Aiken, South Carolina:
A case study of community transformation

by Joe Flower

This article was published as part of The Healthcare Forum's study, "Emerging Best Practices in Partnerships to Improve Health," funded by The California Wellness Foundation.
International Copyright 1996 Joe Flower All Rights Reserved
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Karen Papouchado nearly lost her job early on, and Steve Thompson, the city manager, has taken some hits due to the various controversies the effort spawned. But they do the right thing anyway.

Things were falling apart
and babies were dying.

Things were falling apart and babies were dying in Aiken, South Carolina. And people wanted to do something.

Aiken is a charming Southern town of 20,000 not far from the Savannah River, on the Georgia border, a town of grand historic districts and lanes under arching live oaks. It had long been a winter place for the rich of New England, with soil that was considered "perfect for horses' hooves." The town is still peppered with Goodyears and Whitneys, and still is known for its polo grounds and horse tracks.

Overlay that with nuclear physicists: in 1952 the U.S. Atomic Energy Commission, forerunner of the Department of Energy opened the sprawling Savannah River Site nearby as a place to manufacture nuclear materiels. It grew in time to become the state's single largest employer, with 26,000 workers spread over its 300 square miles. For nearly 40 years, it was the mainstay of the area's economy, and the influx of Ph.D. scientists and engineers, and their college-educated spouses from across the nation changed the culture. The town had always been warm, now it became sophisticated as well.

For most of the same 40 years, the same mayor and city manager ran the quiet municipality. Things were tranquil and life was good.

But the turn of the 1990s brought a different kind of news. The Cold War ended, and suddenly the Savannah River Site, now run by Westinghouse, started laying off people. By 1996 half of its work force was gone, and many of the rest were employed not in nuclear weapons manufacture, but in environmental restoration of the vast site, nearly pristine between the widely-separated reactors, factories, and toxic waste dumps.

Several other things happened at about the same time. The state Department of Health and Environmental Control looked over its statistics and saw that Aiken was among the worst counties in the state in infant mortality rates. And both the long-time mayor and the city manager retired. City governance was turned over to fresh new hands. "It was a shock when the local leadership changed" in the midst of so much turmoil, according to Barbara Strack, a local writer. "It was time to take measures to make sure that the town didn't get ruined. I don't know how many communities get that clarion a call."

Out of these disparate roots rose two separate efforts that coalesced in time to form a revolution for Aiken. As Karen Papouchado says, "The movement was truly organic and real."

In fact, we can start the story with Papouchado. In 1989, the state Department of Health and Environmental Control (DHEC) ranked the counties of South Carolina by their infant mortality rates. Aiken was the sixth worst, at 12.1 per thousand live births, far above the national average. DHEC put a grant together and looked for a local partner. They found that the local Mental Health Foundation, with Papouchado as chair, had widened its mandate to include the problem of children having babies. So they gave the foundation a grant with few instructions beyond "see what you can do about this problem."

What she did was establish the Infant Mortality Task Force. The task force did three things right out of the box. The first was to establish a Fetal and Infant Mortality Review (FIMR) board to review every baby's death. The second was a 12-page survey of 477 new mothers that turned up some sobering numbers. Nearly 60 percent of the new moms did not want their babies, 43 percent claimed to have been using birth control at the time of conception, 16 percent were under 18, 50 percent were on Medicaid, 33 percent had not had adequate prenatal care, and 10 percent of the babies were underweight.

The third assessment tool was the one that almost cost Papouchado her job. With the help of a professor at USC-Aiken, the task force sent a number of students into Aiken's public clinics asking for pregnancy information and testing. They wrote down the details of what happened to them -- every indignity, delay, and unnecessary roadblock from the demoralized under-funded staff -- and Papouchado reported what she found.

The nurses and clinic
managers were furious.

The nurses and clinic managers were furious. Yet she was truly on the clinics' side. "People weren't getting the care they needed," says Papouchado (now Mayor Pro Tem), "because the clinic staff was depressed, and felt it had no support from the community." The Health Department retrained the workers, and the Task force organized a public/private partnership to refurbish the clinics.

The task force's tactics for dealing with the appalling reality that they saw ranged from the classic, such as public information campaigns, better conditions at the clinics, and aggressive case management, to the innovative, such as pre-natal ID cards, and a 24-hour pregnancy line.

The city had already started a "community-oriented policing" (COPS) program, putting pairs of cops on bicycles in one high-crime community, on a regular basis, so that they could get to know people. That worked so well -- with drug use dropping 46 percent and violent crimes dropping 70 percent in that neighborhood in one year -- that they expanded the program to another neighborhood and to the downtown area. They found apartments for several officers in the projects themselves, while others serve as substitute teachers in the public school system.

Then the task force recruited them for a critical task: identifying pregnant women and giving them a little information about the pre-natal care that was available. For every 10 women referred, the officers got a free dinner at one of the town's better restaurants. The program was called "COPS and Moms."

"Once you get policemen back in the community, even living in the projects," says Barbara Morgan, "you increase the care and commitment level." Morgan is the Solicitor in Aiken, in effect the District Attorney for a three-county area, and is now the chair of the task force. She came to realize that health was part of her job as she prosecuted more and more child abuse cases. She is hardly soft on crime: she has sent two murderers to the electric chair, and another to a sentence of life without parole, in the past two years. Yet, to her, the involvement of law enforcement in the nurturing activities of the task force takes no great leap of imagination. "It's a natural progression. No one has to argue the causation here. Monsters do not spontaneously generate. You have to try to have an impact on the front end."

By 1993, when the rest of the strategic planning process was still gearing up, Aiken's infant mortality rate had dropped 40 percent to 7.2. The group's goal was 5.0, the level maintained by Japan.

But it was not enough. Infant mortality, though serious in itself, is truly a red flag of deeper social problems. State statistics showed that Aiken County, with its 120,000 population, was the worst in the state in reports of child abuse and neglect, and in the proportion of children in foster care. The state as a whole was the worst in the country in infant mortality, and ranked 49th in SAT scores.

So by 1992 the task force had already expanded its original mission -- to focus not only on infant mortality, but also on domestic and child abuse, teen pregnancy, the lifestyle choices of young people, and poverty -- and changed its name to "Growing Into Life."

The other half of the story began in 1992, with Steve Thompson, the new city manager.

He didn't have to
convince anyone
of the need to do
something different."

"He didn't have to convince anyone of the need to do something different," says Papouchado. "It was pretty clear."

Rock Hill, South Carolina, had recently gone through a strategic planning process, and it had worked so well that the city manager had quit to start his own consulting firm. The City of Aiken organized a field trip, inviting 40 citizens from business, education, government, faith groups, media, and minority groups to travel the 100-mile width of the state to the North Carolina border for a two-day retreat to take a look at what Rock Hill had done. This "Steering Committee" liked what they saw so much that the City of Aiken hired him, to the tune of some $40,000 over three years, to help them do the same. The city's budget for the entire process was over $100,000.

Strategic planning, traditionally, is a simple process, involving just the top people in the organization, the finance department, and maybe a few consultants. This would be different. Called "Planning Today For Tomorrow," the three-year effort would involve over 300 citizens on 12 committees doing six-month studies of such areas as economic development, education, community building, senior life, safety, the environment, and culture. Growing Into Life became the health arm of the planning effort.

"It comes down to your old-fashioned networking," according to Strack. As Papouchado puts it: "This stuff comes right out of kindergarten -- you've got to like these people, you've got to be friends with them. You don't have to like everybody, but have to have enough friends that other people don't want to be left out. You establish personal relationships, you work by obligations. People who know how to make things work will know what I'm talking about. You work through the 200 or 300 people you know, no matter how big the town is. You do that, and it's not that hard to get these things accomplished."

"But networking by itself was not enough. In the end, only about one third of the group was invited by city officials. The other two thirds called in response to ads that the city put in the paper explaining the project and asking for volunteers.

"A lot of diversity came from those ads," says Strack. The African-American community showed up in droves, and the Hispanic community turned out to be larger than anyone suspected. It had grown rapidly since the last census, and was well-dispersed throughout the community. The newly-arrived Hispanics thought of Aiken as "heaven on earth," says Strack -- friendly, safe, and free of discrimination.

In the end, everyone was involved, African-American, Hispanic, white, school kids, homemakers, entrepreneurs, seniors, city officials. The group even consulted a prisoner for his ideas on crime prevention.

Once the 25-member committees were filled, scores of other people demanded to know why they had not been included -- and they soon were put to work.

A town document describes the liveliness of the ensuing process:

The groups developed very individual leadership styles. Some met before 7 a.m. every week; some needed food and drink to keep them going in the afternoons; and others scurried from work and soccer practice to make evening meetings. The groups devoured information and made site visits all over the city and into nearby states. Requests to travel to other countries were cheerfully denied by the city manager. Controversy erupted in almost every group. Members stated that they would walk out if certain subjects were to be considered, and they did, only to come back because they couldn't stand not knowing what was being hatched in their absence. Each committee had co-chairpersons, and the chairs of the Families group nearly came to blows over a basic difference in leadership styles.

While most community partnership efforts work out their shared vision as a whole, in Aiken it was in the individual groups where people did most of the work toward a shared vision. It was the first item on the agenda. This, too, was lively. As the town document puts it:

This aired most of the controversies immediately. What was good health care? Who got it and who didn't? Why couldn't it be like it used to be when Dr. Jones made house calls? Who wants academic tracking? What about cooperative learning? We want neighborhood schools! We don't need industry -- just send everyone who's moved here in the past 5 years away! I won't let you talk about recreation until you give me more facilities in the minority section.

In the end, each committee came up with a shared vision. For the battling Families group, it took a visit by Papouchado and one of the co-chairs to a national meeting at Jimmy Carter's Interfaith Health Studies Center in Atlanta before they could all see eye-to-eye on the role of religion in Aiken's future. But eventually they, too, found consensus.

After many months of work, the Planning Today For Tomorrow task force brought forward scores of separate, specific goals -- such as "cut teen pregnancy by 50 percent," "construct a Visitors Reception Center," and "build a back entrance to the airport" -- grouped in four general categories:

Each group of goals listed specific actions, along with which organization or partnership took responsibility for that action (such as "City and county: renovate Farmers' Market" or "Aiken Corporation: Construct spec building for Ventures Industrial Park."). The actions and responsibilities were specific enough, and set out clearly enough, that they could be tracked.

In planning actions, says Papouchado, "We tapped into what each group could bring to the table -- the health department is doing this, the hospital is doing that, let's put them together. It was really simple. Everybody had the energy to do something."

The final plan was approved at the opening of a permanent display center downtown, complete with models, video-enhanced drawings, and plans.

To the delight and astonishment of many locals, the action plans are being accomplished. "People come in with their checklists, saying , `This one's done, we're a few months late on this other one.'"

No sooner had the plans been made final than the fund-raising cranked up. The city, the Chamber of Commerce, and the Downtown Development Corporation started Aiken 20/20, pledging to raise $3.5 million in 1994 to start carrying out the plan. By the time the plan entered its public phase in October, 1994, private sources had already pledged over $1.5 million.

It's sustaining
itself, and it's
breeding as it goes."

"People say: you're doing entirely too many things, you can't sustain it," says Papouchado. "But it's sustaining itself, and it's breeding as it goes."

"At times we have had to change our focus," says Strack, "sometimes quickly. We had been focused on domestic violence. Then the state passed a draconian welfare reform law -- two years and you're out, the mother has a job or you're off the rolls -- and suddenly we need to find child care for 800 children, and we have to make sure that kids are not starving on the streets."

Other parts of the project involved a lot of back-and-fill, trial and error, and learning as they went. For instance, "We missed an incredible number of people the first time through," says Papouchado, "especially blue-collar people in the housing projects. We connected with them over the last year and a half through our `Stone Soup' project, which uses John McKnight-style `asset mapping.' We targeted four neighborhoods, sought out and convened people we identified as emerging leaders, trained them, worked with them, and sent them back into the neighborhoods. It really worked. We've adopted into the strategic plan."

Two key people had refused to get involved: the town's African-American obstetricians. They were not hostile to the project or its goals, they just felt that they were far to busy to attend all those meetings. Yet if there was no way to involve them in planning, still there was a way to reach them by action. Growing Into Life simply asked them whether they would like to have a little help: a county nurse working in each of their offices. Their surprised answer was, "Of course." Growing Into Life has had to do without their insight, but it is now working closely with them.

Here and elsewhere, Healthier Communities efforts often serve as seedbeds for other projects. As a spin-off of the Aiken effort, local Hispanics became far more aware of themselves and their needs and capacities. As a first effort, they organized to teach their children English before they reached school age.

"I call these people
`Build Absolutely Nothing
`Anywhere Near Anything.'"

Not that it's all been easy. "Whenever local government is going to be involved, you encounter hornets' nests," says Mayor Pro Tem Papouchado. "We had fire storms more intense than I ever could have imagined. Public art can really sink your ship, for instance. To illustrate the point of creating visual accents scaled for a civic axis, the person doing the computer renditions replaced the little fountain downtown with a big horse statue on a pylon. We were inundated with calls, saying, "Don't move the fountain!" We set to build more bike paths. If anything could be innocuous and safe to be in favor of, you would think it would a bike path. But we got a lot of people that are one step beyond the NIMBYs, the `Not In My Back Yard' folks. I call these people BANANAs -- `Build Absolutely Nothing Anywhere Near Anything.' Every neighborhood had objections. They feared crime, of all things. But we persevered, and now we are building our bike path

"Another part of our plan involved annexation: the city has grown around some `doughnut holes' of unincorporated land. This creates problems for public safety and city services. We got on the wrong side of a local senator, and he was able to block our annexation efforts at the state level. So we just got around it with our terms of service agreements. If any property in those enclaves changes hands, they will have to renew their contracts for public services from the city -- and we won't renew unless they join the city. Our unofficial motto is: `Over, Under, Around, and Through.' If we can't do it one way, we'll do it another."

"Our unofficial motto is:
`Over, Under,
Around, and Through.'"

This flexibility seems key to the whole effort, even when it comes to planning. "We try to have a plan," says Papouchado, "But if someone has energy for something that is a little different from our plan, we'll regroup around that." For instance, one project for bringing Aiken together arose after the planning effort, and is already at work. Two 20-something computer entrepreneurs recently just plopped into town and decided to adopt it. In collaboration with the City of Aiken, they started a local "Intranet" featuring information about the town for residents and tourists alike, and promised to staff it 24 hours a day, making Aiken one of only half a dozen such "wired" towns in the nation. (Go

The task force has quarterly meetings, and out of the meetings the city publishes publish quarterly reports with updates on all the projects.

Monitoring progress is often a continuation and refinement of the original assessment process. In 1996, in fact, Aiken secured a large grant from the March Of Dimes to do a baseline survey of 50 measures from air quality, to the school dropout rate. And the state has asked the original FIMR board to expand its purview to include all deaths of people under 18 years of age in the county.

One task force document summarized three important factors that worked in Aiken's favor: leadership, collaboration, and financing:

Leadership in Aiken is well-defined, with established leaders who are respected and with up-and-coming leaders who are supported because the community knows that sustained change occurs only with leadership that will carry the vision forward. Time-consuming ventures like strategic planning still attract busy leaders because support systems are in place to keep meetings organized, to handle paperwork, and to manage the flow of the project.

The second factor influencing success is collaboration. The Task Force modeled this by creating itself outside of any existing agency or government structure. Led by high-profile health champions and supported by dedicated "worker bees," the Task Force eschewed red tape and solved problems by talking to each other. Small successes led to bigger ones, until now the Task Force is the "grease" in bureaucratic gears. The same paradigm transferred to the Strategic Plan where cooperation showed itself to be non-threatening and even exhilarating.

The third factor is financing. Without funding, plans sit on shelves. The City of Aiken budgeted well for three years of planning, and the other business and industry members contributed generously to implement the vision. Aggressive grant-seeking, partnerships among providers, and in-kind services have added to the resources. When everyone is included from the beginning, everyone seems to have something to offer.

The whole process so far has gone with surprising smoothness. "There have been almost no power struggles," says Strack. "People wind up on opposite sides of various issues, they run against each other for office, but still they know that Growing Into Life and the planning effort are too important to risk."

"Turf issues?" asks Papouchado. "All you have to do is roll over. You can't have a dog fight if one of the dogs rolls over. That's one reason that Growing Into Life is not even incorporated as a 501c3. We can't take the money that would go to another group -- we don't even exist."

"The problem is beyond anyone's turf, so the solution has to be," says Morgan. "If you're not going at it to win for someone or to make someone lose, you can forget the `mud-puddle issues' and get on the solution road. Once you get the taste that you can do something, it gets easy."

"In the early years," says Strack. "the task force moved mountains that they thought could not be moved. `Stop' really isn't in the vocabulary here. People give up and go away, or they come to a consensus. You've got to get along because you will be here for generations -- even those who moved recently just start to take that attitude on. It's almost a re-birth experience -- let's see if we can re-invent ourselves. We won't get another chance."

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