Judith Kurland
on the art of inclusion

interviewed by Joe Flower


This article was published as part of the Healthcare Forum's Healthy Communities Action Kits, Module 4, in 1994
International Copyright 1994 Joe Flower All Rights Reserved
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Concentric Circles

People have to do more than buy your idea: they have to help shape it. You have to keep the project design open as you grow. If they can't help shape the idea, they won't have as much pride of ownership. People want to have added some value. You have to let them participate in the design of a project even if you feel you have really thought it through.

This means you have to be selective about the order of the concentric circle. The first circle, the circle I started with, was people with whom I was totally comfortable, with whom I shared values. It was a diverse group in terms of race, but not in terms of values and ideology. When you first start, you don't want to have to argue about whether people should have a right to vote, or whether every kid should get an education. Don't bring in people in the beginning who are going to challenge the basic idea with a top-down point of view. You'll be arguing with people about things that you won't give in on.

You want to see that each circle buys into the basic design and approach: do you believe in a community ownership of a shared project? Do you believe in inclusion? Boston, after all, has quite a history of non-inclusion. It has always prided itself on its neighborhoods, but "neighborhood" can often be a code word for "ethnic enclave."

Share control, but . . .

So we want to share control, but I get to say a few things at the start: for instance, that the organizations involved in this are going to be inclusive in a variety of ways, including their subject areas. They will have residents, and not just organizations and institutions, as members. They will be inclusive in terms both of ethnicity and of gender, with some process to keep including more. And they will be inclusive in their governance.

You need to have some of the power centers involved. It's hard to build an alternative system based completely on people without power. But the extent to which previously unempowered people now have organizations is much greater than it used to be. So there is some sharing of power already.

The ability to stop things is a million times greater than the ability of people to get things going. Very small organizations can actually prevent things from happening. You get small organizations saying it's a power grab by politicians, or playing racial politics. Some of the health centers, for instance, did not want Healthy Boston to go forward. It was a turf fight. They argued that if there was money to be had, they had needs.

I kept expanding the number and type of participants, so that they wouldn't be the dominant force. I got enough other organizations who had some power involved to outweigh them. In order to protect their interests, they had to come along. Now several are among the most active interests in Healthy Boston. Once they participate, they begin to see how it will work for them. We try to make it impossible for any group or sector to dominate.

It's always tricky, though. This is part of the reason that you want continually to widen the circle. For instance, a self-appointed (and other-appointed) spokesperson for the black community thought that all the money should go to the black community for infant mortality. In public forums it is important to treat all such questions seriously. The community deserves that respect even if the spokesman doesn't. I would just point out that, `This is not an infant mortality program.'

Do you need the mayor?

We had been expanding our circles, but we didn't have enough of a force. Because we have a strong-mayor system, my staff felt that the mayor, Raymond Flynn, needed to buy into it. As Commissioner Of Health And Hospitals for the city, I ran the city hospital, so I had a separate source of funding for the project, in the Medicaid Voluntary Payments Program. I needed the mayor to release the money, but that was really just a technicality. What was more important was the mayor could get city department heads involved.

But Flynn was very sensitive to the existing powers, despite his image as a wave-maker, a rocker of boats. A lot of his staff didn't like the Healthy Cities idea. They saw it as adding to my turf, my own personal power. But some of the more perceptive members of the mayor's staff didn't like it for a different reason. They saw that it wasn't about me. But they saw that it would create an alternative center of power in the city, which was basically true.

So we put together a three-day conference called "Building Health Through Community: International Lessons." We brought in people from all over the world. We invited all the community agencies, including the nay-sayers, and we made them come out with a report, with recommendations on how to go forward. The answers were nearly identical to our internal design, except that they recommended that Health and Hospitals should take the lead. That was the only thing that we hadn't designed. Then we could say that a three-day meeting of 300 community leaders had come up with the design for Healthy Boston.

Once they realized that it was going forward, that I had the money, and that I had told enough of the community that I had the money, they saw that they had to join in. The Mayor was running for a third term. A couple of his staff convinced him to make Healthy Boston the centerpiece of his re-election announcement. They never did any more than that, but we were able to use it. We wanted to include other city departments into our concentric circles, though most did not buy into it. Some loved it, such as the housing and education departments. But we also got a lot of buy-in at second level of departments. The Mayor's chief of staff was helpful. He convened a staff group to work on social services, and I turned it into a Healthy Boston Inter-Agency Task Force.

Even with no opposition, you need wide circles of support. Inertia is the greatest force in the universe.

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