Sustaining The Effort:

Building a Learning Community


By Joe Flower and Tyler Norris


This article was published as part of the Healthcare Forum's Healthy Communities Action Kits, Module 4, in 1994.
International Copyright 1994 Joe Flower and Tyler Norris All Rights Reserved
You can reach Tyler Norris at .
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It's still a work in progress, this craft of building healthy cities and communities. The systems we are working with are so large and complex, so human and political, that there can be no simple rules that lay out how to build -- and sustain-- the transformation of a community. There is no catechism.

But there is a lot of sweat equity out there, a built wisdom counted in years of careful hard struggle, spread among the people who have actually been engaged in this work for the past decade. To gather this wisdom, we talked to a dozen people with a depth of experience. Nine of them are founders or shepherds of ambitious city or community transformation efforts -- eight from North America, one from Denmark. To that we added two people with more global knowledge: Len Duhl, the creator of the "Healthy Cities" idea who, with Trevor Hancock, conducted WHO seminars in over 100 cities around the globe to help them get their local programs going; and Hanmin Liu, head of the United States/China Educational Institute, who for the past year has traveled the globe at the request of a major American foundation, evaluating social change programs from Poland to Ecuador to the Philippines. And finally we added Marvin Weisbord, whose "Future Search" conferences, which "bring the whole system in the room," have turned out to be a powerfully effective tool for creating sustainable positive change in an organization or a community.

We asked each of these dozen the same question: how do we build something that lasts? Out of their experiences they provided answers that were sometimes expectable and sometimes remarkable, such as: there is such a thing as too much money; sometimes the best way to deal with a troublesome outsider is to bring them inside; and sometimes, to sustain a project, the leader has to leave.

Governance, structure, leadership

"As the project matures, it tends to perpetuate itself. The hardest time is the first few years," according to Marian Chambers, who until recently was executive director of the Jacksonville Community Council, which every year publishes a report card measuring community progress on over 70 issues. Sylvio Dupuis, now the New Hampshire Insurance Commissioner, makes the same point: "The Manchester Agenda has taken on a life of its own through the city and the Chamber of Commerce." But how do you reach that point of self-sustenance?

The vehicles to build "something that lasts" are not themselves always meant to last. Many are community based planning efforts, such as Central Oklahoma 2020, which are ephemeral organizations designed to spark sustainable change. Others, such as the Jacksonville Community Council, are established organizations spinning off projects which change and adapt to the needs of the moment. Different local realities call forth different types of organizations -- and one of those local realities is a matter of personality.

Social entrepreneurs

Every social change effort grows from a core of one or a few strong personalities pushing to get things done. But this energy source carries its own problem: it has to be renewed. As Len Duhl puts it: "In order to get it started you need social entrepreneurs. But they have to build a backup team and a set of replacements quickly. Many of these people are loners. They don't build a team, and when they leave, the whole thing starts to die. This happens all over the world. If you want it to last, you really have to be doing two jobs: developing a program and developing someone to replace you."

And in order to keep them around, you have to give your social entrepreneur some room to maneuver in the funding: "Grants for five years are not worth giving. They need to be longer than five years. You need to buy people, giving them the message, `If you are good at it, we'll back you up,' rather than evaluating them constantly."

This ideal butts up against the reality that start-up processes can rarely corral more than two or three years of funding at the start. Practically speaking, local initiatives need to plan on a multi-tiered financial strategy, looking for short-term funds while building relationships and confidence for the long run. They need to use those first years to prove that they have garnered adequate local support and are beginning to generate tangible results. Then they can go after more medium-term funds from sophisticated "investors." The Colorado Healthy Communities Initiative, for instance, is a five-year commitment, with three years of support for each community (one year for planning, two years for implementation). This is perhaps the longest-term, up-front investment in healthy cities in the United States.


Getting the right people with the right motivation involved in your board is central. The whole purpose of the 20-year-old Jacksonville Community Council, for instance, is to improve the quality of life in northeast Florida by involving the citizens. Its board is a group of 25, diverse in race, class, and gender, most of whom have experience as board members. There are term limits, but most board members want to return as soon as they are allowed to, according to Chambers: "It's the only place that they can come and hear everyone's various interests expressed in the public good."

The size of the board is as important as its composition. Experts on meetings say that it's hard to hold a good, all-inclusive, productive meeting with more than eight people -- it's hard for everyone to have their say and take action before people tire. For much the same reason, studies of boards show the upper level of functional units somewhere below a dozen people. But the desire for diversity and inclusion, and the need to raise funds, pushes us to enlarge the board. Symphonies and other arts organizations commonly have boards of 70 or more. The Metropolitan Area Committee (MAC) in New Orleans has a board of 165, and an executive committee of 30.

What is most important is that the governance structure match the task at hand. The task for Central Oklahoma 2020, for instance, was a nine-month-long, community-based planning process. It was designed to dissolve itself at the end of its tenure and leave implementation to existing organizations. It pulled together 80 diverse stakeholders, so that it would have the breadth of diversity to create and nurture its 12 initiatives. At the same time it had a "Coordinating Committee" of 15 to manage the business and logistics of the process. This allowed the 80 stakeholders to focus on content.

Which sector takes the lead depends to a great deal on who steps up to the plate. In many areas, for instance, the business sector and the Chamber of Commerce can be narrowly focused on such business concerns tax incentives and labor laws. In both Jacksonville and Manchester, they are leading the renewal effort. According to Dupuis, the Manchester Chamber sees itself as "a broadly-focused community service agency."

"After all," he says, "If I am a business considering coming into town, I'm not just considering the taxes and the work force, I'm considering the whole community, from the health facilities to the symphony to the educational institutions."

Central Oklahoma 2020 looked for leadership that could be "palatable to all groups," according to Zachary Taylor, of the Association of Central Oklahoma Governments. "The chairman was a businessman, but he was well-respected by the non-profits and cultural organizations. He felt that we must be honest, with no agendas, we must have open meetings, we must be inclusive, and we must not be controlled by any one individual or group."

Struggles over control can be damaging. Strong personalities can step to the plate to take on a lot of the work -- or to shoulder others aside, depriving you of more energy than they in fact contribute. Grant, from Tillery, found this happening even in his tiny hamlet, but "with good leadership, we were able to hold those strong personalities at bay, while helping others to feel more comfortable expressing themselves. I like to try to nurture the leadership ability of the one at the table who feels they have the least to offer. After all, you can't teach them if you intimidate them."

As Taylor puts it: "Interests are often advanced by those who are simply more diligent. The greatest effort to drive the process in a particular direction involved education. We have some very conservative elements. Their agendas, about school choice, charter schools, and parental control, were put on the table. They worked extremely hard to prevail. They were not successful. They opened people's eyes, but the result was not as extreme as the most dominant voice had wanted it to be. It was very frustrating for some. They said `We're not willing to confront it.' Others were. Others said, `We'll manage through it to have balance in what we're doing.'


Canadian and European efforts have usually been anchored in City Hall. American efforts have usually been anchored in independent foundations, business groups, healthcare organizations, or community groups separate from the political structure. Not surprisingly, the Europeans and Canadians insist on the importance of political backing. Real Lacombe, in Quebec, considers the involvement of the municipal government on the three "legs" that supports a healthy community effort. "This gives legitimacy to the project. Cities have resources that they can invest. They collect taxes."

"The political commitment is key," says Jens Houmann, founder and shepherd of the Horsens, Denmark project, one of the most successful examples WHO's work has produced, now approaching its eighth birthday, with more than 50 ongoing projects. "The municipal government is involved in a lot of our projects. Many of the ideas do not come from people inside the systems, but from citizens. We have to facilitate them by creating a working group around them. We have to identify whose job this is, or should be, and involve them. We don't go to their boss, but directly to individuals who are motivated and working with us already, or are easily moved. We contact them, get their acceptance, then help them get permission upstairs."

But though the Horsens effort sprang from City Hall and works closely with it, even Houmann prizes its independence: "The way that we have tried to facilitate the `Healthy City' idea makes it last. We started as a small department in City Hall. Now are a self-owned foundation, independent, a neutral platform. We have access to all the facilities of the municipal system (such as phone and fax). We have a politician as chairman. We have political support, so that the city is not our antagonist but our partner. But what would happen if we came on a problem that the politicians didn't want to touch? If we are part of the system, they could just shut us up. That's not fair to the city. If we lose our credibility to the citizens, we might as well stop."

Similarly, Healthy Boston started within a city department, but with an independent source of funds. [see: Judith Kurland On The Art Of Inclusion]

Healthy City Toronto, on the other hand, is directly funded by the municipal government, and has had to fight political battles to survive [see: Marilou McPhedran on Political Survival], though every individual program has someone else sharing the costs. Horizontal in organization, the director of the project reports not to any one department head but to all department heads -- and the director also has a seat on the committee of senior city management.

All sorts of different structures will work, but they have to stay flexible. "The structure changes as the need arises," as Gary Grant of North Carolina's "Concerned Citizens of Tillery" puts it. "At first the Concerned Citizens board did everything, then as the health concerns grew we developed the Area-Wide Health Committee."

"Most people are not trained to live with ambiguity," Dr. Duhl points out. "In this work, that's the world. So people concretize things as quickly as possible, turn them into bureaucracies. You need to constantly change the organization, personally and institutionally, on a regular basis." Hence the value of the approach that builds a temporary "virtual healthy community organization." This helps diffuse healthy city policies throughout all of a community's organizations, rather than just in the one promoter.

Leslie Gerwin, until recently the executive vice president (functionally the CEO) of the MAC in New Orleans, as well as director of its Education Fund sees this difficulty with ambiguity expressed in a false politeness: "That's a behavior that persists to this day: don't challenge, don't create conflict. Our major problem is the issue of diversity: how do we address our differences and make them acceptable? I don't have an answer to it. On the other hand, I do believe that the starting point is getting the people who have power to share the forum for decision-making with those who don't. Diversity is not really ethnic, racial, or cultural, it's between the haves and have-nots. This is about getting the have-nots some kind of stake in the future, and getting over the civility that prevents that. In the education project, we did have both at the table. What we had not gotten to is going past the niceties, challenging the beliefs, and still building trust."


"The demand I keep getting is `give me the product,'" says Duhl. "But in the first few years, the process is the product." Similarly, Dupuis says, "It can't be a project, it has to be a process. There has to be an understanding by the community that it is a process that will never be finished. The vehicle will always be used to put together groups of people to explore the challenges and opportunities."

The shape of your process will depend in many ways upon the shape of the community, on what kind of cohesion it has to start with. In some places it is hard to find a core group to work with. Gerwin expressed her frustration with this problem: "There is no collection of people [in New Orleans] that can look at a situation and really want to empower people and do something that will yield a real result. I see primarily a leadership that is motivated almost entirely by personal advancement. I find it extraordinarily frustrating"

"In Oakland," says Duhl, "if you try to gather the leaders of the town, you're looking at a list of 400 people. Many cities don't have the small group of insiders who really make the city work. In that case the first act is to help create that group. In Seattle, if you can start by getting Boeing, King Communication, Group Health, and a few others on board, things will work out. Then they can fade into the background and you can bring in the community people. If there is no cohesion, you need to try to create it by bringing the different parts of the system around the same table."

This is an especially important message for health care organizations who serve as the founder of a healthy city project -- they may serve as the catalyst, convenor and initial funder, but if the projhect is to succeed and sustain itself, they must become one partner around the table, creating room for others to take shared ownership.

Gerwin's frustration, on the other hand, reflects the difficulty of cutting across class lines to bring the different parts of the system together. The MAC had organized an historic effort to reform the governance of education in New Orleans through a stakeholders' dialogue. "The process first identified 80 stakeholders in the education system. This was too big a group to work with, but the core committed group was more like 40 or 50. Yet in that core group there were no CEOs, no top-level people at all. Even though education reform is a very big idea, the idea of doing it with people who are not like them was just anathema [for the top people], and they would rather just wait until the opportunity devolved upon them. Even for the most committed ones, it was just not a priority, it kept getting bumped on their calendars."

Similarly, Houmann wants top-level people when that's what it will take: "If we just get a representative from a department, we will just get a passive observer, rather than a motivated partner."

Lacombe agrees: "Successful steering committees usually have as members people who are the decision makers of other organizations. They are the people who can decide to put resources into it. When they are not decision-makers, have to go back to their bosses for support."

As we pointed out in the "Stakeholder" section of Module 1, the process needs to bring in leaders at all power levels. We have to move beyond the "usual suspects," the traditional power brokers, but we must also include the "usual suspects."

"A lot of the buy-in needs to come from within the city bureaucracy," says McPhedran, of the municipally-supported Healthy City Toronto, "so that you can build horizontally. One of the most important parts of that is not to upset anyone, only asking people for what they are ready to give. You also have to prepare them for the substantive work you're going to do out in the community. Easily 75 percent of the time that the team spent on the project was on stuff outside the office, or with people from outside. These connections with the outside tend to make the bureaucrats uncomfortable. But they are crucial to reach a point where the politicians and the bureaucrats feel that they cannot defund the project. The Healthy City Toronto team understood that they were the tugboat, towing a mother ship. Unless you have some cooperation from the bridge, you have a lot of problems."

"Our process," says Grant, "was primarily a matter of helping the community understand that it was something that they needed to do, not something that others could do for them, and that if they give a little time, great good can come of it. Goal-setting was done from within the community by stakeholders. We clearly stated to everyone what would be going on at each stage."

Forest or trees?

Do you building your healthy community one tree at a time, or take on the whole forest at once?

Central Oklahoma 2020 takes a "forest" approach: 100 volunteers from across the political geography throughout the Oklahoma City metropolitan area held meetings every three weeks for a year, starting May 1993, to develop a vision for the region, to plan strategy, set performance goals, and pick 12 major initiatives, ranging from improving air quality to redesigning the juvenile justice system. The biggest initiative, for instance, is an array of "Family Resource Centers" -- neighborhood-based centers for families -- throughout the region. Like the Atlanta Project or Baltimore's Sandtown Project, these centers will focus on helping families and neighborhoods solve their own problems.

The National Civic League supports this "forest" model, which Zachary Taylor, of the Association of Central Oklahoma Governments, describes this way: "You have the vision that you want your community to move forward. Everything you do -- the structure, the process, the outreach -- is all built around that goal, pulling the bow back, pointing the arrow toward the target. Of course, when you start, you don't know what your target is going to be. There were no predetermined outcomes. We would create that vision, and as a region identify initiatives that would take us toward that vision."

Len Duhl's in favor of starting with a fast-growing, pretty tree: "Build small projects early on. Get some success with something that you can build on."

Lacombe echoes his mentor: "Start quickly with easy, visible, concrete projects. People will be more ready to plant trees or build a magnificent garden around a downtown lake -- as they did in Rouyn-Noranda, my home town, which had the first official Healthy City project in North America. Out of 27,000 people in the town, we have had as many as 3000 involved. Then we Built on the success of those early projects, to address more complex problems.

"Another good example is the city of Sherbrooke, with a population of 80,000. The started with an environmental project that involved tree-planting, a youth center in the downtown area, a recycling project, and a project dealing with toxic domestic products and fire risks in the home. These were all very concrete and short-term.

"But in the past year, they have moved to a single priority: the fight against poverty. This is much more complex and long-term. They are focusing on innovative methods that are under their control. For instance, one program encourages public institutions and businesses to each help one community group with staff support, telephone service, and office space, since community groups more likely to be successful in helping the poor than government or large institutions are. They are also getting institutions to review their policies for their sensitivity to the poor. They are building on their previous successes, which have given them visibility and credibility."

"In a large project, people get swamped," Grant observes. "They don't see how they fit into it. But you can plant one tree, get it rooted, and go onto the next one. In a while you've built a forest. Working one tree at a time, people are able to see what they are doing. Their awareness grows, and the needs and the resources become very clear." This approach also allows people to grow into their roles: "You can't make people take the opportunity until they are ready for it. If we had told the people in the Area-Wide Health Committee ten years ago that they needed to go talk to the county Health Department, they would have said, `You're crazy.' By the time we did, we had some successes, and they felt that they could do it."

But Duhl, who advocates the fast-growing tree, is the first to point out that this "project focus" could throttle the goal of systemic change. Paradoxically, the greatest danger of this strategy is that one tree will be too successful. "That really kills it," says Dr. Duhl. "When one particular project becomes the focus of the group, they drive all the other people out. They don't do it consciously, they just do it. You constantly have to remind others and yourself that you need to keep a broader view of the world. The conventional wisdom is to follow what works. But it's like a family with one child that has special needs. If the parents put all their energy into that child, they lose the other kids. You have to have a two-pronged attack: 1) follow the success, and 2) go into areas that are not now rewarding you."

In founding "Healthy Boston," Judith Kurland solved the "tree vs. forest" dilemma with a different approach: building out from a center of clear consensus, "organizing existing community agencies and power centers in concentric circles of support, agreement, ownership, and authorship." The project is now about four years old, with a year and a half of development before its founding.

Speed counts: "What raises the credibility," according to Houmann, "is the shortest possible distance between an idea and visible action. We have created a small unit with a fast-working administrative side. If they want to collaborate with the citizens, they have to work fast. Once you raise the expectations, you'd better live up to them. If you don't, you lose credibility, and may as well close the door of your shop."

In many ways, the "forest or trees" dilemma is a false one, like the false dilemma of choosing the environent or the economy. What is important is that the approach match the purpose. If you are attempting a community-based planning process like Central Oklahoma 2020, Healthy South Bend, or Healthy Detroit, you need both the forest and the trees. On the other hand, if you are designing a stand-alone health promotion project, you certainly don't need to gather the diversity of a community for nine months. Large-scale approaches that set out to change the whole system system can be big medicine for communities -- when the timing is right. But the timing is not always right for major change. Sometimes, in some communities, the best path is to just pick something and do it -- and bulding on the momentum of its success. And even the the large-scale planning approaches need to have two tracks, one for the large-scale planning, and one for short term action, for picking the "low hanging fruit" of obvious immediate actions that do not require planning.

Maintaining Participation

Lacombe, a former student of Len Duhl's, feels that a healthy community project rests on three "legs" of participation: "1) involvement of local government both as leader and as participant, 2) intersectoral cooperation (participation of business, education, environment, and labor sectors, community groups, and religion organizations), and 3) citizen participation."

Greater participation is clearly a shared value of any pushed toward healthy communities. But Kurland complains that "`participation' has become a weak word. Unless larger groups of people have not just participation but ownership, in the sense of control, you can't sustain things over a long period of time with little or no funding. Healthy Boston has shared decision-making control. Some things, such as the allocation of all funds and choosing of projects. still have to be central, because of our fiduciary responsibility. But long-term the notion is that there would be shared ownership, control, and decision-making over joint resources, the funds themselves."

You can even have so much participation and interest that it becomes a problem. "If new people are showing up at every meeting, you're always starting from scratch," says Duhl. "Again, you need a two-pronged approach, with one piece always moving forward, and one part always starting over. You can't parse it out. The people who are moving ahead carry others along with them. This gives the newer people some ideas and some hope: `Gee, they were able to accomplish that!'"

How the organization works with those who want to help is equally important. "There have to be specific roles for people to take so that they can feel equal. There are those that try to take it all," as Gary Grant says. Chambers points out that the organization that survives will be "one that knows how to empower and enable volunteers. People can get fed up real fast if they feel they are being manipulated."

In the end, of course, people are self-empowering -- it's up to the leadership to remove the barriers.

On the flip side of this same thought, the volunteer team must have at its core a group that truly understands where you're headed. Gerwin, in New Orleans, was frustrated with her volunteers: "In Neil Pierce's writings [about the "City-State"] and the thought of the National Civic League, there is such a broad vision. The Metropolitan Area Committee could be the vehicle for that vision. But the volunteers are so entrenched in an old vision. They lack the ability to live in the future rather than the past."

As Lacombe puts it, "The staff and the core volunteers must have a certain profile. They must have the vision, the attitudes, and the skills that fit the vision of a healthy city."

Her complaint touches on a deeper thought: the organization as a whole must have fresh clarity on its reason for being. "MAC is 28 years old," she points out. "It came into being because the integration of schools was coming, and people didn't want New Orleans to be Little Rock. The white business people realized that it was in their interest to cause integration to happen peacefully. They wanted to work with the black leadership, and to convince the white uptown folks to go along. It was a model of delegated power. But today New Orleans is forced into a mode of sharing between the races. If there is a need for largesse it must come from black majority to white minority. The basic question is: what does MAC want to be? It hasn't defined itself in a zillion years."

"You have to have the ability to learn and to change," says Liu. "Some organizations have great vision and programs, but are not in touch with their constituencies. They think everyone has to come to them. That doesn't work. People don't get the message. Some very in touch with constituencies, have no capacity to learn what it is that they are doing that is working, and how to make it better. From what I have seen of the different foundations that I visited, those that had the capacity both to be in touch with their constituencies and to change what they are doing to provide for that constituency, are more capable of sustaining themselves."


"I draw the circle of inclusiveness very large,"says Duhl.

This echoes Marvin Weisbord: "If people feel strongly about leaving someone out, or that someone is powerless and has no influence, I push to have them there."

One of the reasons some community members get so outrageous in opposition to new ideas is simply that they have been excluded from the club that makes the decisions. Not only is inclusion the right thing to do, it also brings fresh talent and energy to the table. And those that you exclude may be able to block your initiatives. The cynicism and sense of hopelessness present in our communities is one of the greatest obstacles to change -- and inclusion is a key to overcoming it.

Taylor, reflecting on the struggles over educational policy in Central Oklahoma, says, "When we put the lists of stakeholders together, there was a lot of concern over whether some individuals should be there. But the process brought them in, allowed the issues to come up, and even allowed people to arrive at some conclusions. Even those who felt most strongly about one position or another ended up respectful of the process and the conclusions.We are all blessed by the fact that what we agreed to do can be supported by the consensus of the whole group. The process created the opportunity for a real conversation about these issues to occur. So often its not a conversation, it's sound bites in the news, and blurbs in the paper"

"We worked to ensure that all areas of the community were represented," says Grant. "We mainly did that through the churches in each crossroads community. We gained the approval of local leaders, churches, ministers, heads of local deacon boards. We got the `doers' involved at the earliest stage, rather than just making plans and asking them to carry them out."

"If someone is going to put in substantial amounts of money or energy," Hanmin Liu comments, "you have to create a lot of room for that. You have to create opportunities for them to define what they want, what their vision means for your project. You have to move to a higher order concept, and give up your own control. Some people and some institutions are unwilling to give up control, so they're not going to attract significant players to partner with them. It's important really to hear your partners' interest, vision, mission, and strategy as well as your own."

Central Oklahoma 2020 found it had failed to include a great resource in its own backyard: an ecumenical Christian organization called "World Neighbors" that has worked in Third World countries around world to help villages identify problems and form solutions to them. Zachary Taylor says, "They contacted us, and said, `We're stakeholders, and we don't feel we're involved in what you're doing.' I said, `You're about to be.' They had never done anything domestic. They have become partners in the endeavor, are helping to train people. They secured someone from Kenya to help in the training. We secured funding to bring the person here. They have been very helpful to us in training our outreach workers in how to work with smaller areas. You always have to put more people on the ship with you. Inclusiveness is something that you build as you go along."


Sustainable resources are broadly-based resources. The Horsens project, though it was rooted in City Government, gathers its funds from a variety of sources, including foundations and a for-profit subsidiary that sells its "Healthy Cities" expertise all over Europe. "If we put all our eggs in one basket," says Houmann, "we would die the minute we were not interesting anymore."

"We never fund anything totally by ourselves," says McPhedran. "Everything has to be cost-shared, whether internally within the city or with outside institutions (like Women's Hospital). That is a non-negotiable principal of the team."

The Colorado Healthy Communities Initiative, with its 28 sites, was seed-funded to the tune of $6.8 million over five years, by grants from the Colorado Trust, Colorado's largest health philanthropy formed by the sale of a non-profit hospital system. The Trust recognized a need for a broader and more leveraged approach to approving health status than just giving out grants to a range of academic institutions, healthcare organizations and community based service providers. It selected communities which demonstrated a strong local coalition and a readiness to take on a broad-based collaborative planning effort.

Healthy City efforts such as Central Oklahoma 2020, Columbus 2000, the St. Joseph County Healthy Communities Initiative (South Bend), Healthy Orlando, and Healthy Detroit were all launched via public-private-nonprofit collaborations, with diverse funding sources. These typically included local foundations, businesses, hospitals and health care systems and a mix of city and county public sources. This approach generates a diverse funding stream that creates a more broadly-shared community ownership and reliable supply of funds.

Staff support

At the core of the resources for a project is one very simple thing: staff support, some group of people, however small, who can field the phone calls, do the photocopying, and find the meeting spaces. Rene Lacombe says of the 94 projects he has spread like Johnny Appleseed across Quebec, "Those that fare best are the ones with continuous staff support for coordinating the project. Inter-sectoral cooperation not an easy thing to do. People can be discouraged if the process is not adequate. This is even more important than getting great funds. There has to be someone who helps the various committees, who gathers the information. I have seen projects just disappear because the staff support was interrupted. It doesn't have to be a huge amount. It can be voluntary . It can be part-time. It can be shifted from the government or any other institution involved. In Quebec, it usually comes from the city government or from the local community service center. It can be as little as a half day per week."

Marilou McPhedran, who ran Healthy City Toronto for four years, agrees: "It's very important, when you have to generate a number of pieces of paper to get the support you need, to be able to pull together documents. People say, `Yes, I'll do this for you, but I need this and this.' It becomes very onerous to the team. They get stopped from the real work. It's great to be able to put a few grand into someone who can put together a report or a document that it is readable, accessible, and pleasant to look at."

But it's also possible to have too much staff -- or the wrong staff. Becoming "staff driven" can sound the death knell of a process, by crowding out the need for volunteer support, even at the most basic level. The opportunity for voluntarism engages people. When one gives to an effort, one becomes a part of that effort. If the response is, "Don't worry, that will be handled by staff," staff will be all that is left in the end.

You need the same qualities in the paid staff that you need in the volunteer leadership: they must be inclusive, sharing, engaging, and welcoming of other's ideas and energy. A staff that sees the healthy city effort as "their" mission, a staff that is controlling in nature, will never generate the support we need for sustained change.

Beyond staff support, a number of people spoke of the importance of organizational continuity. Marian Chambers was executive director for 15 years at the Jacksonville Community Council, which every year publishes report card measuring community progress on over 70 issues: "You have to have some organizational continuity and staff continuity. It helps that I really cared about the report card, and kept pushing it. Someone else might have said, `If they won't fund it this year, then we'll do something else.' The effort can be a partnership, but one organization has to be in charge, and that has to be an organization that is perceived as neutral and objective.

In New Hampshire, Sylvio Dupuis takes a different tack: "The Manchester Agenda is more of a monitoring idea. It's a figment of our imagination. It doesn't have a board or anything. We are not trying to build another organization, or a bureaucracy, we are trying to build a public/private process. The resources for the Manchester Agenda are provided through the Chamber of Commerce and the Manchester Economic Development Office, which reports to the Mayor."

This parallels the National Civic League experience: in many communities, the last thing they need is another not-for-profit organization with another board of directors. Many projects focus on form rather than function. Form must follow function. If there is an existing or emerging collaboration that can serve as the form for this function, let it.

Too much money?

"Sometimes money kills the project," says Duhl. "Back in the Model Cities program in President Johnson's `War On Poverty,' the amount of money we had to throw around created a lot of what we called `poverty pimps,' a lot of people ripping us off, figuring out an angle. Too much funding can discourage people from stretching and using their mental muscles. Without adequate funds, people imagine how to find solutions. So the WHO process helps in this way: there is no money attached to it."

"A lot of developing projects only live as long as they have extra put in," says Jens Houmann, "extra time, extra money, extra effort, extra facilities. We have a double strategy. We start anchoring the process at the very minute that we start the development project. We don't make projects, we facilitate and mediate. We are like parents. Once it has its own life, we have to let go, but not move so far away that `junior' doesn't feel safe. We are always trying to get away. We always say that we don't have any money (which is a lie) and we say that we won't be in the working group for very long. This is also a lie sometimes, but it helps to get the right focus in the group."

Lacombe insists that "it's important, in fact, that there not be resources from the central level. Central funding can be cut. If it's cut everything stops. Here in Quebec there has been no funding from the province or federal government. They have only funded the information center. This forces people at local level to find their own funding. They have to interact right at the start, just to put together the necessary resources.

"Often organizations will apply for funding just because it's there, and they will tailor their requests to the objectives of program. This creates dependence. If it is to be sustainable, it's better to do it with your own resources. It's like the small town of 1000 people here in Quebec that wanted some funds for recreation. They were told that all that was available was funds to build arenas. So they got a government grant and built an arena. Now this little municipality is impoverishing itself trying to maintain the thing."

The Colorado Trust recognized this risk in putting together the Colorado Healthy Cities Initiative. It asked organizations and government agencies in the state to apply funds for technical assistance, planning, and implementation. The first challenge was to select recipient communities in which a groundswell of support was more evident than talented grant-writing. They did this by visiting the communities and talking to people. The second challenge is the transition to other sources of funding after the Colorado Trust implementation grants are expended. All through the process, the Trust emphasized the need to demonstrate local resources and commitment. In reality, if a community cannot generate local financial support after three years, it is probably more from a lack of clear purpose or a solid plan, than from a lack of community resources.

McPhedran, in Toronto, says. "When I began as project director in 1991 the budget was close to $800,000. Most of my work has been in non-profits, so that was a lot of money to me. At the end of the 80s, to the bureaucrats at Toronto City Hall, it was easy money. But the recession hit at just about that time. The budget is now $421,000, and they are doing more. The Healthy City Toronto model is actually a model for doing better with less. I don't think it's terrific that the budget is half what it was, but it's workable. When there is too much money, it works against partnerships. It's against everyone's interests for the five levels of government to work together.

"But now Toronto is experiencing a poverty unlike any it has never known. It's worse than the depression of the `30s (in percentage drop from 1989 to 1994). When the mayor was ready to change her vote (see box: McPhedran on Political Survival], she went through all the economic partnerships, and showed their economic efficiency.

"We have been working with churches, and non-profits, we have even founded a local economic development group for homeless women. A lot of these projects incubate out of our offices, literally in the back room, then move out. That kind of resources -- space, semi-independence, some authority to dispense some money, a few grand here and there, $500 on printing or mailing, can be powerfully important. We funded a coordinator position for just four months to get the Clean Air Partnership going. We kept it going a few more months at a time, with federal and provincial money. It's still going two years later."

Transferring knowledge and capacity

In Jacksonville, the annual report card is the core of the Community Council's effort. But there was a problem: how to keep the top people in town involved and aware. The solution was both clever and effective. The report card is funded by the Chamber of Commerce. Every year the Community Council staff prepares the report card. A review committee looks over what the staff has done, ensuring its accuracy, and prepares a report emphasizing gold stars and red flags. According to Chambers: "We institutionalized the idea that the chairman-elect of the Chamber of Commerce sits on the review committee, and then presents the findings to the Chamber's Board Of Governors. This gives the new person a complete education on the community, all 74 indicators, and makes them an advocate of the process."


"Evaluation in a very wide sense is very important," says Lacombe, "but not necessarily always in the fashion done in the academic or bureaucratic world, as a complex statistical process. It's hard to measure the impact of planting 200 trees in a neighborhood. Some communities, for instance, might include a measure of satisfaction as reported by a list of key informants."

Many evaluation processes beat with a purist academic heart, and operate separately from the process itself. Rather than recognizing the iterative nature of each approach -- learning, modifying, correcting in mid-course, trying again -- they often evaluate in order to generate lessons for processes other than the one they are studying. They miss the substantial opportunity to provide meaningful input to the process itself and perhaps help it work better. Evaluation should be the method that the initiative uses to refine itself.

In Central Oklahoma, each initiative has its own measurement vehicle. And one initiative is to create an overall report card, like Jacksonville's, which will look at quality of life indicators, including subjective surveys. "It's to establish a framework, so that we can see how we effect the numbers," says Taylor. "One initiative, for instance, is to attain and maintain clean-air status. We will look at the numbers for air pollution season-to-season. We can call an alert, then look at transit ridership to see our effect."

Sometimes, measurement itself can produce results. "We didn't start the project thinking that it would bring about a direct result," Chambers says of the Jacksonville "report card" project. "We looked on it as a measurement tool that others could use. We never said that we would take each of these things on. But a lot of things have happened. For instance, we saw that the school dropout rate was bad and getting worse. Some citizens did a study of the problem, and that resulted in a push by citizens to adopt the Cities In Schools program, which brings into the schools a number of existing social services, such as counseling, tutoring, and health services. It started in two schools five years ago, and this year it will be in 25. In every school where they have done it, the dropout has declined.

"In another example, the Chamber of Commerce got concerned about the declining water quality in St. Johns River. They decided they needed to increase citizens' awareness, and worked with the Water Management District to publicize the problem. That got a citizens group going, the Stewards of the St. Johns River, along with the Young Stewards for kids, plus a River Watch Hotline to report dumping

Similarly, the reports have shown a high rate of lung cancer, but nobody knows why. A number of people have been trying to get a sophisticated epidemiological study. Because of the data in the report, they were able to get the city to fund part of it."


"Many places put a lot of energy into celebration, such as community festivals," says Rene Lacombe. "Rouyn-Noranda started its project with wide community consultation, including the kids in the schools, at beginning of winter, 1987-88. To thank the kids, they organized a winter celebration in February on the lake in the middle of the town. Since then it has become a yearly event, which last year lasted 15 days and had a budget of $150,000. They give out healthy city awards, which helps people's motivation and focuses the local media."

Among other things, celebrations can tie the city's transformation to its history and mythology through a set of rituals. Oakland, California, puts on a Festival Of The Lake around Lake Merritt in the center of town every year. "Every group in town comes," says Duhl, "because it's the only thing that has no tension attached to it."

Every city and community has its own mythology, expressed in images and stories. Toronto, for instance, expresses both its sophistication and its Canadian fastidiousness in the often-retold, probably apocryphal story of a filmmaker who came up from Hollywood to make a film set in New York: Toronto was cheaper and safer, but looked much the same. But it wasn't dirty enough. So he had his crew secure a bunch of garbage and strew it around. They left for a coffee break, and by the time they came back to start filming, the mess was all cleaned up.

"You build on that kind of mythology, and you put the images to use" says Duhl. "One town, for instance, had kids draw pictures of what they thought a healthy city looked like on all the construction sites, and put the Healthy City logo on the pictures. You build on the existing mythology, even if it's a negative one. You re-frame the negative mythologies: `That's the right story, but the interpretation is wrong.'"

Celebrations can also transform people's image of themselves. In April of 1993, Gary Grant and the Tillery Area-Wide Health Committee journeyed to San Francisco for the Healthcare Forum's first annual Healthier Communities Summit, to pick up their first-place award. The journey had a profound affect on the committee, according to Grant: "The trip out to San Francisco did wonders for us. You brought the nurturing we had been doing to fruition. They came back with new steam and new commitment, willing to take on even more, because now they felt they could handle it. Now the members of the committee will go into the community to sell the health clinic, and outside the county as well. I couldn't get them to do that before. Now they are coming in asking, `Why don't we do such-and-so?' In the meetings, they are much more verbal about what we should be doing. They even serve on other committees. One member has become part of the AIDS Task Force. The visit to San Francisco gave her the little extra push she needed to believe that she could do it. I no longer have to entertain funders by myself. Before, I just couldn't get people to come out. Now I basically don't have to do anything. Before, the members of the health committee would have been very fearful, asking, `Am I saying the right thing in the right way?' Now they deal with all the questions themselves. People are getting real confident. For instance, the Open-Minded Seniors kept having to change their meeting times to accommodate the federally-funded transportation program. When the program wrote them a letter saying, `This is when you have to be there for the bus,' the Open-Minded Seniors just fired them. Now they use personal cars and the Tillery van. And there's me in the background going, `Yay! Yay!'"

"At the end of the year-long planning project in April," says Taylor, "we had a parade downtown, with ethnic groups, groups representing different areas, bands, children's groups. It ended at a beautiful historic building. We had kids reading from vision statements -- representing the generation that will be of age in 2020. We had a poster/essay contest for kids sponsored by the largest newspaper. Mayors gave speeches (we kept the speeches short). It was a great, happy moment.

"We build a lot of celebration into every gathering. That's very important. A lot of this is not easy. We have some very tough conversations. Celebration helps to sustain people."

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