started plan also represented the first official recognition in to make changes after hearing what the neighbor- San Diego that infrastructure, land use planning, af- hood wanted. fordable housing, and transportation policy were all having a significant effect on childhood obesity lev- The first change the city council made was toget els in the county and would have to be addressed to the transit agency to install bus shelters at bus stops. bring childhood obesity levels down. Fresno can get extremely hot, and bus riders need a shaded waiting area. This simple change energized As with Fresno, San Diego’s efforts were supported the community. Next, the public health department by Kaiser Permanente’s Community Benefits Pro- got the public works department to repaint all the gram, TCE, and others that funded the city’s Public faded crosswalks in the neighborhood. Health Department to help it create environments where healthy eating and physical activity were eas- Eventually, Rosemarie and others were able to get ier to achieve. They also funded ChangeLab Solu- a joint use agreement signed among the Burroughs tions and others to build local knowledge and policy Elementary School, the Burroughs Neighborhood change capacity in San Diego.

50 National Civic Review DOI: 10.1002/ncr Spring 2014 Cheryl and her colleagues in San Diego started away and ensuring a safe venue where people can from a very different place than Rosemarie and have honest conversations and build the sorts of re- her colleagues in Fresno. With such strong support lationships and trust needed for successful multi- and backing from the county board of supervisors, organizational collaborations. Cheryl and others were empowered to begin with a more expansive vision than Rosemarie was able to Riding on this proven policy success, San Diego attempt. In San Diego, the list of policy accomplish- County’s public health department applied for and ments of the Childhood Obesity Initiative is long was awarded a $32 million Communities Putting and impressive. Since the adoption of the county- People to Work grant from the Centers for Dis- wide childhood obesity action plan in 2007, these ease Control and Prevention in 2009. The health health-related policies have been adopted by public department wanted to use the funding to enact sector organizations in San Diego County: strategies to reverse the childhood obesity epidemic and prevent/reduce tobacco use, and $16.1 million ● The City of San Diego passed an Urban Garden was directed at anti-obesity efforts. This was the Policy and revised ordinances on healthy retail largest anti-obesity grant given to any county in the and ownership of bees and chickens. country. ● The City of Encinitas included a health element in its general plan. ● The City of La Mesa made it easy for people to Institutionalizing Change keep chickens on residential properties and added Although a tally of approved policies is one mea- a health and recreation element to its general plan. sure of success, there is more to the story of what ● The San Diego Unified School district passed a res- has taken place in Fresno and San Diego. It is also olution to explore community gardens on school important to look at the other outcomes of our en- property. gagement with the dedicated partners in the commu- ● The San Diego Unified School District drafted nities in which ChangeLab Solutions works. a shared use license agreement for one pilot at Montgomery Middle School. ● The San Diego Unified School District permitted Helping Partnerships, Collaboration, and Organizational Springall Academy (a charter school leased from Alignment Grow the school district) to enter into a community ChangeLab Solutions links our technical assistance garden lease agreement with San Carlos United recipients with other key individuals and groups Methodist Church. to enhance their efforts. In many cases, the orga- ● The San Ysidro Unified School District passed a nizations that we work with have little experience resolution allowing district schools to begin to de- working with each other before we become engaged. velop their garden projects. With our technical support, new relationships are ● The City of La Mesa approved a shared use agree- fostered and common vision, goals, and actions are ment with Grossmont Union High School Dis- developed. trict. Although the high school district did not ap- prove the policy, the policy’s wording is being used Helping New Advocates and Champions Emerge elsewhere. Through training, ongoing technical support, and the creation of targeted technical assistance ma- To accomplish all of this, Cheryl and her staff, terials, ChangeLab Solutions helps advocates and like Rosemarie and her colleagues, had to build champions take the lead in the local policy devel- partnerships with community members, public opment process. health advocates, and policy makers across a range of organizations. Because childhood obesity is an issue of concern to so many organizations, Cheryl has Crafting Salient Messages and Written Products to been able to get many partners to work together. Address Local Issues In doing so, she has made sure to remain neutral ChangeLab Solutions crafts salient and con- and inclusive—not turning any potential partners crete technical language for use in ordinances,

National Civic Review DOI: 10.1002/ncr Spring 2014 51 agreements, responses to legal questions, and ● Starting with simple interventions and then get- proposals. Among the most useful to communities ting more sophisticated over time over the years have been these articles and toolkits ● Staying in touch and delivering on promises (see http://changelabsolutions.org/): That last step is going to be the most difficult, partic- ● “Opening School Grounds to the Community Af- ularly as long-term financial support for efforts like ter Hours: A Toolkit on Joint Use” these remains difficult to secure in an era of public ● “How to Create and Implement Healthy General sector cutbacks. As Cheryl noted, “Policy adoption Plans” doesn’t just happen. It has to be driven by an orga- ● “Healthy Planning Policies: A Compendium from nization that is skilled at moving people and organi- California General Plans” zations forward.” ● “Seeding the City: Land Use Policies to Promote Urban Agriculture” Cheryl refers to such organizations as “backbone or- ● “Getting Involved in Redevelopment: Strategies ganizations” and building and sustaining them is the for Public Health Advocates” key to institutionalizing policy change in commu- ● “How to Use Redevelopment to Create Healthier nities. In addition to the aforementioned need for Communities” long-term financial support, building and sustaining ● “How to Use Economic Development Resources backbone organizations requires skilled leadership to Improve Access to Healthy Food” and supportive partnerships. This last part is the role that ChangeLab Solutions plays. By working with partner organization over the long haul and by pro- Developing the Organizational Capacity of Partner viding ongoing legal and policy technical assistance, Agencies ChangeLab Solutions helps people like Cheryl and Perhaps most important, and most challenging over Rosemarie stay at the forefront of the community- the long term, is how we develop the organizational based policy change process and continue to work capacity of partner agencies. Although relationships to create places where the healthy choice is an easier have been built, trust has been earned, and policies one to make. have been adopted, those successes have to be institutionalized and built on as those agencies proceed Reference with further work. Call to Action: San Diego County Childhood Obe- sity Action Plan. Revised September 2007. http://www. When asked how she was so successful in Bur- ourcommunityourkids.org/media/8160/8action%20plan% roughs, Rosemarie identified these key steps: 209-11-07.pdf.

● Identifying community challenges ● Helping the community figure out intervention Robert Ogilvie serves as the vice president for strategic en- strategies gagement at ChangeLab Solutions. Over the past twenty years he has worked extensively in community development ● Inviting those who can help to come and meet and planning to help improve low- and middle-income neigh- with the community so the community can put borhoods. faces to names and build relationships

52 National Civic Review DOI: 10.1002/ncr Spring 2014 BY LOWELL KRUSE Communities of Excellence 2026 AND RICK NORLING

As we mark the twenty-fifth anniversary of the organizations reinforced our belief that the health Healthy Communities movement, we note the great of communities transcends their health care insti- progress toward the movement’s ambitious goal of tutions, meaning that to succeed, those institutions achieving measurable improvements in Americans’ must meaningfully engage in their communities. health status and quality of life. The anniversary—as well as this special issue of National Civic Review— The Baldrige criteria helped us to achieve this in the also provides the opportunity for a wide-ranging organizations we led, and we believe the criteria can conversation about the movement’s agenda and be adapted to provide the same for communities— strategy for continuing that progress. an idea that a team of Baldrige experts from across the nation has endorsed. A systematic, Baldrige-like As the leaders of large health care enterprises, we approach to performance excellence can instill in bore a responsibility to run high-performance orga- communities a long-term commitment to harvest nizations. It was a fiscal responsibility but a moral best practices, collect and act on performance data, and ethical one too. We met this obligation by bring- promote collaborative leadership, and continuously ing to our enterprises the Baldrige Performance Ex- improve processes across sectors, generations, and cellence Program, established in the late 1980s as a organizations. means to boost U.S. companies’ sluggish response to rising economic powerhouses elsewhere in the world, primarily Japan. Originally tailored to man- Communities of Excellence 2026 ufacturing, in the 1990s the Baldrige criteria were adapted for enterprises in the health care and edu- That belief leads us to propose a new way for Amer- cation sectors. ican communities to address the challenges they face in health status and the closely related social The Baldrige program helps companies examine determinants of health status—educational attain- their practices, benchmark results against the best ment and economic well-being. It is an initiative performers, and map out and execute changes called Communities of Excellence 2026—in antic- needed to operate leaner, faster, and better, focusing ipation of the 250th anniversary of our nation’s sharply on customers’ needs and expectations and founding—that will help communities discover and following decisions and strategies based on fact. implement fundamentally new and permanent solutions to these challenges using the model of Achievement of performance excellence based on collaborative leadership and performance excellence the Baldrige criteria is a journey—for most, a already proven to work by some of the nation’s lead- journey of many years—and is recognized by the ing enterprises. Baldrige Award, given annually by the president of the United States to organizations that have demon- Communities of Excellence 2026 is adapting the strated performance excellence. Winners have in- Baldrige criteria and incorporating the Healthy cluded such respected companies as FedEx, IBM, Communities movement’s Seven Patterns of Success- Nestle´ Purina Pet Care, Texas Instruments, Ritz- ful Communities to create a framework for commu- Carlton Hotels, and divisions of Boeing, Cargill, nity performance excellence, a road map for com- Merrill Lynch, and Xerox. munities that choose to confront their challenges by adopting a proven course of action that demands Our own organizations, Premier, Inc., the largest high performance and a commitment to achieve and health care alliance in the country, based in Char- sustain the highest quality of life for their people. lotte, North Carolina, and Heartland Health, an integrated health delivery system based in St. Joseph, Focused initially on community collaboration and Missouri, received the Baldrige Award in 2006 and performance excellence in the critical and elabo- 2009, respectively. Building Baldrige Award–worthy rately interrelated sectors of health, education, and

C⃝2014 Wiley Periodicals, Inc. Published online in Wiley Online Library (wileyonlinelibrary.com) A Publication of the National Civic League National Civic Review ● DOI: 10.1002/ncr.21177 ● Spring 2014 53 economic vitality, Communities of Excellence 2026 ence others across the country to strive for commu- was established to provide the training, skill build- nity performance excellence. ing, research, knowledge of best practices, and the coaching resources communities need to engender The Path Ahead collaboration across sectors. Communities of Excel- The work of implementing the community perfor- lence 2026 will help communities outline a baseline mance excellence framework will be difficult. We are of performance, determine assets and challenges, es- grateful to our two pilot communities—Rochester, tablish community criteria for quality and commu- Minnesota, and Northwest Missouri—that will nity goals, and measure progress and enact practices help to test, refine, and perfect the framework. The for sustainability. Communities of Excellence 2026 experiences and first outcomes of the pilot com- will also facilitate communities learning from each munities will become the foundation upon which other. Communities of Excellence 2026 will reach out to and engage a second generation of communities to adopt and implement the community performance Communities of Excellence 2026 will help commu- excellence model. nities outline a baseline of performance, determine Americans have a long history of working to make assets and challenges, establish community crite- things better. That energy, ardor, and passion are as ria for quality and community goals, and measure robust today as ever before. We celebrate this spirit progress and enact practices for sustainability. and applaud the efforts of leaders and communities nationwide. To make good the promise of that spirit, we propose a new model of community per- Why the focus on communities? Because despite the formance excellence, and we established a nonprofit importance of federal and state policies and prac- organization—Communities of Excellence 2026— tices, we advance the common good most effectively to help communities achieve it. and durably when we work together in a local community to identify, implement, and sustain improve- As leaders of health care enterprises, we know that ments that work for that community. Implementing health status is inextricably interwoven with edu- a Baldrige-like standard of community performance cational attainment and economic prosperity. We excellence will not be easy; unlike the organizations know that America can again lead the world in that have successfully adopted the Baldrige criteria, these measures of well-being—but only when com- no community has a single broker or agent that can munities nurture a culture of collaborative leader- establish new practices and habits. And communi- ship across sectors and generations. Only when they ties often are more diverse, with more complex cul- commit to continuous improvement everywhere and tures, than individual organizations like businesses, root their decisions and strategies in fact. Only when schools, hospitals, and others. they are willing to leave no one behind. And the work of communities must be to encompass The framework of community performance excel- the diverse interests of all residents, to insist on per- lence will enable diverse interests and broadly in- formance excellence, and to coalesce to identify and clusive leadership to formulate and act on a shared implement solutions to common problems. In doing community identity and vision. In doing so over so, American communities will continue building on the coming decades, such communities will form a the foundation of democracy and liberty established growing archipelago across the nation where com- by our nation’s founders. munity performance excellence is achieved and sustained. These will be communities pursuing collaborative strategic plans aimed at achieving bold Lowell Kruse was chief executive officer of Heartland Health, goals—and measuring progress in ways that both St. Joseph, Missouri, from 1984 to 2009. prioritize and inspire further action. They will be Rick Norling was chief executive officer of Premier, Inc., communities that consistently outperform others in Charlotte, North Carolina, from 1997 to 2009. the nation, and their success will meaningfully influ-

54 National Civic Review DOI: 10.1002/ncr Spring 2014 Preventing Urban Violence to Save Lives and Foster Healthy

Communities BY RACHEL A. DAVIS

Violence undermines the community experience and is a public health approach to address violence affect- a terrible burden on young people, families, and ing youth in large US cities. While cities continue neighborhoods. US Bureau of Justice statistics re- to experience a range of violence problems, espe- veal, for example, that more than 1.3 million people cially firearm and gang violence, many are now tak- ages twelve to twenty-four were victims of assault ing a fundamentally different approach to address- in 2010. Violence disproportionately affects young ing the problem by focusing on it as a public health people of color; the US Centers for Disease Control issue rather than purely a criminal justice problem. and Prevention (CDC) found that among African Consequently, cities are shifting toward prevention Americans, Hispanics, and Native Americans, homi- strategies and not solely relying on intervention or cide is a leading cause of death for youth ten to suppression methods. twenty-four years old. In addition to the devastation that the loss of community members and loved ones The public health approach emphasizes the preven- yields, violence deeply influences a community’s rep- tion of violence before it occurs and fosters strate- utation and economic climate. The failure to prevent gies that address the safety of the entire community, violence is costly to taxpayers, necessitating large as opposed to one individual at a time. To accom- outlays for law enforcement, medical care, criminal plish this, strategies address risk and resilience fac- justice, mental health care, and social services. Vi- tors at individual, family, community, and societal olence also reduces neighborhood business activity, levels. Risk factors are conditions or characteristics home and property values, and tourism. Conversely, that increase the likelihood that violence will occur reducing violence is an effective way to stimulate (e.g., alcohol use, availability of weapons, academic economic development and enhances a community’s failure, and poverty). Resilience factors are charac- ability to thrive. Safe communities are key to im- teristics that are protective against the likelihood of proved education, housing, and economic opportu- violence (e.g., positive adult-youth relationships, nities and to reducing associated health problems, neighborhood cohesion, and economic opportu- such as diabetes, heart disease, asthma, and depres- nity), even when risk factors are present. sion. Public health–based strategies are preventing vio- Historically, violence has been viewed as either an lence. Examples include: inevitable aspect of the human condition or as a criminal justice issue. In 2008, Billie Weiss’s Assess- ● The Cure Violence model has reduced shoot- ment of Youth Violence Prevention Activities in U.S. ings and killings by 41 to 73 percent and re- Cities confirmed that law enforcement and crimi- taliation murders by 100 percent, and promoted nal justice were the most prevalent strategy, and few norm changes in communities. Baltimore’s repli- cities reported using primary prevention to stop vi- cation program, Safe Streets, reduced overall gun olence before it occurs. The tide is shifting. As city violence and also reduced nonfatal shootings by and law enforcement leaders are acknowledging that 44 percent and homicides by 56 percent. we cannot “arrest our way out of this,” the pub- ● Communities That Care has reduced crime com- lic health model is being recognized as a viable ap- mitted by youth by 33 percent by reducing proach that is complementary to criminal justice ef- risk factors and promoting resilience through a forts. UNITY (Urban Networks to Increase Thriving coalition-based system. Youth) is an initiative funded by the CDC to advance

C⃝2014 Wiley Periodicals, Inc. Published online in Wiley Online Library (wileyonlinelibrary.com) A Publication of the National Civic League National Civic Review ● DOI: 10.1002/ncr.21178 ● Spring 2014 55 ● Neighborhoods with Business Improvement Dis- community. Consequently, preventing violence is es- tricts saw a reduction in all violent crime by 8 per- sential to promoting thriving, healthy communities. cent and robbery by up to 27 percent. It facilitates community cohesion and participation, ● Universal school-based violence prevention strate- fosters neighborhood improvements, and encour- gies can reduce violence by 15 percent in six ages employment and educational opportunities. As months. Beyond individual programs, communi- communities focus on implementing effective strate- ties need strategy and coordination across mul- gies and coordinated approaches, they will become tiple sectors. In the UNITY Assessment, cities safer and healthier. As Lieutenant Michael Sullivan with the greatest coordinated approach also had of the Minneapolis Police Department explained in the lowest rates of violence affecting youth. The an interview with the author, “The public health Prevention Institute’s UNITY RoadMap (2008) approach works. It’s working right here in my city identifies the essential elements that commu- where we reduced violence by 40 percent in just two nities can put in place. It describes the who years, and then brought it down another 20 percent. (high-level leadership, community engagement, We didn’t do it by increasing arrests. We did it by staffing/coordination), what (prevention strate- giving young people opportunities to thrive.” gies, communication, training), and how (strategic plans, data and evaluation, adequate funding) to effectively prevent violence and sustain efforts. References Prevention Institute. November 2008. “UNITY RoadMap: Minneapolis is one locale where these elements have A Framework for Effectiveness and Sustainability.” http:// www.preventioninstitute.org/component/jlibrary/article/id- come together. In 2006, the city implemented a pub- 30/127.html. lic health–based blueprint: (1) connect every young person to a trusted adult; (2) intervene at the first US Bureau of Justice Statistics. “Number of Aggravated As- saults, and Simple Assaults, by Age.” Generated December sign of at-risk behavior; (3) restore youth who have 5, 2013, using the NCVS Victimization Analysis Tool at gone down the wrong path; and (4) unlearn the www.bjs.gov. culture of violence. Over the next two years, Min- neapolis saw a substantial drop in juvenile crime US Centers for Disease Control and Prevention. “Youth Violence: Facts at a Glance 2012.” http://www.cdc. in its most violent neighborhoods. Following this gov/violenceprevention/pdf/yv-datasheet-a.pdf. success, the plan was expanded to the twenty-two neighborhoods most impacted by violence in 2009. Weiss, Billie. 2008. An Assessment of Youth Violence Preven- tion Activities in USA Cities. Los Angeles: Southern Califor- Homicides of youth decreased by 77 percent over nia Injury Prevention Research Center, UCLA School of Pub- three years, and in 2010 the number of people under lic Health. 18 years old either suspected or arrested for violent crime dropped to the lowest it had been in a decade.

Violence is a leading cause of injury, disability, and Rachel A. Davis is managing director of the Prevention Insti- premature death. Further, it shapes and defines com- tute. munities and is detrimental to achieving a healthy

56 National Civic Review DOI: 10.1002/ncr Spring 2014 Community-Centered Health Homes Engaging Health Care in Building BY LESLIE MIKKELSEN, LARRY COHEN, Healthy Communities AND SONYA FRANKOWSKI

In Oakland, California, a comprehensive community Envisioning a Community-Centered Health Home clinic called Asian Health Services initiated a cam- Conversations with Asian Health Services and other paign to prevent traffic-related injuries after an el- medical care organizations that regularly step out- derly community member was hit and killed by side their clinic walls to find solutions to health a car. Youth from the clinic’s leadership program problems inspired the Prevention Institute to de- conducted research, including mapping of crash lo- scribe a coordinated set of practices to systematically cations and photo documentation of pedestrian- connect medical institutions to broader community- vehicle conflicts, such as autos blocking crosswalks level environmental change that we call community- or turning in front of pedestrians. They presented centered health homes (CCHHs). This concept in- their findings to the city council, and their local tentionally expands on the related emphasis of the council member used these data to secure funding Affordable Care Act on medical homes (better care from the Caltrans Environmental Justice grant pro- coordination at an individual patient level) to de- gram to plan street improvements. This led to the scribe practices that can link the medical system with implementation of a pedestrian scramble (all traffic community action to address the underlying deter- is completely stopped during a red light, and pedes- minants of illness and injury to improve the health trians are able to cross the street in any direction, in- of an entire community. The model builds on pio- cluding diagonally) in a few key intersections, which neering work in community-oriented primary care reduced conflicts by nearly 50 percent, ultimately at the heart of the establishment of the nation’s first reducing risks for death and injuries. community health centers in high-poverty communities in the 1960s. This example illustrates the value of health care/community partnerships. Asian Health Ser- A CCHH not only acknowledges that factors out- vices played a critical role in bringing a very side the health care system affect patient health important medical condition—traffic-related in- outcomes but also actively participates in improv- juries and fatalities—to the attention of city leaders. ing those factors in order to improve health and The solution to prevent these injuries was designed safety for all residents. The defining attribute of the in partnership with the Oakland Chinatown Cham- CCHH is translating high-priority medical condi- ber of Commerce, the Oakland Pedestrian Safety tions into active involvement in community advo- Project, City of Oakland council members, and cacy and change. In recent years, as practitioners the city’s public works staff. The potential Healthy look to heighten their impact on their patients’ well- Communities benefits are far-reaching. Health and being, more and more health care providers and quality of life benefit through the prevention of institutions have moved closer to this model, al- devastating injuries and fatalities. Also, safer streets though they still remain a distinct innovative mi- encourage more pedestrians; higher rates of walking nority. The CCHH provides high-quality health care help prevent and control diabetes, cardiovascular services while also applying diagnostic and criti- problems, and other chronic diseases; and economic cal thinking skills to the underlying factors that benefits result from a reduced demand for high-cost shape patterns of injury and illness. By strate- trauma and rehabilitative care, lower need for gically engaging in efforts to improve commu- police services, and greater patronage of local retail nity environments, CCHHs can improve the health and services. and safety of their patient population, improve

C⃝2014 Wiley Periodicals, Inc. Published online in Wiley Online Library (wileyonlinelibrary.com) A Publication of the National Civic League National Civic Review ● DOI: 10.1002/ncr.21179 ● Spring 2014 57 health equity, and reduce the need for medical develop effective prevention and remediation strate- treatment. gies. A formal relationship between Children’s Hos- pital and the Cincinnati Health Department allows doctors and families on the inpatient unit to initiate The defining attribute of the CCHH is translating home inspections. A second partnership with the Le- high-priority medical conditions into active involve- gal Aid Society ensures that housing violations can ment in community advocacy and change. be addressed.

On the health care side, the skills needed to engage in community change efforts are closely aligned Creating a Health System: Integrating Health Care with the problem-solving skills providers currently and Healthy Communities employ to address individual health needs. It is a It seems fitting to be celebrating the anniversary of matter of applying these skills to communities. healthy communities at the same time the United Specifically, with patients, practitioners follow a States is reaching major milestones in the implemen- three-part process: collecting data (symptoms, vital tation of health reform. Both herald major changes signs, tests, etc.), diagnosing the problem, and un- in US approaches to health, and effectively inte- dertaking a treatment plan. The CCHH functions grating medical care reform with Healthy Commu- in a parallel manner by developing capacity and ex- nities efforts can be truly transformational. After pertise to follow such a three-part process for ad- twenty-five years, Healthy Communities approaches dressing the health of the community, classified as have helped catalyze a new way of thinking. New inquiry, analysis, and action. approaches and resources are emerging. There is widespread recognition that many of the chronic dis- For example, this approach is being applied to pre- eases and injuries accounting for more than 75 per- vention of childhood asthma attacks in Cincinnati, cent of the nation’s increase in medical care expendi- Ohio. Nearly all children under twelve who need tures are preventable through attention to such un- emergency asthma care in Hamilton County end derlying determinants. Research has identified un- up at Cincinnati Children’s Hospital Medical Cen- derlying community determinants linked to many ter. During inquiry, Cincinnati Children’s Hospital preventable conditions, and these community fac- Community Health Initiative staff mapped the ad- tors explain inequities experienced in communities dresses of patients and identified geographic clusters of color and low income. The National Prevention of these children in the metropolitan area. Through Strategy, an important element of the Affordable analysis, the hospital, working with the Cincinnati Care Act, engages virtually every key government Health Department and the city’s building depart- sector, from transportation to housing to agricul- ment, found overlapping clusters of building code vi- ture, in advancing community health. Community- olations correlating with patients’ residences. Based level prevention efforts, including community trans- on the strong evidence linking poor-quality housing formation grants, are now an integral component of to asthma morbidity, the hospital partnered with the health reform, signaling the recognition that the bur- Legal Aid Society of Greater Cincinnati to take ac- den on the health system, and its inequities, can be tion to pressure landlords to improve the housing reduced by better aligning resources to address the conditions and ensure that asthma triggers were ad- factors that shape health and safety outcomes. This dressed. Efforts ultimately revealed nineteen build- alignment alleviates the frustration of clinicians who ings in disrepair all owned by a single landlord. feel powerless to change the social circumstances Through this experience, the following practice has that shape the health of their patients. Through com- been institutionalized: The electronic health record munity transformation grants and other HCC ef- template prompts hospital staff members to ask forts, private and government funded, a strong set about the housing conditions of any patient admit- of organizational practices and public policies have ted for asthma-related complications. This allows emerged that can be employed to change community researchers to identify emerging hot spots and to environments and advance equity.

58 National Civic Review DOI: 10.1002/ncr Spring 2014 We have a singular opportunity to re-envision our national approach to health and shape a quality Leslie Mikkelsen is managing director of the Prevention health system that meets the needs of all. The health Institute. and well-being of individuals depend on both qual- Larry Cohen is founder and executive director of the Preven- ity coordinated health care services and commu- tion Institute. nity conditions that support health and safety. This coordinated thrust will produce the most effective, Sonya Frankowski is completing her master’s of public admin- sustainable, and affordable health solutions, and istration in health policy at New York University’s Robert F. simultaneously advance community health—a fit- Wagner Graduate School of Public Service. ting opportunity for a twenty-fifth anniversary.

National Civic Review DOI: 10.1002/ncr Spring 2014 59 Public Policy Transforms When Health Expertise and the Public

BY MARTY KEARNS Come Together AND ELIZABETH BROTHERTON-BUNCH

Public health is a discipline that focuses on improving But the advocates kept hitting roadblocks. What the lives of individuals by changing public policy and they needed to do was make an impact. social norms. Those working in public health space are motivated by science that finds certain behav- In the weeks before the Board of Health was sched- iors and policies cause people to be sick. But even uled to vote on the guidelines in 2012, Netcentric the most convincing science is not enough to create Campaigns worked with the public health advocates real, lasting change. The most effective and transfor- to circulate an online petition to gather signatures mative public health work also rallies people to act from local residents who supported the proposed on the scientific evidence. Public health leaders must guidelines. More than eight hundred people affected rely on grassroots support to achieve their goals and by the county’s air quality signed on. create a healthier world. The day of the hearing finally came. As the board At Netcentric Campaigns, we regularly work on began work on the guidelines, an advocate walked evidence-based public health projects that rely on up and dumped more than eight hundred surgical both scientific data and grassroots and social media masks across the hearing table. Each mask had the support to achieve change. This article discusses a name of a local petition signer on it, representing few important lessons we have learned about grass- someone whose health was negatively impacted by roots advocacy in the age of connectivity. air pollution—and whose life would be improved if the new guidelines were passed.

Policy Makers Expect Public Support for Important It was a powerful visual. The story was even picked Policy Change up on local news. Yet the board still opted to defer Public health is dominated by policy experts and the vote. scientific researchers, and for good reason. Inor- der to make the policy and environmental changes But that only motivated the advocates to work needed to advance health, advocates must be backed harder to gather grassroots support. They continued by sound science and clear reason. But public health to gather signatures and urged their newly recruited advocates also need the backing of the public and supporters to keep pressuring the board. often rely on social media and grassroots mobilizing to build support. In November 2012, the scientific evidence and outcry of the public finally drove the Alleghany To be successful, advocates need to know their au- County Board of Health to pass stronger air quality dience and then figure out how to reach and engage guidelines. them.

For example, public health advocates worked for years to convince the Board of Health in Allegheny Building Public Support Requires a Disciplined County, Pennsylvania, to pass stronger air quality Approach to Grassroots Work guidelines. They talked with policy makers, they Achieving grassroots success in the public health nailed down their facts. As time went on, the sci- space is not as simple as gathering a couple hundred ence driving their push to establish guidelines only signatures, however. It is important to know how the became stronger. grassroots works.

C⃝2014 Wiley Periodicals, Inc. Published online in Wiley Online Library (wileyonlinelibrary.com) 60 National Civic Review ● DOI: 10.1002/ncr.21180 ● Spring 2014 A Publication of the National Civic League There are essentially two kinds of people working in the concerns of people to shape communications and the advocacy space: organizers and mobilizers. Both policy on public health data and determine how to are needed to achieve success. deploy public health resources. Organizers can be both big and small—or in one example, massive. Google helps the Centers for Disease Control and There are essentially two kinds of people working in Prevention (CDC) listen as an organizer with its Flu the advocacy space: organizers and mobilizers. Trends tool. Flu Trends aggregates Google search in- quiries to make pretty accurate predictions about flu activity. So, when there’s an uptick in searches for Organizers bring people together and create com- “flu” in a region, Google compares those searches munity among the people they gather. They are the with traditional flu surveillance systems and can pro- folks who hand out flyers, canvass door to door, vide predictions of where, and how severely, the flu and organize meetings at local recreation centers. might strike. The CDC can then warn doctors and Their mission is to create community among neigh- help regions prepare for the impact of the outbreak. bors and elevate the needs of the community, and then work alongside the community to address those Public health advocates without access to Google’s needs. Mobilizers, meanwhile, aim to attract partic- resources also can utilize social media to function ipation as part of a larger advocacy campaign, of- as organizers. When childhood obesity advocates fering potential participants an inspiring set of goals wanted to spread the word about the importance set by others, along with a clear way to help achieve of healthy school snacks and beverages in spring those goals. 2013, they held weekly Tweet chats using the #Food- Fri hashtag. During the chats, experts responded to Although they operate differently, both organizers questions with information as to why improved nu- and mobilizers are essential for advocacy. Public trition standards for school snacks are so vital for health history is full of stories of both types of grass- kids’ health, and members of the public had an easy roots success. Organizers have the pulse of the needs way to join the conversation. of communities, while mobilizers can generate the mass support that often is needed to move an issue Public health mobilizers, meanwhile, often use so- forward. cial media to scale an advocacy campaign. Petition- based Web sites, such as Change.org and Care2, allow users to mobilize significant public support for Engagement Strategy Should Dictate Use of Social an advocacy effort in a centralized place. Mean- Media while, utilizing Twitter, Facebook, Pinterest, and Social media can be overwhelming. Fit your mes- other channels to broadcast messages that include sage into 140 characters on Twitter! Use pictures specific calls to action can generate additional pub- on Pinterest! Do both on Facebook! But the basic lic support. approach to public health advocacy is not different in the age of connectivity. Although the way to lis- In summer 2012, mobilizers turned to social me- ten and deliver the message has changed, the overall dia to boost support for the plan of New York goal remains the same: help people to take action to City’s mayor, Michael Bloomberg, to limit the size support a useful shift in policy. In order to success- of sugary drinks sold in many city venues to sixteen fully merge social media and grassroots advocacy, it ounces. Bloomberg’s proposal had generated major is important to function as both an organizer and a backlash from the restaurant and beverage indus- mobilizer. tries, and the public health community needed to send messages of support for the plan to the city’s An organizer needs to scale the way a community Board of Health. Working with a New York–based working on an issue comes to know each other. Pub- leader from our PreventObesity.net network, Net- lic health organizers can leverage social media to lis- centric Campaigns utilized Change.org, Twitter, and ten loudly and gather lots of community input into Facebook and generated roughly 25,000 messages a discussion of health policy and better understand of support.

National Civic Review DOI: 10.1002/ncr Spring 2014 61 PreventObesity.net is a unique advocacy network edge and scientific expertise needed to advance the that functions in both the organizing and mobiliz- issue. However, to ensure it would be successful, ing role. For example, a weekly newsletter serves those organizers needed the help of mobilizers. to connect the network’s more than 3,200 advocacy leaders, who also regularly interact with one another Mobilizers across the childhood obesity movement at conferences and other events. Meanwhile, those utilized the power of the online space to send mes- leaders are able to access a grassroots supporter e- sages to the USDA backing the proposed nutritional mail list of more than 300,000 people to mobilize guidelines. They posted action alerts and online peti- public support for specific, large-scale campaigns. tions to gather names and letters of support, spreading the word on social media Web sites such as Twit- In 2013, the US Department of Agriculture (USDA) ter, Facebook, Pinterest, and even LinkedIn. unveiled proposed nutritional guidelines for snacks and drinks sold in schools and opened a sixty-day By working together, organizers and mobilizers public comment period to gather feedback. Health gathered nearly 250,000 letters of support to send experts considered these guidelines crucial to the ef- to the USDA. As a result, the USDA announced its fort to reduce childhood obesity rates, as students interim final rule for school snacks and beverages in consume up to half of their daily calories at school. June 2013.

Organizers and mobilizers needed to work together to ensure the USDA would take the next step and Marty Kearns is the founder and president of Netcentric Cam- implement the guidelines. paigns, a nonprofit that transforms advocacy for foundations and nonprofits by building networks of people to move In this case, the organizers were the public health change forward. experts who had spent decades lobbying the federal Elizabeth Brotherton-Bunch is content strategy manager for government to create guidelines for school snacks Netcentric Campaigns. and beverages. They had the on-the-ground knowl-

62 National Civic Review DOI: 10.1002/ncr Spring 2014 What Can Federal Officials Do to

Support Healthy Communities? BY REGAN CRUMP

As a federal public health official who has been observ- ings and practice exchange convenings to sup- ing, learning about, and contributing to the Healthy port healthy communities—these are strategies that Communities movement since 1998, I am convinced work. that although we have had mixed results with a variety of challenges, we have made some significant In 1999, a group of managers in the HHS at- progress. What is most exciting now is the emerg- tended training on enlightened leadership led by ing array of opportunities to bring better health to Doug Krug, author of the books Enlightened Lead- more people at a lower overall cost when we all ership (1994, with Ed Oakley) and The Missing work together. In this article, I review several exam- Piece in Leadership (2012). We learned principles ples of alliances that worked, propose a way to over- and practices to use in our own signature style to come some of our perennial challenges, and clarify run more effective campaign style meetings, develop what can be harnessed to catalyze more meaningful bold goals, and enroll six hundred communities in planning, more powerful joint investments, and sus- a partnership called the Campaign for 100% Ac- tained action for the benefit of the American people. cess and 0 Disparities. The practices refined by Den- Past experience suggests that continued public sector nis Wagner of HHS were simple concepts, such as engagement and a resurgence of our nation’s twenty- “framing” to gain participant agreement on using five-year-old Healthy Communities movement will an open “yes and” mind-set as opposed to a “yes contribute even more to the prosperity of our nation but” mind-set during meetings, always harnessing than many imagine possible. the “Net Forward Energy” in conversations, and acknowledging the power of an “abundance” perspec- What Has Worked tive rather than the stagnation of a scarcity perspec- In 1998, federal officials in the Department of tive. We agreed to always conduct real work when Health and Human Services (HHS) were deeply convening—real work consisting only of making of- involved with the Coalition for Healthier Cities fers, making requests, making commitments, or de- and Communities. I represented the Health Re- livering on commitments. Our campaign approach sources and Services Administration (HRSA), along was to identify communities that were successfully with colleagues from the Office of Disease Pre- eliminating disparities or increasing access to care vention and Health Promotion (ODPHP) and the without new assets and have them serve as bench- Centers for Disease Control, on the Coordinating marks, inspiring other communities that wanted to Council for the Coalition. The national coalition replicate that success in themselves. We used a lim- was an organization composed primarily of pri- ited amount of federal funds to orchestrate “perfor- vate sector leaders, including state affiliates and mance partnerships” to coordinate the campaign for over a hundred community-based coalitions. The a set number of communities. Incentivized commu- ODPHP developed a publication on healthy com- nity groups started by developing a clear but auda- munities, the HRSA and CDC purchased and dis- cious goal (the what), followed by developing broad tributed community dialogue guides developed by agreement on “the how.” This approach won the the coalition, and HRSA awarded a grant to sup- Business Solutions in the Public Interest Award in port coalition efforts in public health and brought 2000 through a competition sponsored by the Gov- a number of community-based organizations with ernment Executive, Visa USA, and US Bank. The use grants into healthy community coalitions. Build- of this “signature style” for conducting meetings, ening public-private coalitions that leverage federal, rolling communities in campaigns, setting clear and state, and local investments; producing standard- audacious goals, and use of community benchmarks or process-setting publications; conducting train- is a strategy that works.

C⃝2014 Wiley Periodicals, Inc. Published online in Wiley Online Library (wileyonlinelibrary.com) A Publication of the National Civic League National Civic Review ● DOI: 10.1002/ncr.21181 ● Spring 2014 63 From 2001 through 2005, the Healthy Communi- prevention of substance abuse for all youth in addi- ties Access Program (HCAP) was funded by HHS. tion to the beneficiary population that each partici- It provided assistance to communities and consor- pating organization is responsible for serving. What tia of health care providers to develop integrated works is their determination to build a broader community health care delivery systems and coor- health and wellness sector and focus national public dinated health care services for individuals who are attention and effort on the health and prosperity of uninsured or underinsured. This program spawned our nation. We can all aspire to America being the 193 healthy community coalitions that provided ac- healthiest nation in the world by 2025. cess to care for over 500,000 uninsured individuals. As the program drew to a close, federal officials and private sector organizations active in the HCAP Health is both a national security issue and a na- program met to devise an approach that would sus- tional imperative. tain the effort with an emphasis on health, wellness, and equity. That led to formation of Communities Joined in Action (CJA). The mission of CJA is to mobilize and assist community health coalitions in their pursuit of better health for all people at less cost. Overcoming Challenges and Seizing Opportunities This private, nonprofit membership organization The Affordable Care Act presents state and local has enrolled nearly 200 community health coali- health system leaders and healthy community ad- tions, each committed to improving health, improv- vocates with one of the greatest opportunities for ing access to care, and eliminating disparities in their advancing health and wellness since the advent of communities. CJA facilitates rapid dissemination of Medicare. It also challenges us to overcome the innovations across communities, provides access to heightened competition and political divisiveness so technical resources and peer mentors from model that public and private sector organizations can communities, and hosts conferences for sharing of leverage social, economic, education, housing, recre- best practices. This type of networking, technical ation, and health-related resources for healthy com- assistance, and knowledge transfer function works. munities and a healthier nation. For information, go to: http://cjaonline.net. Collaboration between public and private sector The Federal Health Futures Group is a cadre of as- organizations has been challenged by overly cau- pirational and strategic thinkers from the US Air tious interpretation of regulatory limitations, by pri- Force, Army, Navy, Public Health Service, HHS, and vate sector mistrust of government intentions, and the Veterans Health Administration who meet and through disruptive changes in policy and organi- plan regularly. For several years, they have envi- zational position when leaders change. These chal- sioned strategic approaches to optimal US health lenges have been overcome when there was mutual twenty to thirty years ahead. By 2012, the group clarification of common goals, unification of politi- had evolved to include participants from the Office cal will, and the occasional signed memorandum of of Personnel Management, the Office of Manage- understanding. ment and Budget, and several private sector leaders outside the health sector. They began taking proac- Coalitions of Healthy Communities have proven tive steps to realize the optimal future. During an very helpful in sharing lessons learned, technol- April 30–May 1, 2013 Interagency Health Leader- ogy solutions, and the provision of mutual sup- ship Roundtable attended by eighty national health port. They often have struggled with funding sector leaders, there was agreement that health is because public and philanthropic investors de- both a national security issue and a national im- mand tangible results from the coalitions instead perative. Participants agreed to work together on: of acknowledging the qualitative and quantitative (1) moving the national conversation from health impacts of the individual organizations and local care to health and wellness; (2) aligning a cohort collaboratives these coalitions support. National of meta-leaders in the federal health sector; and prosperity demands that the public sector join in (3) promoting healthy eating, physical fitness, and sustaining the convening, knowledge transfer, and

64 National Civic Review DOI: 10.1002/ncr Spring 2014 mutual support that has served healthy communi- ● Advancing the Movement—www.advancingthe ties so well so far. movement.org ● Communities Joined in Action—www.cjaonline. Federal and state programs for recreation, nutrition, net housing, education, health, and safety have a clear public purpose: to serve the taxpayer citizens of their Our country would be well served if everyone read- jurisdictions. In service to our democracy and our ing any article in this special issue were to align people, governments need to align those public pur- forces around a “National Wellness Agenda” built poses with the will and declared need of communi- from guidelines and objectives in the National Pre- ties. We cannot afford to use authority, power, and vention Strategy, the National Quality Strategy, position in a way that separates government from Healthy People 2020, and the National Stakeholder communities and the people. Realizing that our pur- Strategy of the NPA. Taken together, these doc- pose as government officials is to use the resources uments provide a road map and a scorecard for entrusted to our care for bettering the life, liberty, healthy communities, healthy states, and a healthier happiness, and health of the American people re- nation. We actually can achieve the vision of being quires a closer connection and acceptance of com- the healthiest nation on earth by the year 2020 or munity engagement. 2025 if we collectively commit now, make offers of assistance to like-minded people and organizations, Opportunities to Harness Going Forward make requests for the resources and policies that We need to unleash the evolving cadre of collabora- are truly needed despite previously perceived bound- tive or meta-leaders in the health and wellness sector aries, and simply deliver on all the commitments to build bridges, partnerships, and coalitions and to made to commonly held objectives. Having worked catalyze the revitalization of the Healthy Commu- with federal officials in HHS, the Department of nities movement. These leaders are both in govern- Defense, Department of Education, Department of ment and in the private sector. You can identify col- Housing and Urban Development, and now in the laborative health and wellness meta-leaders by their Department of Veterans Affairs, I know that the ability to lead, leverage, negotiate, and drive posi- best public service is servant leadership, grounded in tive action and population health outcomes across our values and American dream, achieved through organizational boundaries. We need to support the civic action on clear goals that can be achieved only “Wellness Initiative for the Nation,” which is fo- by working together. There is no better time than cused on enabling community success, creating well- now! being, human flourishing, and national prosperity. Human flourishing as described by the Samueli In- stitute is what healthy communities seek for resi- References dents. Core components of human flourishing in- Antonovsky, Aaron. 1979. Health, Stress, and Coping. San clude psychological resilience, social cohesion, op- Francisco: Jossey-Bass. timal nutrition, safe substance use, regular physi- Krug, Doug. 2012. The Missing Piece in Leadership: How to cal exercise, and optimal sleep. The evolving “Well- Create the Future You Want. Aurora, CO: AMP Press & Mile ness Initiative for the Nation” will strive for Aaron High Press, Ltd. Antonovsky’s (1979) “salutogenesis,” an approach Oakley, Ed, and Doug Krug. 1994. Enlightened Leadership: focusing on factors that support human health and Getting to the Heart of Change. New York: Fireside. well-being rather than on factors that cause disease. Samueli Institute. 2013. “Annual Report 2012.” Alexan- dria, VA: Author. https://www.samueliinstitute.org/ Going forward, we need to support and consider file%20library/about%20us/samueli 2012 annualreport how to align healthy community and health equity final web.pdf. collaborative networks such as these:

Regan Crump, DrPH, is director, Office of Strategic Planning ● National Partnership for Action (NPA) to and Analysis for the Veterans Health Administration, Depart- Achieve Health Equity—http://minorityhealth. ment of Veterans Affairs. hhs.gov/npa/

National Civic Review DOI: 10.1002/ncr Spring 2014 65 The Futures of the Healthy Cities

BY CLEM BEZOLD and Communities Movement AND TREVOR HANCOCK

The Healthy Cities and Communities approach is an the good news, the bad news, the same old news, exercise in futures thinking; at its best, it asks and some form of transformative change. the deceptively simple question—“What would our 4. The preferable future, the way we would like the city/community be like if it were more healthy?”— future to be for ourselves and our descendants. and then sets out to answer that question by estab- Usually it is either one of the plausible scenarios lishing a vision of a preferred future and working to or, more often, a combination of elements from create that future. two or more scenarios; our preferences express our values. The Healthy Cities and Communities movement around the world brings together local leaders and In our thirty or more years of working as health organizations to pursue better health in their com- futurists, sometimes together, we have focused on munities. Better health involves equity, sustainabil- these latter two: exploring alternative scenarios of ity, and participatory governance. It also requires plausible futures and helping people create visions the recognition that, according to the World Health and scenarios describing their preferred future. We Organization, health, particularly the social deter- use these two approaches because we believe that if minants of health, is shaped by the distribution of people explore and understand some of the forces money, power, and resources at global, national, that shape us and the range of alternative futures we and local levels. The forms that these local efforts face, they are better able to make choices about their have taken over the course of twenty-five years vary own future and then work to create it. In this article, widely, as do their funding, duration, focus, and re- although somewhat constrained by space, we do the sults. Yet as the articles in this issue of the National same for the Healthy Cities and Communities move- Civic Review reveal, they have done many good and ment as a whole. some amazing things in those years. So, what might this movement accomplish in the next twenty-five years, and what are some of the challenges and op- Major Forces Shaping the Future portunities it might encounter? One of our guiding principles has always been that the tail does not wag the dog; the health care system In a nutshell, there are four sorts of futures: in the future, for example, will reflect the society of which it is a part. So, a high-tech society will have a 1. The probable future, what most people and orga- high-tech health care system, while in a declining or nizations think will likely happen, often described collapsing society the health care system will also be as “business as usual,” in which life continues declining or collapsing. The same is generally true much as it is, but more so. (However, in some for the Healthy Cities and Communities movement; cases, the probable future is seen as more of a it will reflect the state of society, the value thatso- gloom-and-doom or even doomsday scenario.) ciety places on health, the health status of the soci- 2. The possible future, all the things we can dream ety and community, and especially the state of cities of, our flights of fancy, often straining the lim- and local governments. Changes to these parame- its of imagination, even defying the known or ac- ters over the next few decades constitute the driving cepted laws of physics; think science fiction. forces that the HCC movement will need to address, 3. The plausible future, a narrower zone within the accommodate to, and, perhaps, shape. realm of possible futures, more constrained by what we think is reasonable but well beyond What are the forces that will shape the Healthy what we think is probable. Usually, a set of quite Cities and Communities movement? While there is detailed scenarios are developed that range across always great uncertainty, especially looking far out

C⃝2014 Wiley Periodicals, Inc. Published online in Wiley Online Library (wileyonlinelibrary.com) 66 National Civic Review ● DOI: 10.1002/ncr.21182 ● Spring 2014 A Publication of the National Civic League into the future—twenty to thirty years or more— ● Employers and businesses seeking better health some of the major forces are readily apparent: conditions for their employees because it makes good business sense ● Societal forces such as population growth, urbanization and the growth of slums, housing condi- In the United States, some unique developments are tions, and food security worth noting: ● Economic forces such as economic growth and in- equitable income and wealth distribution ● Nonprofit hospitals and health care providers ● Environmental forces such as climate change and providing support for healthy community efforts, loss of biodiversity often as part of their required local community ● Political forces of concentrated power yet growing benefit contributions. participation and disruption ● Support for HCC efforts by national founda- ● Technological forces including, ultimately, sus- tions, such as the Robert Wood Johnson Foun- tainable renewable energy production and stor- dation and the Kellogg Foundation, as well as age, smarter Internet, and social media local foundations, particularly “conversion” foundations (those endowed by the proceeds of While many of these effects are negative, cities the sale when a not-for-profit hospital is sold to also represent tremendous opportunities to improve or converted to a for-profit entity). health. They are generators of economic opportunity and sources of innovation and creativity, and What this all means for cities and for the health of their concentration and population density enable their populations will depend on how cities, their them to be generally more environmentally sus- governments, and their citizens respond to these tainable on a per capita basis and to provide ser- challenges and opportunities. It will also depend on vices efficiently. Indeed, it is worth recalling that how regional and national governments, the private in many cases—from anti-tobacco laws to sustain- and nonprofit sectors, and international organiza- ability, from taking action on fast foods to partici- tions respond. patory budgeting—it is the cities that have led the way, not provincial/state or national governments. Scenarios for the Healthy Communities Movement Cities often are the incubators of social and po- In this section, we suggest how cities and the litical change; they take global thinking and act Healthy Cities and Communities movement might locally. respond to a couple of different, plausible—but not preferable—futures. At the end, we discuss how we Positive trends that we see occurring now in leading hope it will respond—that is, our vision for a health- cities and that are likely to grow include: ier future. We do so by using the aspirational futures approach developed by the Institute for Alternative ● The realization that “healthy community” efforts Futures in the 1980s in conjunction with Trevor can prevent, slow, or at times reverse the increas- Hancock. This approach calls for an “expectable” ing prevalence of chronic disease and the epidemic or “most likely” scenario that extends present trends of obesity and their increased costs into the future; a “challenging” scenario that ex- ● More health-conscious political leadership in plores some of the things that could “go wrong”; communities and one or sometimes two “surprisingly successful” ● The growing awareness, at least in some sec- or “visionary” scenarios. tors, of the importance of equity or fairness, including health equity—healthy community efforts Scenario 1: Most Likely/More of the Same: The Healthy move upstream to shape the social determinants Communities Movement Is Getting By of health Given the array of negative forces noted earlier, the ● An understanding of the health implications of prospects are not good for the populations of many unsustainable development cities, especially the poor populations and those ● A broadening of the ideas of participatory democ- who live in the cities of low- and middle-income racy, including the use of social media countries. They will continue to face significant

National Civic Review DOI: 10.1002/ncr Spring 2014 67 environmental, social, and economic challenges. Yet do not succeed. In the face of this declining ca- even in the wealthier countries, cities will face many pacity, the city fractures into well-off, walled-off of these same challenges. Some will manage these communities and the rest; the middle class is essen- challenges well; others will not and may even suc- tially hollowed out, and society becomes quite polar- cumb to them. ized. The poor and the underemployed are kept de- pendent and subservient and distracted with social media and other means of entertainment (a classic Strong political leadership, inspired community ac- bread-and-circuses approach first perfected by the tion, civic-minded private sector investment, and Romans two thousand years ago). This approach is committed nonprofit, faith, and academic organiza- complemented by a strong authoritarian and repres- tions can create pockets of excellence and best prac- sive regime, including the extensive use of electronic surveillance, that keeps the lid on most social un- tice that others can emulate. rest most of the time. Those who can do so, leave— the rich to better places, the poor to the country- side, where they hope to grow their own food, find But the good news is that cities can respond effec- water, and the like. Moving back is easier in the re- tively to these challenges. Strong political leader- cently urbanized cities of low- and middle-income ship, inspired community action, civic-minded pri- countries, where these populations still have some vate sector investment, and committed nonprofit, rural connections and related skills. For the long- faith, and academic organizations can create pock- urbanized underclass in the cities of high-income ets of excellence and best practice that others can countries, however, getting out is more difficult, if emulate. Examples abound of empowering and mo- not impossible. bilizing communities to create effective community economic and social development initiatives; of de- In such a situation, there is little or no support for a veloping public policies that favor the disadvantaged Healthy Cities and Communities approach. If there by ensuring that basic needs are met for all, that is, it is largely subverted to be a protective man- create environmentally sustainable urban develop- tle for the rich, aiding and abetting the repression ment, and that establish supportive environments and social control needed to keep the elites safe and for health; and of creating meaningful, healthy work healthy. Concern for social and health inequality is that pays a decent wage. minimal, and the last thing the elite want is an empowered and mobilized underclass; they want the However, in this scenario, these initiatives remain underclass pacified and repressed instead. Ecological the exception rather than the rule, isolated initia- sustainability is also subverted, conserving resources tives born of unique circumstances and special peo- so they can be used by those who can afford them; ple, beacons of hope, but not taken to scale, not they cream off the best while ensuring there are just widely disseminated or adopted systematically and enough of the poorer-quality resources (food, water, supported nationally or by provincial or state gov- materials) to keep the underclass satisfied. ernments. In such a situation, the Healthy Cities and Communities movement remains underfunded, In such a future, international institutions and net- somewhat marginalized, and trying hard with very works will be concerned largely with managing limited capacity to nurture and disseminate the in- crises, preventing massive social unrest, and control- novations that seem to work or have promise. There ling migration from damaged to less-damaged na- is no strong national or international network or or- tions and regions; there will be no appetite for move- ganization, so lessons are not easily transferred from ments such as HCC. one part of the world to another or even from one city to another within the same country. Scenario 3: Surprisingly Successful/Visionary: The Healthy Communities Movement Is Flourishing Scenario 2: What Healthy Communities Movement? National and provincial/state governments around In the face of multiple challenges and crises, cities the world catch up with the cities, which have struggle to maintain even basic services—and many had a strong emphasis on measuring quality of

68 National Civic Review DOI: 10.1002/ncr Spring 2014 life rather than economic development. Governance healthy communities—these include urban gar- at all levels becomes human-centered and ecolog- dening, aeroponic household food production, co- ically bound, with the approach being the maxi- production/time-dollar exchange of time/services, mization of human development and social equity and growth of local and alternative currencies. within the constraints of natural ecosystems. Lo- cal economies move toward self-sufficiency and co- In such a context, the Healthy Cities approach be- production. Cities adopt the best practices gleaned comes central to the governance of cities and of from the first twenty-five years of experience inthe nations. National and provincial/state governments global HCC movement: strongly support this approach without imposing it, which would be counter to the entire ethos of ● A Healthy City plan created by municipal gov- the approach. They support and fund the creation ernments in partnership with private, nongovern- of arm’s-length regional, national, and international mental, faith, academic, and other sectors brought networks that are often but not always aligned with together in a municipal Healthy City Leadership or part of municipal associations. These well-funded Council. networks act as facilitators, coaches, and knowledge ● A Healthy City Office within city government brokers, sharing best practices widely and undertak- to support a whole-government approach across ing evaluation and performance improvement. municipal government that facilitates health impact assessments and the creation of healthy public policies. Conclusion ● Support for local Healthy Community/Neighbor- hood organizations, especially in disadvantaged We cannot predict the future, nor can we fully con- communities, that bring people together to im- trol it. However, the future does not just happen to prove the conditions for health in their own com- us. We are not victims of the future, but together munities. we are shapers of our own futures. What can we ● Participatory democracy using social media and do to make the “preferred future” more likely? The the crowdsourcing of policy; participatory bud- Healthy Cities and Communities movement needs geting is adopted by many communities with regu- to take a long, hard, realistic look at the future chal- larized input and a growing percentage of citizens lenges we face, then create a vision—remembering taking part. that “Vision is values projected into the future”— ● As advanced economies transform and many and work, along with others whose values and vi- jobs are lost to automation and expert sys- sion are aligned, to create more sustainable, more tems, alternative economics emerge that reinforce just, and healthier communities.

Table 1. Proportion of Population Urbanized (2012 and 2014) and Proportion of Urban Population Living in Slums or Informal Settlements % Urban % Urban % Current/Recent Region Population 2012 Population 2040 Urban Population in Slums Global 53 64 36 Latin America 79 85 24 North America 82 87 6 Europe 76 80 6 The Arab World 57 66 n/a China 52 73 29 Sub-Saharan Africa 37 51 62 India 32 46 29

Sources: World Bank Data—Urban development (2013); United Nations, Department of Economic and Social Affairs, Population Division (2012); WHO and UN Habitat (2010); Urban Trends: 227 Million Escape Slums; Based on UN Habitat data for “developed regions.” Source: WHO and UN Habitat (2010); Millennium Development Goals Database, United Nations Statistics Division; UN Habitat. State of the World’s Cities 2010/2010/2011; Millennium Development Goals Database, United Nations Statistics Division.

National Civic Review DOI: 10.1002/ncr Spring 2014 69 References WHO and UN Habitat. 2010. “Hidden Cities: UN Habitat Millennium Development Goals Database, United Na- Data for ‘Developed Regions.’” http://www.hiddencities.org/. tions Statistics Division. Slum population as percent- World Bank Data—Urban Development. 2013. http://data. age of urban, percentage. http://data.un.org/Data.aspx?d= worldbank.org/topic/urban-development. MDG&f=seriesRowID%3a710. UN Habitat. State of the World’s Cities 2010/2011. Ur- ban Population Living in Slums. 1990–2010. http://www. Clem Bezold is chairman and senior futurist of the Institute unhabitat.org/documents/SOWC10/L7.pdf. for Alternative Futures. United Nations, Department of Economic and Social Affairs, Population Division. 2012. “World Urbanization Prospects: Trevor Hancock, one of the founders of the Healthy Cities The 2011 Revision.” http://esa.un.org/unpd/wup/CD-ROM/ and Communities movement, is a public health physician and health promotion consultant and currently a professor and Urban-Rural-Population.htm. senior scholar at the new School of Public Health and Social Urban Trends: 227 Million Escape Slums. http://www. Policy at the University of Victoria unhabitat.org/documents/SOWC10/R1.pdf.

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