Healthier Communities:

A compendium of best practices

by Joe Flower


From the Healthcare Forum Journal, May-June 1993, Vol. 36, #3.

International Copyright 1993 Joe Flower All Rights Reserved
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"Ask a person what creates health. The answer always starts with what he thinks you expect him to answer: healthy nutrition, clean environment and exercise. But after a while he will also tell you about the importance of joy, love, well-being and quality of life. . . . This list is more or less identical no matter who you ask. You get as far as number 20 or 25 on the list before doctors, hospitals, or the health system in general appears."

-- Healthy City Foundation, Horsens, Denmark

What makes a community healthy?

It's not just doctors and hospitals, skilled medical professionals, the right drugs and the right machines, though these things certainly help a lot. People live longer and healthier lives if they eat a good diet, are well housed, secure from war, crime, and domestic violence, not deranged by drugs or alcohol, if they have plenty of clean water for drinking and washing, if they can breathe clean air, if they have access to basic vaccines and antibiotics, if they can exercise some sense of choice in their lives, and if they have friends and family to give life meaning.

The overall health of a community depends upon factors far beyond medicine, such as how many children people have, at what age and in what kind of families, what dynamics exist inside their homes, how much money and education they have, with whom they have sex and how, and what they do with their sewage.

If we consider ourselves the hospital industry, then perhaps these things are no concern of ours. Perhaps we can just continue to stitch up the victims of the knife-and-gun club on the streets, set the bones of the battered children, and do bypass ops on people who never gave a thought to diet or exercise.

If, on the other hand, this is truly the healthcare industry, the business of caring for people's health, then it is our business to ask, "What can we do?"

Many of these problems have their root in the way the community is put together. Unsafe sex, ruinous drug use, violence, and broken children flourish where the bonds of community have atrophied. Unsafe water, unsafe sewage practices, and air fouled with pollution speak of communities too weak to stand up for themselves.

Of course, some problems, such as diet, can be individual -- and others, such as poverty and war, grow out of dynamics far larger than a community can influence. Yet the best approach to dealing with them is still through the bonds of community, through education and organization, through giving people real choices.

As the Horsens Healthy City Foundation puts it: "In Denmark people are aware of health factors, but we don't act on them. This is important for the information strategy of our project. People's need for health information is not so much for the traditional chemical or biological explanations, or for the moralistic `you must' or `you mustn't.' People need more action-oriented information, such as, `You have a choice to make,' or `Here's something you could do . . .'"

Growing a community is itself a health practice -- no matter what specific issues the community organizes around. The bonds of community make an enormous difference in people's health.

Healthcare institutions can't build the bonds of community for other people. People can only build those bonds for themselves. But healthcare institutions can be catalysts and supporters and links in the net and centers of energy in the work of community building.

Every year, The Healthcare Forum puts out a call for people to tell us what they are doing to build healthier communities. They look for projects that not only improve the health of the people in the community, but strengthen the bonds of community at the same time. This is from their first such search, in 1993. They received an astonishing array of responses from across the United States and from six other countries, from major institutions and small citizens' groups, from city councils and from government projects. Eighty-one came as formal applications for the Healthier Communities Award.

This is the report on that search. It includes ideas from the formal applications, other ideas that people sent, and other projects of which the Forum had heard. We arranged them as exemplars of the eight criteria that the Forum specified for the award. You will find here the best practices that they found in community building. For addresses, telephone numbers and key contacts in each community, click on the project name.

1: Discover just how healthy the community is

Every community has its own set of problems and its own strengths. The first step is to use every tool at your command to assess your community: what works, what's missing.

The HEALTHY CITY FOUNDATION of HORSENS, DENMARK, interviewed 1000 citizens about health and published the results as a book.

In southwest Georgia, the COMMUNITY HEALTHCARE NETWORK used available statistics to search among the yellow pine woods and ramshackle family farms of ten counties, piecing together an appalling picture of the effects of rural poverty: an infant mortality rate twice that of most industrialized nations, and mortality rates from breast cancer, hypertension and diabetes well above the national average -- for blacks, sometimes twice the national average. Access to care was low -- and it was decreasing. Of the three small civilian hospitals outside Columbus, one had been forced to close its doors in 1991, and another offers no obstetrical services.

Two states north, but not so removed at all, up the wandering Roanoke River from Albemarle Sound in the flatlands of northeastern North Carolina, the Area-Wide Health Committee of the CONCERNED CITIZENS OF TILLERY drew a very similar picture from statistics -- high infant mortality, 97 percent African Americans with a median income of $8500, 40 percent of the families headed by single women, 39 percent of the children living in poverty. They combined these with simple observations: most people in Tillery make their living at minimum-wage second- and third-shift factory work, there are no doctors or public health facilities within 20 miles and no public transportation, doctors in the area are white and refuse to physically touch black people, and the industries that the state has lured to the area -- mass hog farming, poultry-processing, a paper mill, a hazardous waste incinerator and a hazardous metals recycling plant -- pour nitrates, dioxins and other toxic chemicals into the air, water and soil.

Solano County, California, was once just as rural, and the parts of the county in the California Delta region still boast some of the richest soil in the world. But in recent years the county has come to be seen as the empty space between the San Francisco Bay Area and Sacramento, the place for suburbia and inner city ills to spill over, and its population has grown by almost half in the last decade alone, to nearly 400,000. The COALITION FOR BETTER HEALTH CARE dug into available statistics (the lowest discretionary income of any county in the state, per-capita health expenditures one-third the state average, four primary care sites for 80,000 poor residents). But the Coalition needed a deeper analyses. Eventually it got help from UC Berkeley's Center for Community Health and its Schools of Public Policy and Public Health, as well as private consultants. Many of the numbers these closer looks brought up (such as: nine Medi-Cal pediatricians for 53,000 children, and more than one quarter of all mothers getting no pre-natal care in the first three trimesters) were even more melancholy.

But the prize for the most rigorous statistical examination of health status might just go to Somerville, Massachusetts, a dense settlement of 76,000 on four square miles bordering Boston and Cambridge, a community that includes over 30,000 Portuguese speakers (17,500 of whom speak little or no English) and some 16,000 recent immigrants from Brazil, other Latin American countries, Haiti, and Southeast Asia. Most speak no English, are undocumented, uninsured, and either unemployed or underemployed. The COMMUNITY HEALTH AGENDA (a joint effort of the Somerville Health Department and the Somerville Hospital) gathered data from public sources, including the Annual Reports of Vital Statistics from the Massachusetts Department of Public Health, other state agencies, the 1990 federal census, and the Massachusetts Health Data Consortium. To this they added Somerville Hospital's own data and the results of a survey of community leaders and health providers. But they filtered and focused the data through APEXPH (Assessment Protocol for EXcellence in Public Health), a process developed by a group that includes the American Public Health Association, the National Association for County Health Officials, and the Centers for Disease Control. The result was a clear community profile that identified and ranked problem areas, as well as institutional capacities for dealing with them.

Utah's SALT LAKE COMMUNITY HEALTH AGENDA COMMITTEE did the same thing, funneling its data through the APEXPH process to to filter the enormous flood of problems. It helped the Committee pick up problems they might have missed, such as the surprisingly high rate of infant mortality in the central area of Salt Lake City, and the rapid increase in cases of family abuse and neglect. Using APEXPH, they narrowed the focus to the areas of concern that need to be addressed immediately, and that the Committee felt it could do something about: maternal/child health, communicable disease, access to primary health care, cardiovascular disease, and air quality.

FAIRFAX COUNTY, Virginia, a western suburb of Washington, stands in marked contrast to Tillery, Solano County, Southwest Georgia, or Somerville, as one of the most affluent, stable, growing areas in the nation, with a median family income over $65,OOO. But the County's Department of Community Action pierced the veil to discover a surprising and growing number of poor and medically indigent people. Using data from Needs Assessment Surveys conducted in 1986 and 1989, census data, a private study, and a 1991 Primary Care Needs Assessment carried out by the county Health Department, the DCA found some 93,000 poor people out of a population of 819,000, and over 19,000 medically indigent children. It also rooted out the wide combination of factors -- including income, language problems, cultural differences, and poor transportation -- that kept people from using health care services.

A HEALTHIER ROEHNERT PARK, north of San Francisco in relatively affluent Sonoma County, also worked through a community needs assessment that surveyed 276 "key informants." To this it added surveys on specific subjects, such as tobacco consumption. But Roehnert Park found that it had another source of valuable information: in 1990 the city government developed an "information and referral (I&R)" program. This database listed services from over 225 agencies that were available to Roehnert Park residents. By tracking the I&R calls, and how they were resolved, the city has been able to find the holes -- the services that people call up for, but no one is offering. These included a teen pregnancy program, after-school activities for kids, help for the homeless, a fund-raising network, and a volunteer center.

Buffalo, New York's Millard Fillmore Hospitals added an important element when they gathered data for their ACCESS TO CARE program. After gathering the usual data stream for the zip code areas that they cover, analyzing such sources as the census, along with regional data on infant mortality, disease incidence, HIV incidence and utilization, hospital officials went one step further. They realized that what people feel they need is just as important as what the data say they need. So, with the help of a consultant, they asked the citizens, in focus groups, what they needed. They found, especially among the Hispanic poor of Buffalo, a number of ways the felt need differed from what the numbers said. For instance, people paid a lot of attention to the immediate necessities and much less attention to long term needs; the need for dignity and cultural sensitivity was very high; and people really wanted to be able to just walk in off the street and get care for minor problems. The focus groups added depth to the statistical information.

2: Conceive a vision of a healthier community

Every journey needs a goal, every effort needs a compelling vision to draw it forward past all the obstacles it will encounter. The vision that will have the most power is one that:

Such a vision must go beyond traditional medical models, which only hospitals and medical professionals can effect, to encompass what the community can do for itself.

In some areas, though, such as southwest Georgia, access to basic medical care is the most effective way to improve the health of the community. There the vision took the form of a "seamless" COMMUNITY HEALTHCARE NETWORK to extend access among the poor.

The Solano County, California, COALITION FOR BETTER HEALTH CARE started with the same vision: rather than waiting for the state or the nation to solve the crisis, the Coalition must find a local way for every citizen of Solano to have access to paid healthcare. But it moved further, acknowledging that "leaving the community's health status in the hands of hospitals and doctors will not work." Instead, the Coalition envisioned giving even the poorest and most culturally isolated people the means to learn to live a healthier life, and to create the resources they need for health.

In North Carolina, the CONCERNED CITIZENS OF TILLERY hold an even broader vision, in which healthcare is woven together with social and economic goals, with land ownership, housing, education, transportation and work cooperatives to build the entire fabric of the community. They aim to build a community center, a seniors group, a summer enrichment camp, and a farmers cooperative, as well as a health clinic.

CHESAPEAKE, VIRGINIA faces a different complex of problems. Neither rural nor isolated, its population and economy growing, with 14 new factories opened or announced in the last year alone, Chesapeake nonetheless finds itself with a growing population of poor and working poor. Helping them to a healthier life is key to the community's vision: "We, the gainfully employed, the minimally employed, the unemployed, and the unemployable, are in this venture together."

HORSENS, DENMARK, holds a sweeping vision of the health of the community. The basic goal of the master plan of the this thousand-year-old city reads: "Health, well-being, and better conditions of life for the citizens must go hand in hand with development of industry and trade, considering nature and the environment."

The little town of NAMPA, tucked into the Canyon Country near the Snake River in southwestern Idaho, has a vision as sweeping as Horsens. Determined that their town would become "the healthiest place to live in the Northwest," Nampa citizens widened the definition of a healthy community to include:

Similarly, Winchester Hospital's HEALTH PROMOTION CENTER in Woburn, Massachusetts envisons a healthcare system that "extends itself outside the boundaries of traditional medical care" and which "centers on the needs of individuals and their families."

The SAN GABRIEL VALLEY MEDICAL CENTER recognized "access to health care, wellness information, and community support systems" as the core of its vision, but it added something that shaped that vision to their local reality. The San Gabriel Valley, a collection of Los Angeles suburbs inland of the Civic Center, is unusually culturally mixed. About one third of the population is Asian, and another third is Hispanic -- and many of both groups are new arrivals. The area is heavy with uninsured, and 18 percent of the population is on MediCal. So the Medical Center's vision includes access that is brought to the schools, workplaces, community centers and churches where the people can be found, in the languages and dialects that they speak, and with a sensitivity to their various cultures.

Sometimes ceremony and ritual can help move a project forward. For the past three years, the community leader of West Philadelphia have joined with government officials, business leaders, and the leadership of Mercy Health Corporation's Misericordia Hospital to create PARTNERSHIP 2000, a broad-guage effort to improve the quality of life in the area. They expressed their vision in a ringing pledge, written down and signed by all partners in a grand ceremony in September of 1991. Based on the sonorous language of the preamble to the Constitution, and the Declaration of Independence, the pledge reads:

We the people of the West Philadelphia community, our representatives, and our friends, in order to form a more compassionate society, provide for the common good, and secure the blessings of health and opportunity to all, do hereby pledge our partnership.

We pledge ourselves to pursue a vision of a community in which families may thrive and children learn and grow to their fullest; in which all citizens may feel secure in their homes and on their streets; and in which each individual is free to enjoy the highest possible state of health and standard of healthcare.

With this partnership, we affirm the strength of our community, the goodwill of our friends and neighbors, and our faith in a brighter future for ourselves, our children, and our children's children.

3: Work out a way for the whole community to plan together

People tend to give energy to things they helped create. If they planted it, they will water it. The process of creating the plan will work best if it involves everyone that the plan will affect, and if it aims for a genuine consensus of the community. But the shape of that process can turn out neat or messy, vast or tiny, evolving over time or all hatched in a weekend.

The HORSENS, DENMARK, HEALTHY CITY FOUNDATION was very neat and conscious about its process. The City Council set up the foundation by appointing various office-holders, business leaders, and citizens to its board and its Health Committee, and appointing clinicians and other professionals to a Health Advisory Board. These groups then organized a series of seminars in day-long sessions. They took the 38 model goals of the World Health Organizations Healthy Cities program, divided them by subject area (such as "Youth," or "the Environment") and spent a day on each area, first listening to speakers, then brainstorming. The ideas that emerged formed the basis for the Foundation's annual planning process.

Tillery, North Carolina, provides the other extreme: an organic, day-by-day, person-to-person model of planning. Born, as it was, when the area's whites -- three percent of the population -- abandoned the community school system and let it die rather than integrate, the CONCERNED CITIZENS OF TILLERY spreads so widely through the area's black population that it needed no special planning effort. The plans evolved from efforts around health fairs, monthly health screenings, as well as five years of local meetings of the Area-Wide Health Committee. Starting in 1988, they converted the old community Potato House into a Health Clinic and Curin' House, and persuaded East Carolina University to staff it once a month with fourth-year medical students. The subsequent plans grew organically out of this experience, using the motto, "Do it when the people are ready."

The Solano COALITION FOR BETTER HEALTH CARE is a very different group, made up of institutions, governments, and providers. But it was born in a similar crisis: saving one of the County's two primary care clinics. From there, "it just growed." Emboldened and more than a little surprised by their success, the original group of providers took on bigger game. From an ad-hoc group saving one clinic they shifted to gathering information about the health of the county as a whole, and finally to revolutionizing the county's health delivery system for Medi-Cal recipients and the uninsured.

First they recruited students from UC Berkeley's School of Public Policy to survey the health status of the county's poor. They presented the results of this study in a working session of the county Board of Supervisors and recruited them to join their Coalition. The supervisors said, "Fine, but only if you get the cities to join in, too." The cities said, "Fine, but only if you're not asking us to pay for the care of the uninsured." Eventually the Coalition included representatives of the county, the cities in the county, all the hospitals and community clinics in the county, the county medical society, and Kaiser Permanente, which provides care for half of the county's population.

Then everybody picked an area and set to work. The Coalition formed three smaller groups: a Work Group of staff professionals to work on plans with consultants, a Technical Committee of the chief administrative officers of all the partners, and a Policy Committee of elected officials and members of the boards of the partners. A Physicians Steering Committee set out to recruit doctors and physician groups and set up networks. Another committee did the same for hospitals. Kaiser set up internal groups to reorganize itself for the challenge. Planned Parenthood signed up and looked into providing primary family care, with help from other partners. Health and human services partners set to work on the non-medical access problems, such as transportation, language, and cultural barriers.

In Vallejo, the County's largest city, the Coalition built a partnership with people from Hispanic, Filipino, and African-American background, as well as the recovery community, to put energy into the city-sponsored Fighting Back Program, funded by the Robert Wood Johnson Foundation to prevent and treat substance abuse among young people. The Valleo African-American community has asked for their teenagers to trained as health facilitators. Nearby, the Healthy Vacaville Task Force has involved the city, business leaders, church members, minority groups, schools, and civic groups in health promotion and prevention campaigns. At the same time, the Coalition and the Solano Economic Development Corporation have formed a Business Task Force to stop the erosion of healthcare benefits in the workplace, and to raise funds to buy health insurance for working families that earn just a little too much to qualify for Medi-Cal. By the time the Coalition was well into the planning process, the process had worked deep into the communities of the county.

In Somerville, Massachusetts, the COMMUNITY HEALTH AGENDA'S information-gathering segued straight into planning. The survey of community leaders and health care providers also invited people to participate. Once the Health Committee had evaluated all the data and identified five critical areas, they held a press conference and a community meeting to present the data. Then, from people who had volunteered at the meeting or in answer to the survey, they formed a work group to evaluate each critical area and brainstorm solutions.

Way down in Tucson, in the crook of Arizona desert hard by the Mexican border, the PIMA COUNTY COMMUNITY HEALTH COMMITTEE used the APEXPH process as the spine of its entire planning effort. The committee used the process' computerized "forced-choice" questions to reach consensus on a ranking of 14 health issues facing the county.

But if, as in Pima County, the process reaches out into the community, still the APEXPH process maintains a fundamental focus on the county health department and its effectiveness. We can find an excellent example of a different method, one that puts the community at the core, even when the process is started by an institution, in what might seem an unlikely spot: the MADISON COUNTY HEALTH CONSORTIUM way out in the hills and "coves" of western North Carolina. And they got their process from an even more unlikely source: the Zulu of South Africa. When the Mountain Area Health Education Center in Asheville, North Carolina, went after a grant from the W.K. Kellog Foundation to try out some new methods of enhancing the health of the people of nearby Madison County, they decided to try a concept called Community Oriented Primary Care. Two doctors, Emily and Sidney Kark, had developed COPC in the 1940s while working with the Zulu. According to the Karks, COPC has four stages:

  1. identifying the entire community, and studying it, from its social institutions, relationships and economy, to its diet, nutrition, and traditional methods of healing.

  2. identifying the community's major health problems

  3. involving the community in deciding priorities among these problems

  4. monitoring the projects that come out of this evaluation in oreder to determine their effectiveness, and modify them, if necessary

Madison County is pretty scattered: 17,000 people sprinkled in nooks and cracks over 456 square miles of the rugged Bald Mountain territory where North Carolina pokes into Tennessee. The Madison County Community Health Project's epidemiologist and sociologist started by asking the three postmasters to name the area's communities. The postmasters came up with 72 of them. Then they visited those communities and asked who they would call on, locally, if they needed help. That produced a list of 350 "community helpers." This was the base on which the project would be built.

Rather than survey these communities to determine their health needs ("These people have been surveyed to death!" said one project board member), the project staff did 40 small group interviews. They talked to volunteer fire departments, teachers, church groups, doctors, sheriff's deputies -- a wide array of citizens, plus people in the helping professions. They asked them a half dozen general questions about health and access to care, and took notes on the discussion. They also asked people to write down anything else that occurred to them on the backs of the lists of questions -- and people did. One teacher, for instance, couldn't bring up family violence in a discussion with her students, but she could write about it on the back of the form.

In the process of applying for the grant and gathering the information, the project staff gathered a broad group of people who were interested in carrying out the project over a long period. This Madison County Community Health Consortium (an amalgam of members from the Cooperative Extension Staff and the Rape Crisis Center to local ministers, primary care providers, and representatives of the Council on Aging, the League of Women Voters and Neighbors in Need, a local volunteer relief effort) now guides the project. It has grown in two years from 25 to 40 members -- the kind of people who get up and do what needs to be done. It is this group that took the data and (with help from the project staff) decided which were the county's most serious health problems, who was affected by them, who was already working on them, and what more could be done.

In creating HEALTHY STUDENTS 2000, the Genesys Health System of Flint, Michigan. used a traditional 4-part planning process:

  1. Making sure that the project is consistent with the system's mission

  2. Conducting a situation analysis that includes a community needs assessment, plus an analysis of the system's strengths and weaknesses, threats and opportunities.

  3. Working out and ranking the program's goals, and

  4. Creating a workplan, evaluation process and budget.

The difference was that, for all but the first stage, Genesys went far beyond its own walls to plan the program. It brainstormed with superintendants, staff and teachers of the Genesee Intermediate School District, an amalgam of 21 public and private school districts in Genesee County, teaching over 83,000 students. It held focus groups with school and business leaders, teachers and community agencies. Then Genesys met with the Flint Roundtable of community leaders, and the FOCUS Council, a business coalition, and melded its project with theirs. Genysis dedicated $1 million to kick-start the project. All partners committed to the project for a decade, so that three generations of high school students will be touched by Helathy Students' emphasis on prevention, early intervention, safety, and self-esteem.

4: Create a plan of action

Create a plan with goals that you can reach in three to five years. Look for new approaches, and look for results that will last. Map out what resources you will need, and how people can be drawn into the plan.

Southwest Georgia's COMMUNITY HEALTHCARE NETWORK, for instance, set four goals: 1) developing a health status baseline, 2) consolidating health and human services in a convenient place in Columbus, 3) finding ways to deliver primary care throughout the region, and 4) consolidating pediatric services for the region.

In contrast, Solano County, California's plan calls for nothing less than a "massive Countywide restructuring of health care financing and delivery." The COALITION FOR BETTER HEALTH CARE stakes out four goals: 1) shifting Medi-Cal in the county to a managed care plan (to be called the "Solano Health Care Partnership," to go into business on January 1, 1994), 2) inventing new health promotion strategies for individuals and whole comunities, 3) slowing the erosion of work-place benefits, and 4) finding a way to include the working poor in Medi-Cal.

The six-year plan of the CHESAPEAKE, VIRGINIA, Health Department set out a number of specific, ambitious goals including: freedom from violence and substance abuse for children and pregnant women, a specific lowered infant mortality rate, a mortality rate from socially important communicable diseases of zero, and a health care access rate of 100 percent.

Similarly, the COMMUNITY HEALTH AGENDA in Somerville, Massachusetts set a broad, ambitious agenda grouped in five areas: tobacco, HIV/AIDS, violence in the streets and the home, the health of uninsured immigrants, and substance abuse and mental illness. The solutions to these problems ranged from local, nuts and bolts solutions such as working out better emergency room protocols, or lending Lifeline beepers to the police for women who have filed restraining orders against violent men, to lobbying state and federal lawmakers.

Some groups took a much wider view of what it means to be "a healthier community." The CONCERNED CITIZENS OF TILLERY laid out a broad, 16-point agenda that addressed everything that stood in the way of a healthier community, from staffing a clinic and getting area health professionals to volunteer one day a month for it, to making the clinic self-supporting within five years, educating county and regional politicians on Tillery's needs, setting up a fund to help pay the medical bills of the poorestorganizing transportation for those who need it, lobbying the state legislature to tighten environmental regulations, and even building low-income housing.

In a far different situation, the SOUTH ST. PAUL HEALTHIER COMMUNITY PROJECT in Minnesota has taken a similar broad stance. Once a center of the meat-packing industry, the economy of this town of 21,000 on the Mississippi collapsed when Swift closed its plant in 1969, followed by Armour in 1979. Young white people with families streamed elsewhere to find jobs, leaving behind their older relatives to deal with the poorer, ethnically diverse families that moved into the old houses. Stillborn attempts at redevelopment devastated the downtown, destroying more than 100 old buildings.

But since its centennial in 1987, South St. Paul has regrouped, using Town Meetings, block parties, Community Partnerships, and the River Environmental Action Project to pull the community together around a series of goals that range from re-developing the riverfront to dealing with the lead-based paint in all those old houses and fostering a sense of neighborhood amid the new ethnic mix.

The most sweeping "healthier community" action plan has grown up under the nurture of the ERIE EXCELLENCE COUNCIL in Erie, Pennsylvania, where the state's northwest corner touches Lake Erie. The leaders of the area, including the Chamber of Commerce, the county executive, the mayor of Erie, the hospital council, the heads of all the educational institutions in the area, the major employers -- everyone whose opinion makes a difference -- have committed to a 1989-1999 "Decade of Excellence." They intend to penetrate very facet of community life -- education, retail, government, health care, industry, labor, sports, the environment -- with training and practice in "continuous improvement" fashioned on W. Edwards Demings' famous 14 points for management.

This seems to be far more than window dressing. For instance:

Erie's vision is long, its horizons are wide, and it seems to have ferocious communal energy to focus on building what, in every way, promises to be a "healthier community."

FIGHTING BACK, a community initiative in northwest New Mexico, has taken the opposite tack -- focusing resorces on a single problem -- for a very good reason. The people of these high, sparsely populated rural plateaus, 180,000 whites, Hispanics, and Native Americans of four nations spread over 15,000 square miles, have one problem that stymies all other efforts: the abuse of alcohol and other dangerous drugs. Poverty, isolation, competing cultures, governments and world views, have combined to gain Gallup the tag "Drunk City." Gallup's county won a prize community leaders would rather have avoided: in an NIAAA epidemiological study of "county problem indicators" for alcoholism, McKinley County came in first out of all 3,106 counties in the United States. Domestic violence and fetal alcohol syndrome, with their melancholy long-term affects, are far too common. Forty percent of all deaths in the area are alcohol-related: car, truck and train wrecks, suicides and homicides, drownings, and acute alcohol poisonings. As Fighting Back's report put it, in tragic understatement, "This does not make for a healthy community in which to raise a family."

But the Northwest New Mexico Council of Governments, armed with a $200,000 grant from the Robert Wood Johnson Foundation, has started the Fighting Back initiative to turn the situation around. Besides calling a regional summit meeting, sponsoring a Walk for Hope to Santa Fe to demand tougher laws and stronger enforcement of them, and founding the Na'nizhoozhi Center in Gallup to bring a number of services together, the people of the region have laid out an ambitious 5-year plan to attack the problem locally. The seven goals range from enforcing laws, training bartenders and waiters and attempting to change the cultural values around being a "host," to intercultural training, a regional case management system, and a mobile treatment unit, all designed to make the maximum use of the resources that are available. The plan cuts across lines of jurisdiction, profession, culture, and levels of education and class, involving local groups in each of the areas three small cities and 78 towns. It may reduce alcoholism, and the attempt certainly will strengthen the community.

  • 5: Decide how you will know whether the plan has worked

    If your plan works, you will be able to measure just how well it works, what parts work better, and what did not pan out.

    With some plans, the outcome is obvious: by a certain date, there either is or is not a clinic in operation, or a series of classes up and running. Other initiatives call for more sophisticated measurements. The SOLANO COUNTY COALITION FOR BETTER HEALTH CARE, for example, decided to measure a series of specific numbers in the years 1994-1997 to tell them whether their plan was working.

    Healthy Vacaville and the Business Task Force will survey similar numbers, while the Kaiser Research Institute and the UC Berkeley School of Public Health will team up to evaluate the Coalition's outreach efforts.

    The SOMERVILLE COMMUNITY HEALTH AGENDA will base its evaluation on the "Healthy Communities 2000" program, setting out 15 specific goals to be reached by the year 2000, such as reducing drug-related ER visits by 20 percent, or increasing to 90 percent the proportion of professionals who can successfully identify and refer victims of family violence.

    Similarly, in the suburbs of Newark, New Jersey, the IRVINGTON COALITION OF MATERNAL AND CHILD HEALTH set six specific, easily tracked measures: a lower infant mortality rate, an operating pre-natal clinic, reduced adolescent fertility rate, expanded services and more clients served by existing programs, expanded Coalition membership, and increased funding for all programs.

    Such methods can even measure something as hazy as the social utility of a new building. When Tacoma's United Way undertook to buy and renovate an old building to create the BETYE MARTIN BAKER COMMUNITY SERVICE CENTER, they wanted to make a synergistic space that would help all of the 15 to 20 non-profits who would occupy the building give more value to the community. And they wanted to know whether they did what they set out to do. So they studied their assumptions (if we put a foundation resource library in the same building with other non-profits, more people will use it; common meeting spaces will be used more efficiently than separate ones), wrote them down as objectives, and found specific ways to measure each one.

    Within a few years of the opening of Jackson, Michigan's CENTER FOR HEALTHY BEGINNINGS, designed to provide pre-natal care and newborn care, some of the results were obvious: the number of women walking into the ER at the local hospital in labor with no pre-natal care dropped from one per day to one per month. At the same time the infant mortality rate in Jackson County dropped from 17.6 to 7.1. But, for a deeper look, the Center contracted with the College of Nursing at Michigan State University to do a two-year professional evaluation of the project.

    Oregon's TILLAMOOK COUNTY HEALTH DEPARTMENT adds a revolutionary element to the usual measures for feedback to federal, state, and local funding sources: they ask the customer. They use both surveys and client evaluation forms to ask their mostly low-income clients, "How are we doing?"

    LIFEGUARD, a Silicon Valley HMO, wants the answer to one outcome question, a very important one: if we spend money and effort to evaluate our least-healthy patients, design wellness programs for them, tell them where to find the necessary resources (such as self help groups, weight-loss or smoke-ending programs), and follow up with encouragement and regular contact, does it save the system money in the end? They devised a simple experiment: they will send out Short Form 36 (a simple questionnaire often used in medical outcomes studies) to several thousand Lifeguard card-holders and sort the results to find those whose self-reported health scores in the highest and lowest fifth. From the lowest fifth, they will randomly pick a test group that will be given the wellness treatment. The others, both high and low scorers, will serve as control groups, and will receive only the traditional reactive medical care -- they will be treated when they are sick, and otherwise they will be left alone. All these groups will also be surveyed using a "Health Behaviors Questionnaire." Every six months they will fill out both surveys again. Lifeguard will analyze the results using software from the American Group Practices Association -- Outcomes Management Project Consortium. Over the course of two years Lifeguard hopes to be able to give some weight and reality to one of today'd fundamental health care management questions.

  • 6: Grow partnerships and nurture leadership to carry out the plan

    Partnerships, links in the net of community, and community leadership are not just means to an end. To a great extent, they are the end. The partnerships, the delegation of power, the cooperation and trust, must be real, they must be continuing, and they must be flexible enough to accommodate change. Old, hierarchical, territorial models of leadership will stifle the very community bonds you are trying to grow. Inclusive leadership, such as team leadership, visionary leadership, and mentor relationships, give the entire community real power and choice.

    Partnerships cut across boundaries. In many cases, these boundaries are jurisdictional or bureaucratic: people with great resources to help each other are suddenly able to look beyond their own walls and link up. Sometimes the boundaries are geographical: isolated communities can reach out to each other. Often, in these United States, the boundaries are walls of race, color, class, and culture: people who are very different can find a common ground in caring for their own health and the health of their children.

    Nurturing leadership is much like nurturing creativity: you don't have to build it, or pry it out of the cracks. You mostly have to offer the opportunity, and stand out of the way.

    In southwest Georgia, the COMMUNITY HEALTHCARE NETWORK and Blue Cross/Blue Shield worked out a pilot partnership to provide health insurance to the "working poor" whose employers provide no insurance and who cannot afford it on their own.

    For the CONCERNED CITIZENS OF TILLERY, partnership with each other was about all they had to start with. All their projects are staffed by volunteers, and worked cooperatively. But the process of organizing around health and environmental concerns has pushed many of the poor, rural black citizens of Tillery into doing things many of them had never done before, such as write letters to the editor, carry petitions, attend and speak at County Commission meetings, and even organize conferences -- one 92-year-old black woman addressed a hearing of the State Department of Environmental Management. The effect of taking leadership has been revolutionary. Suddenly Tillery finds itself helping other communities throughout the area organize around health, the environment, and housing.

    One of the best projects in CHESAPEAKE, VIRGINIA, is in many ways the simplest: a partnership between the health department and the area's doctors -- each time the health department sees one of its indigent clients, in a clinic or at home, the computer automatically kicks out a report that goes by mail to the client's physician, one of the 61 local doctors who have volunteered for the project. The health department focuses on the long-term, the preventive, the situational, the domestic and chronic; the doctors take care of the episodic and acute, and are available for consultation. Chesapeake General throws in funds for sophisticated radiological and laboratory testing, and its medical staff contributes to a fund to help pay for people's drugs. Among the patients enrolled in this Coordinated Health and Medical Program (CHAMP), hospitalizations have dropped by nearly two thirds, emergency visits to ER by more than two thirds, and non-emergency visits by nearly one quarter -- and the doctors say their patients are more informed and active in their own health.

    In Somerville, Massachusetts, the COMMUNITY HEALTH AGENDA began as an unusual partnership between the city Health Department and Somerville Hospital. And it found that, given the chance, people came forward to take leadership on issues that they cared about. In each area they had identified as ciritical, they had assembled work groups to evaluate the data and brainstorm for answers. But when those few meetings were finished, the work groups didn't want to go home. They wanted to carry on the work.

    And those groups spun off other groups. The data that the Agenda presented at community meetings showed clearly the powerful influence that socioeconomic factors have on health. So some citizens organized the Somerville Community Planning Group to see what they could do about such things as housing, economic development, education, and the environment. The growth of partnership was strong because it was organic.

    UTAH NORTH MISSION 2000, centered in Ogden, organizes everything as a series of partnerships that cut across traditional lines, such as:

    At one time or another since its founding in 1986, Mission 2000 has involved nearly every one of the area's community agencies and organizations in some project.

    Houston's SOUTHWEST TASK FORCE has brought an even wider array of agencies to focus on one particular part of the city in dire need of services. The Gulfton area has run a demographic roller coast in the past decades. During the oil boom of the '70s the area built up rapidly with "swinging singles" apartments, filled mostly with young whites. When the oil economy fell off the table in the '80s the young whites left in search of greener pastures, and rents dropped precipitously. Suddenly the area became a haven for poor Hispanics, Asians, and African-Americans, who needed far more social services than the young affluent whites did, and had far less access to them. Drugs, prostitution and other crimes became commonplace, infant mortality rose, and local people began streaming to nearby hospital ERs for treatment of conditions that could have been easily prevented, or treated more simply in a clinic.

    In the spring of 1990, however, a coalition of residents, health and human service organizations, local businesses, churches, schools, and elements of government formed the Southwest Task Force. They rapidly founded the Southwest Community Health Clinic (SCHC), put together a plan (which has not yet found funding) for a Southwest Community Health Center for Comprehensive Care, and widened their net to provide the area better access to all social services.

    They managed to bring in an astonishing array of partners, including:

    The task force has also spun off two other organizations: the Gulfton Area Planning Survey, a group of academics from universities and colleges in Houston that will perform on-going needs assessments and surveys; and the Gulfton Area Neighborhood Organization, formed last fall to nurture the residents' own leadership in growing their community.

    A similar, though smaller, effort is underway in National City, California, where the suburbs of San Diego shade toward the Mexican border. Paradise Valley Hospital, a member of Adventist Health Systems, covers an area that includes the poor barrios of Encanto and Barrio Logan. The population is half Hispanic, and heavy with Asians and African-Americans. As in many other areas, the question was how to cut across the boundaries of these diverse neighborhoods, as well as the boundaries of bureaucratic, jurisdictional, and social divisions, to help people live healthier lives. In June, 1991, Paradise Valley started a coalition called PARTNERS FOR PREVENTION that has rapidly launched one initiative, "Mammography on the Move," and undertaken a comprehensive assessment of the health needs of the community.

    The rapid success of their breast health initiative is due largely to their success in pulling together the skills and access of an unusually wide array of partners:

    These cross-pollinations have not only begun to attack a health problem that is unusually serious in the area, it has also helped build community by linking up people who had not previously ben involved with one another.

    In West Philadelphia, HEALTHY START has been taking on another problem: infant mortality, low birth weight and lack of prenatal care. To do this, the five-year, federally-funded program, administered by the Philadelphia Department of Public Health, has taken on an unusual structure that knits community concerns directly with bureaucratic goals. At first glance, there would seem to be no community in the project area, only poverty and crime, from the dilapidated housing projects of West Park and the drug corners of Mantua and the everyday violence of Kingsessing. But there are community leaders and organizations eager to fight the chaos, and Healthy Start is eager to tie in with them and to cut through the apathy that too often greets grand government programs.

    The Department of Health has recruited local community leaders, health consumers from the area, and health care providers to serve on the Healthy Start Consortium, which advises the project. The Consortium provides an umbrella for five work groups, on collaboration, linkages, public awareness, public policy, and support services. Each group has staff support from the Department of Health, and representatives of all three types. Their job is to recommend policies and strategies to Healthy Start.

    In addition, the Department has held meetings in the community, and contracted with dozens of small local organizations to carry out the work, from peer home visits and outreach teams to drug and alcohol programs and community education. Many of these groups, which include churches and neighborhood groups, have never contracted with the department before.

    At the same time, Philadelphia Magazine has 368-page GUIDE TO HEALTH CARE IN THE DELAWARE VALLEY, which intersperses articles on every aspect of health with lists of hospitals, doctors, exercise programs and health projects throughout the region. the magazine formed a partnership with Independence Blue Cross to distribute the $6.95 book free to its members. Metrocorp, the magazine's parent company, has formed Metro Health Media to duplicate the concept in partnership with insurers, hospitals, and other institutions in such areas as Boston, Washington, D.C., Pittsburgh and Baltimore.

    Schleicher County, Texas, is not large -- fewer than 3,000 people spread over 1300 square miles, a lot of sheep, goats, cattle, and cotton, some gas and oil wells, and one town by the name of Eldorado. You wouldn't think it could attract the direct representation of 27 different agancies. But it does, through a very simple device: they share space and staff, a little pied-à-terre called the SCHLEICHER COUNTY COMMUNITY RESOURCES CENTER. A pilot site, one of three in the state, this one building and combined staff provide a presence for 11 state agencies, 4 county agencies, 6 regional projects, three local social projects, the city housing authority, the American Cancer Society, and the Social Security Administration -- one-stop shopping in the social services.

    The ROCHESTER AREA HOSPITALS CORPORATION, is a prime example of the forging new partnerships, in this case between the hospitals, major businesses and business associations, and insurers of the Rochester area.

    7: Design specific projects to further the plan

    The most powerful projects arise directly from your vision of a healthier community. They are parts of the plan. They are creative and flexible, adapted to the special circumstances of your community. They meet your needs and make the best use of your resources. Their effectiveness can be measured.

    The projects, like the plans, vary like the fingerprints of each community. Even rural southern commmunities have widely different situations. Southwest Georgia's COMMUNITY HEALTHCARE NETWORK established primary care centers in two counties, along with community health centers in another county and in south Columbus. It planned a mobile primary care unit to travel throughout the area doing exams, basic treatment, mammography and hearing screenings, case management and referral, as well as basic health education. In Columbus, the Network has begun planning a Health and Human Services Campus to bring together a number of available programs in one place, and a comprehensive Regional Pediatric Center.

    The CONCERNED CITIZENS OF TILLERY, on the other hand, had similar needs, but almost no infrastructure to work with. So they started at the most basic level, enticing the medical schools at Duke University and East Carolina University to send out volunteer fourth-year medical students to train local people in health matters -- how to take a blood pressure, what diabetes is about, what good nutrition means. The classes started in 1988. After three years, this core group of local volunteers went on to start another series of classes in a nearby hamlet, Scotland Neck.

    Now the parents in Tillery have begun to get together in a group called "Grown Folks," just to talk about their mutual interests. Other groups pursue housing initiatives, focus on the environment, or educate the area's politicians about Tillery's needs.

    Among the raft of initiatives in CHESAPEAKE, VIRGINIA, that spring from the health department or major foundations is one that springs from the mind of one man: Dr. Juan Montero decided to open a free clinic. He asked around, and before long he had rounded up a place to hold it, medications, furniture and equipment, nurses and other doctors, plus offers of help from a medical school and the local medical association. The shingle is up on Wednesdays and Saturdays for the working poor with no insurance.

    The needs of uninsured children -- and the burden brought on the system when their minor health problems become major -- is the focus of many projects. In California, which counts some 2.1 million uninsured children, the new comprehensive state Access for Infants and Mothers (AIM) program targets kids up to the age of two. Blue Cross has just started CALIFORNIAKIDS to cover the gap: uninsured children from two to 18 in families whose income puts them above the MediCare guidelines.

    Blue Cross designed a basic primary and preventive health care package with a price tag of $400 per year per child for capitated, managed care. Underwriting all the administrative costs, and throwing the first corporate donation into the kitty itself, Blue Cross then went looking for other deep pockets to help out. For the pilot, designed to cover 1,000 kids in the Los Angeles area, Blue Cross got help from the California Community Foundation, Merck Pharmaceuticals, and Proctor and Gamble.

    The children will be identified through schools and community groups and (to avoid the problems of "labeling") will be issued a standard "California Care" HMO card. Blue Cross hopes to enroll 3500 children statewide by the end of the year.

    In Philadelphia, HEALTHY START is focused on getting its pre-natal care message to the community. It uses two main weapons: a public relations/education campaign, and a van. The campaign, carried out by three community developers and one PR expert, consists of educational presentations before church and civic groups, public forums to ferret out the barriers to health care in the area, plus press releases, fact sheets, public service announcements, buttons, brochures, and a newsletter. The van is the successor to the successful MOMobile, run by the Maternity Care Coalition and staffed largely by local people. Now called the Healthy Start Express, the MCC van meets the community on its own turf for outreach and referrals. In 1992, the MOMobile counted 1200 contacts with pregnant women. Nearly 30 percent received intensive followup to encourage pre-natal care. It is a prime example of one-on-one education carried out through local people.

    Boston's poor neighborhoods of Roxbury, Dorchester, and Mattapan now boasts its counterpart to the MOMobile: the FAMILY VAN, sponsored by a consortium of grass roots organizations, service groups, hospitals, clinics, churches, government agencies, and individuals, and operating out of Beth Israel, a major teaching hospital associated with Harvard.

    Monday through Thursday, this 35-foot RV with the "We are family" logo on the side parks at its regular spot in one of the neighborhoods it serves. Inside, in the comfy living-room-like front half of the van, drop-ins find hot chocolate or soup in cold weather, and lemonade in the warm months. They also find a public health nurse from the Healthy Baby Program, a WIC nutritionist, a staff member from the nearest health center, and Susan King, the Family Van coordinator. Men find free condoms with some educational material attached; very young men find some counseling attached to the condoms, too. The bilingual staff gives free diabetes and blood pressure screenings, along with fact sheets in English, French, Creole and Spanish; free maternity and infant clothes to the needy; and emergency supplies of infant formula and diapers -- coupled with immediate triage to the WIC nutritionist. They hand out multilingual health education materials; show videotapes on such topics as breastfeeding, and preventing family violence and STDs; and give counseling, along with personalized, advocate-style referrals to homeless shelters, food pantries, drug detox and rehab programs, job training programs, community multi-service centers, free or inexpensive medical care, and local STD programs. The staff see themselves as a stepping stone for people who have been prevented from making use of available services by barriers of language, cost, or culture. The clients choose the terms of their interaction -- including anonymity, if they wish.

    In its first year, the popularity of the van has grown exponentially as word-of-mouth has spread.

    Another group in Boston, SOCIAL JUSTICE FOR WOMEN, focuses its attention on a group that is even more medically deprived than the uninsured poor, possibly the most medically deprived group in our society: pregnant prisoners. Of the 2700 women each year sentenced to the Massachusetts Correctional Institute at Framingham, an average of 70 are pregnant, and 18 give birth in prison. Because of addictions, diet and other underlying health problems, an estimated two thirds of these pregnancies are at high risk of complications. Before SJW's intervention, these women received no special care -- no improvement in a diet that included no milk and only a rare piece of fresh fruit; no prenatal exams or tests; no family, coaches or company for labor; no nurse to monitor those at high risk; no special programs to help them stay drug-free at least until delivery; no isolation from infectious diseases; no maternity clothes. They were confined without exercise in the prison's health center for weeks prior to delivery, often sleeping on the floor for lack of beds. When they did deliver, it was in a hospital, but shackled, and under the eyes of their guards. Their babies were routinely taken away from them 48 hours after delivery.

    In 1989, SJW was able to open the Neil J. Houston House, a residential facility outside the prison grounds, with the capacity to care for 15 women and their infants at a time. To get into the program, pregnant women have to commit to a long-term program of staying off of drugs, counseling, and "well-baby" checkups at the house. The house has seen 55 drug-free births. So far, 15 women have remained drug-free for a year and are building a new life with their babies.

    Inside the prison, SJW has been able to provide the services of a nurse-midwife, along with basic obstetrical and peri-natal care, and a medically supervised methadone de-tox program. SJW is also able to help women put together a comprehensive treatment plan (including health care, day care, job training and placement, substance abuse counseling, and safe housing) as part of their parole.

    For this persistent concern, the SJW was named a "Point of Light" by President Bush, and honored for "nonprofit innovatoin" by the Peter J. Drucker Foundation.

    Many parts of the country suffer from a shortage or bad distribution of trained healthcare personnel, and Nebraska suffers more than many places. It also, like many places, has a surplus of single mothers on welfare with little hope for the future. RAMBO (the Rural Allied Medical Business Occupations program) seems to be what we all look for, a win-win situation. RAMBO trains people, mostly single mothers collecting welfare, for such jobs as LPN, CRTT, histology technician, or drug and alcohol counselors. After the pilot program, the annual income of the participants more than tripled, from $5214 to over $17,000. The program costs the state $7000 per student -- but the savings to the state from the drop in AFDC and other aid programs pay back that amount in less than 18 months.

    Oregon's TILLAMOOK COUNTY HEALTH DEPARTMENT has started several innovative projects, including:

    At The Dalles, 150 miles up the Columbia from Tillamook County, the MID-COLUMBIA MEDICAL CENTER has improved the community's access to health care by raising the training level of every emergency medical technician from EMT-II (basic life support) to EMT-III or -IV (advanced life support).

    But MCMC's largest contribution to a healthier community has already been discussed in these pages: it is the first facility to convert completely to the "user-friendly" Planetree model. Rather than finding new ways to take health care beyond the forbidding walls of the institution, MCMC re-invented the institution to make it less forbidding. Every in-patient has many opportunities to learn more about living a healthy life. Non-patients do, too, now that MCMC has bought and converted a condemned landmark in the center of town to serve as a sophisticated health library and resource center.

    The "strictly-medical" side of the ledger has benefited, too: the Planetree program has attracted a greater number and quality of nurses and doctors than a hospital in a rural town of 11,000 could expect to attract. Within the past year alone, six board-certified physicians have moved to The Dalles from Boston, Chicago, Denver, and Seattle -- and all have cited the Planetree model as one major reason for doing so.

    One project of the MADISON COUNTY HEALTH CONSORTIUM in western North Carolina deserves our particular interest. To increase the health and safety of newborns, the consortium put together a kit of information and safety devices (including smoke alarms). But instead of just handing them out to new parents, they went to the Laurel School PTA, and asked them to recruit volunteers, who were parents themselves, to deliver the kit and follow up with visits over the babies' first six months. The visits were to include explanations of the health and safety information, reminders about immunizations, and pointers about access to health care.

    The project is still being evaluated, but it shows promise: recruiting neighbors and peers with a little more experience to deliver crucial information is one way to help it stick.

    HORSENS, DENMARK is bubbling with Healthy City projects, many of them far afield from the strictly medical. The list includes:

    The NORTH KARELIA PROJECT in Finland has, in contrast, a relatively narrow focus -- preventing heart disease, yet its efforts have had a broad effect on community bonds, diet, personal habits, and even the economy of the area. It was started in 1972 in response to an alarmingly high rate of heart disease in North Karelia, a relatively backwards rural area of eastern Finland bordering on what was then the Soviet Union. By the mid-80s, the project had tried most of the usual methods of health outreach, and they needed to move a step further. Some of their more unusual initiatives included:

    Over the years the project has convinced a number of people in the area to quit smoking, change their diet, and exercise more. The result so far has been a drop in the rate of heart disease of over 50 percent.

    In all these projects, the people in the trenches have had to grope forward. There seems to be considerable white space between the maps labelled, "Medicine," and those labelled, "Public Health." No one trains medical professionals to work with the community -- or no one did until now. In the past few years, the CENTER FOR COMMUNITY RESPONSIVE CARE in Boston has graduated scores of doctors and other health professionals trained in the community-oriented primary care (COPC) model we saw used so effectively in Madison County, North Carolina. Those graduates have fanned out to hospitals and clinics around the Boston area and across Massachusetts.

    Founded with start-up funds from the W.K. Kellogg Foundation and the Health Resources and Services Administration, the CCRC has expansive goals. Through training professionals, through research, evaluating programs and disseminating its findings, the Center hopes to lead a revolution in health care in America, "reconstituting the social contract" between the medical community and the public by "merging medicine and public health."

  • 8: Commit to improving the life of all members of the community

    The most vulnerable (in many communities the children and young people, the old, the disabled and the poor) also have great resources to offer. They offer great opportunities to knit the community across generations and classes. Including them can release powerful energies.

    For many of these projects, involving the disadvantaged, the minorities, the "others," is the point of the enterprise. In TILLERY, NORTH CAROLINA, for example, it is the whole of the enterprise. The entire community is one of the "others" that has been ignored.

    Other communities have to go out of their way to bring in everyone. Many projects, such as the two versions of the "MOMobile," the Houston House, and the COPC program in Madison County, North Carolina, are specifically designed to seek out the most vulnerable and least served. We offer here a few examples of particularly innovative ways of bridging cultural barriers to serve those who need it the most.

    HORSENS, DENMARK, has only a few minorities. One is a small, tightly-knit group of immigrant Turks, few of whom speak any Danish. To protect their culture and religion, the men only allowed the women to go where they went, which for the most part was not anywhere they would contact Danes. A Healthy Cities group concerned with children's health in that part of town realized that this was one group of children they could not reach. Rather than invent some bureaucratic answer to this isolation, they searched for something they might have in common with the Turkish women. They threw a few parties, got up a few Bingo games, and got to know about 15 families. Then they hit on sewing. That was innocuous enough -- the men would allow their women to go alone to a sewing class and sewing circle with Danish women. When the Turkish women showed up, they brought 50 kids with them. So daycare was arranged for the next session. After the sewing became routine, the Healthy Cities group introduced another idea: the women could learn Danish. By this stage, the men would even let the women do that. Bit by bit, the walls crumbled, and the Danes gained the confidence of the Turks.

    Stanislaus County, in California's great Central Valley, is in a classic bind. Its population is growing rapidly (39 percent in the past decade), unemployment is rising (17.2 percent), and the percentage of people from different cultures is growing -- the population is 71 percent white, 22 percent Hispanic, 5 percent Asian and Pacific islanders, and 2 percent African American. The poorer population moves often in a restless search for work -- 36 percent of the school district's children come or go each year. Further, the traditional extended family structure of the minority groups, and their isolation from, and distrust of, the white system, tends to mask the presence of elderly, chronically ill and disabled family members. Traditional social services that focus on a particular problem could not address the web of issues that affect the health and well-being of whole families.

    The county came up with a strategy expressed in two basic decisions. First, the approach had to be multi-disciplinary, cutting across established categories and bureaucratic turfs. Second, the opening wedge for dealing with whole families had to be the health of the children. Bringing health and social services through the schools' HEALTHY START projects to the children in the communities where the families live gives these multi-disciplinary case management teams the opportunity to deal with the needs of everyone in the family.


    International Projects


    Healthy communities projects in other nations have their own flavors. In many cases, as we have seen in Horsens, Denmark, the flavor is more inclusive: people define the health of the community in ways that go far beyond the medical, and even beyond traditional public health concerns to include environmental issues, family violence, psychology, and even the area's economic health. This reflects the sweep of the World Health Organization's "Healthy Cities" initiative (see the interview with Dr. Leonard Duhl), as well as WHO's emphasis on the importance of grass-roots organizing.

    In some cases, the different roster of projects reflects a profoundly different local situation. Unlike most U.S. programs, for instance, the KELOWNA HEALTHY COMMUNITIES INITIATIVE in British Columbia, Canada, is not concerned with homelessness, or low birth weight, or addiction. A rapidly-growing agriculture and tourism area with a burgeoning population of retirees on 50-mile long Lake Okanagan, Kelowna's top concerns are growth and traffic safety. The initiative has resulted in a Federation of Neighborhoods to get quality-of-life discussions going between the neighborhoods and City Hall, an Injury Prevention Festival "Heroes Program" aimed at young people, and "Zero Accident Days," which involve local businesses in promoting traffic safety.

    Similarly, when the SURREY HEALTHY COMMUNITIES INITIATIVE, in suburbs of Vancouver, went to the town of Fleetwood, local residents identified their top concern as having more input into the recreational facilities the town council was planning. In nearby Cloverdale, the residents first set to work on a volunteer-staffed police sub-station. Then the Provincial government closed a nearby park, a major source of income in the area, and suddenly the local Healthy Communities steering committee reconstituted itself as the "Revitalization Committee," and began working with the Province and the town council on economic development projects.

    When the ENHANCED QUALITY IN LIFE project in St. Albans, England, evaluated the health of its area, it concluded that it was "no worse than most." The main problems were the problems of an aging, settled, middle-class population: too much smoking, too much drinking, too much red meat and dairy products, too much sitting still -- as well as too many people not watching where they were going. Home accidents, a major concern, inspired such educational projects as over-sized mock-up kitchens, living rooms, and home workbenches rigged to display common safety problems.

    In contrast, the very young "healthy community" of GOLD RIVER, British Columbia, has had to build itself from scratch. A logging-company town of 2000 in a deep wooded valley on the far west coast of Vancouver Island, Gold River was founded only in 1965. It lacked recreational facilities, any health facilities beyond the most rudimentary, and job opportunities for women. Their community projects have included:

    A mining and smelting community on James Bay in Quebec, far to the north of Montreal, Rouyn-Noranda might seem like an odd place to declare a "healthy community." Though the clouds of sulfur dioxide from the Noranda Mines smelter that earned the town the reputation of "the most polluted city in Canada" have been substantially reduced, still the problems of lead contamination, other toxic elements, and acid rain, added to a climate that counts only 100 days per year frost-free, would seem overwhelming. But in fact ROUYN-NORANDA VILLE EN SANTE started in 1987 as one of the world's first "Healthy Cities" projects. A robust local committee, operating at first without the blessing of the municipal authorities, gradually gained the confidence of the town and began an impressive series of projects. They started with projects with what they call "sparkle," such as a winter festival, and a botanical garden at a local lake. From these they moved to more substantial projects, such as recycling, and the creation of a network of healthy towns and villages in Quebec, and then to such heavy-duty projects as convincing Noranda Mines to do their part cleaning up the lead contaminating the neighborhoods near the smelter and reducing the pollution at the source. Their projects are all the more impressive in that they had no one to copy, and no encouragement or funding from outside.

    SMITH COLONY #1 in Comayaguela, Honduras, stands somewhere near the other end of the scale from Kelowna, British Columbia or St. Albans, England. Recreation and traffic accidents are not on the short list of problems here. The big problem is keeping the kids alive through the years of malnutrition, diarrhea, respiratory infections and dengue fever. The 208 families of Smith #1 have a lot in common with many of the people of other marginal areas around Tegucigalpa, the capital. The average family has six members, no family planning, and a marginal existence. Almost a quarter of the children are malnourished, and more than a third of the homes have no functioning latrine.

    Yet the desperately poor people of Smith #1 have shown a remarkable energy in working to pull themselves out of their desperate situation. Through community effort, they have succeeded in:

    By any measure, the vision of Smith #1 stands out as an exemplar of building health through community action.

    PROYECTO GLOBAL DE CIENFUEGOS, CUBA stands as another contrast, this one a contrast in time. If there is one area in which the Cuban revolution is an unarguable success, it is in the health of the community. Thirty years ago the health profile of the poor of Cuba was much like that of Honduras, or any other Third World nation: infectious and parasitic diseases were rampant, family planning nonexistent, life expectancy short, medical services expensive and rare. Life is still hard in Cuba, especially since its one friend, the Soviet Union, died. But today the health profile of Cuba looks more like that of a developed nation, and in many ways is better than our own. Life expectancy at birth is 76. The major concerns are not infectious and parasitic diseases but heart conditions and cancer. Infant mortality is down to 8.2 per 1000 live births. The aging of the population has, for the first time, become a problem.

    The method for this shift was quite straightforward. The Cuban government made health a priority, developed a National Health System, and promised free health care to every citizen. Then it moved to keep its costs down through preventive measures. The same top-to-bottom street-by-street organization that the United States has traditionally found repellant about the revolution's political side proved ideal for spreading basic health knowledge, identifying trends, and assessing needs. Many of the U.S. projects that we have discussed consist of finding ways to get existing services to the people who need it. In the Cuban system, that problem is greatly obviated.

    But when the national and provincial health ministries looked at their statistics during the late '80s, they realized that they had to do something to kick out the walls. The principal problems were not, at root, medical. They were lifestyle-related. So they began to look for new ways to deal with them. The solutions in the mid-sized city of Cienfuegos, for example, look surprisingly like many of the "Norteno" projects we have already seen: form multi-disciplinary teams, go to the communities, hold forums, involve the people, get projects going. Their targets were such risk factors as smoking, alcohol consumption, obesity, lack of exercise, unhealthy diet, high cholesterol, and high blood pressure. They spun off projects dealing with such specific areas as education, nutrition, and the environment. They went to food processors and convinced them to try healthier product lines, such as low-fat ice cream; created a youth health group; collected and published some 1500 examples of healthy life choices; and helped a city gardening movement get off the ground.

    Even in a highly organized public health environment like Cuba, it is necessary to get outside the ordinary channels to encourage people to make healthy lifestyle choices.

    In Israel, the City of TEL AVIV uses, for business-as-usual, the multi-disciplinary, community-based approach we have seen used in special experimental pilot projects here in the United States. For planning and budget purposes, city departments consult with each other, then send teams out to each of the city's neighborhoods to tease out the local needs and concerns in public meetings. Many of the city's health initiatives are based on this familiarity with the neighborhoods. For instance, one program teaches parents to teach other parents in their neighborhoods how to improve their parenting skills. Information carried by peers and neighbors (like the information and safety kits carried by neighbors in Madison County, North Carolina) can be accepted more easily. Primary care is carried out in the city's 23 neighborhood family health centers, 15 of which are staffed by multidisciplinary teams that include doctors, nurses, psychologists and speech and occupational therapists. This intensive focus on the child and family in the community has led to, among other things, an infant mortality rate of less than five per 1,000 live births -- one of the lowest in the world


    Project Names, Addresses, and Contacts