Building Community Power To Dismantle Policy-Based Structural Inequity In Population Health

Public health agencies, philanthropy, and hospital community-benefit programs have been confounded by the persistence of population-level health disparities for several decades.¹ The recent COVID-19 pandemic has shined a spotlight on the compounding effect of these disparities, given that communities already experiencing higher levels of chronic illness, such as diabetes and obesity, have endured more severe forms of COVID-19.² In the US, COVID-19 disparities, similar to virtually all other significant health disparities, are profoundly racialized, with African American, Latinx, Native American, and Pacific Islander populations experiencing a disproportionate burden of morbidity and mortality.³

It is well established that socioecological conditions are fundamental to health—that one’s ZIP code matters more to one’s health than one’s genetic code.⁴ These conditions are strongly influenced by past and present policies,⁵ especially in employment, land use, housing, and access to health care. These policies continue to be shaped in the US by the country’s unique legacy of racial and economic segregation and marginalization. Health disparities, then, are better understood as health inequities⁶—socially unjust and often structural, in that they are highly aligned with policies that have denied and continue to deny certain groups the opportunity to be healthy.⁷

The central challenge for public health, philanthropy, and health care organizations focused on population health is understanding how to design health improvement strategies that can confront and dismantle policy-based structural inequity.

Centering Policy

Although some US population health strategies have focused on policy change,⁸ most continue to focus on individuals’ behaviors, genes, or access to health care and are solely informed by a biomedical understanding of health. We call these strategies technocratic because they largely ignore both the history of different communities and their current socioecological context—most notably, the profound impact of racism in both eras. These strategies have had limited success. For instance, the most common of them—those that seek to change individuals’ behaviors such as smoking, eating high-fat diets, or physical inactivity—have largely failed.^9,10

If health inequities are, in fact, the byproduct of socioecological conditions, and if these conditions exist as a result of policies that are insufficiently health protective for certain groups (and, in many cases, racially discriminatory),¹¹ then policy reform must be at the center of population health efforts. We call this a democratic approach to health improvement rather than a technocratic one.

We define democracy as a form of governance in which people have the authority, directly through civic participation, indirectly via advocates, or both, to hold policy makers and institutions accountable. This process is fundamentally political, a term we use not in a partisan way but to refer to the struggle over the allocation of public resources. These resources are administered at local, regional, state, and federal levels and can be used to create conditions that protect health, such as the presence of parks and grocery stores or basic infrastructure such as sidewalks or pipes that deliver potable water.

To hold policy makers and institutions accountable, communities have to build and channel their power. In this context we lean on the work of others^12,13 to define community power as the ability of people facing similar circumstances to develop, sustain, and grow an organized base of people who act together through democratic structures to set agendas, shift public discourse, influence who makes decisions, and cultivate ongoing relationships of mutual accountability with decision makers that change systems and advance health equity.

The above definition explicitly calls out the importance of community members acting together. Although it is individuals who vote, in democracy it is their combined voices that have the potential to change policies and socioecological conditions. Our definition of community power also speaks to the plurality of democratic structures. Democracy plays out through a number of arenas, with the electoral arena being just one. Others include the legislature, judiciary, and administration, all of which can be influenced by organized communities to varying, often state-specific, degrees.¹⁴

Implicit in the democratic approach to health improvement is the idea that communities are geographic, with their “similar circumstance” being the space they inhabit. People form communities on the basis of all sorts of circumstances and interests, however, from ethnic origins to supporting the same team. Indeed, people are part of numerous communities simultaneously, and these communities often overlap with or nest within each other.¹⁵

In this article we look at how health researchers have come to the link between community power and health and some of the empirical research examining it. We then share an example of our work at the California Endowment, where, since 2010, we have been learning how to support fourteen low-income communities to build and channel their power as a strategy to address health inequity.

Theories Linking Power And Health

In 1989 S. Leonard Syme posited that the degree of control someone has over their life may be fundamental to health.¹⁶ He made this suggestion after observing that risk factors failed to explain why rates of disease increased progressively as one moved down the socioeconomic ladder. Syme observed that the one thing that changed with every rung is how much control individuals have, which he suggested involved things such as money, power, information, and social status.¹⁷

In 1995 Bruce Link and Jo Phelan posited that the fundamental cause of disease is a lack of access to resources that can be used to avoid risks or minimize the consequences of disease.¹⁸ They defined resources broadly, including money, power, knowledge, social status, and social support.

In 2004 Sir Michael Marmot posited that for people above a certain threshold of material well-being, two things matter most to health: how much autonomy they have over their lives, and the opportunity for social participation. In his book The Status Syndrome, he illustrated how inequalities in these two things play a big part in the social gradient in health.¹⁹

One of the things to note is how these researchers used different terms and how those terms sometimes overlap. In 2016 Margaret Whitehead and colleagues brought together the key terms and synthesized the main theories linking differences in power to health inequity.²⁰ They separated the theories into three levels: individual, community, and societal. Although the levels interrelate, in this article we focus on the community level, given that, as outlined above, it is implicit in the democratic approach to health improvement.

According to the theories, community power can protect health directly, such as when a community successfully deflects the placement of a toxic waste facility in its neighborhood, and indirectly, such as when community action fosters social support and inclusion, which can, in turn, increase trust among community members, reduce alienation, and improve mental health. In these examples, community power is an instrument, a means to an end. But community power is also fundamental, an end in and of itself.¹³ This is best illustrated by its absence. When a community feels powerless, it can lead to a collective sense of mistrust, which causes distress. This distress can lead to poorer mental and physical health.²⁰

Research Into Community Power And Health

Finding good-quality, empirical research on the link between community power and health is difficult, partly because of the many terms and theories used and partly because the research itself is difficult to do. With the guidance of nine key informants (see the Acknowledgments), we identified seven articles that reviewed evidence related to concepts such as collective empowerment, coproduction, and community participation.^21–27 Within these articles, we looked for research in which communities either led parts of the work or were in complete control.²⁸ We identified ninety-three observational and experimental studies. Our detailed analysis of the studies is described elsewhere;²⁹ we summarize some of the key findings below.

According to the literature, community power is linked to better prevention of disease (such as improved rates of immunization³⁰ and reductions in cardiovascular risk factors³¹); reductions in the severity of disease (such as lower infant mortality³² and positive impacts on mental health³³); improvements related to care services (such as better facilities,³⁴ greater efficiency,³⁵ and more equitable distribution of services³⁶); and enhancements to the environment (such as greater access to green space,³⁷ less polluting practices in local industry,³⁸ and better health and safety conditions for workers³⁹).

Community members involved in the work reported improvements to their emotional, social, organizational, communication, and financial skills, which had an overall impact on their confidence³⁷ and sense of empowerment.⁴⁰ And there were positive impacts on the social fabric between people,³⁷ which were linked to greater involvement in local organizations,⁴¹ the strengthening of civil-society organizations, and enhanced participation in local government.^36,42

There was a mixed picture when it came to trust, however. Some studies reported that trust in local agencies increased,⁴³ whereas others reported that it decreased.⁴⁴ There were also a few negative findings. For instance, some studies showed that community power had little impact on intended outcomes,⁴⁵ whereas others showed that any increase in community power was countered by a reluctance to share power among people within systems.⁴⁶ With regard to the process of the work, some studies described how community members were fatigued by the strain,⁴⁴ whereas others described tensions and disagreements with other community members.³⁷ Some studies reported that community members either did not feel they had any influence in the work⁴⁷ or were disappointed with its pace or its outcomes.⁴⁸

These negative findings and procedural challenges withstanding, however, the overall picture is that communities with power can protect and improve their health.²⁹

Despite the wealth of research linking community power and health, it is important to note three limitations. First, although community power may be related to better health, something else may explain the link. For instance, efforts to build the power of sex workers to improve their health appear to have had limited results, perhaps because of these workers’ low social status.⁴⁹ This suggests that social status is at least an important moderator. Second, given the dynamic nature of social and political contexts, community power has to be seen in terms of possibility rather than probability.¹³ In other words, community power cannot be viewed in the traditional scientific manner of “X amount of power will lead to Y outcomes.” Rather, it is necessary to appreciate that whether that power will achieve something will depend on the ever-changing landscape of opportunities and barriers. And third, consideration needs to be given to whether researchers have adequately considered racism in their analyses. It is likely that this has not been routine, given that it has not been a routine consideration in medical research generally.⁵⁰ In the US, communities of color have had access to profoundly fewer opportunities and have endured substantially greater barriers. Any analysis of community power that has not considered whether racism directed at that community was a factor is unlikely to yield a true understanding of how power affects health.

Community Power Building In Action

Our core belief is that those most affected by health inequity should take the lead in crafting and prioritizing the solutions.

At the California Endowment, our community health improvement work borrows heavily from the environmental justice movement. However, we have expanded the concept of “environment” beyond the physical to a broader embrace of the role that the social determinants of health play in shaping healthy “opportunity environments.” This includes the performance of key systems such as education, health care, land use, and criminal justice. As with environmental justice, our core belief is that those most affected by health inequity should take the lead in crafting and prioritizing the solutions. Experience has shown that such people are more likely to push for structural, rather than incremental, change. With that in mind, we sought to support the residents in fourteen low-income communities across the state to build and channel their power. We called the initiative Building Healthy Communities. To illustrate our approach, we share here how it has created lasting change in the availability and distribution of parks in Fresno, California.

Although it is well established that access to parks is important to health, the Fresno work did not start from scientific evidence. Instead, it started with a question posed by local community organizers. Residents of Southwest Fresno, an area that has suffered from redlining and decades of disinvestment and that contains one of the poorest congressional districts in the US, were asked, “If you had all the money in the world, what would you change about your neighborhood?” A significant number wanted to address the dearth of parks and open space.

It was not surprising that parks featured so frequently in residents’ responses. In 2012, Trust for Public Land, the nation’s largest national nonprofit working to create and improve neighborhood parks, launched ParkScore, a rating system to measure how well the largest US cities are meeting the need for parks.⁵¹ From 2012 to 2015, Fresno was the lowest-rated city in the country.⁵² Data from Trust for Public Land also illustrated an income and racial bias in the distribution of parks.⁵³ In Los Angeles, California, for instance, residents in low-income neighborhoods or Latinx, African American, and Asian American/Pacific Islander neighborhoods were less likely to be near parks, playgrounds, and exercise facilities than residents in wealthier neighborhoods or largely White neighborhoods.

In response, Fresno residents created Parks4All, an effort that included a public education and advocacy campaign and the building of an alliance of residents led by African American, Latinx, Oaxacan Indigenous, and Southeast Asian residents. The advocacy work involved engaging elected city leaders in community meetings and public hearings about the lack of parks and its impact. One youth, for instance, described how it took hours, using multiple buses, to reach a park with amenities such as a skate park. The residents’ stories illustrated the need for parks within walking distance that have green space and adequate lighting.

During the Parks4All effort, the City of Fresno was updating its General Plan, the foundation for local land use. Organizers noted that the neighborhoods of North Fresno, which have a higher proportion of White people, had 4.5 times more park acreage per resident than South Fresno’s Latinx, Black, and Southeast Asian neighborhoods. To raise awareness of this, they created an advertisement to be used on buses: It depicted a split-screen image of a young girl’s face, with each side reflecting the park acreage per 1,000 residents in North and South Fresno. In addition to communicating the difference in the availability of parks, the advertisement sought to reinforce the fact that one’s ZIP code predicts one’s health.⁴ However, the city refused to allow the ad, stating that it was “political.”⁵⁴ This led to an uproar that caught the national media’s attention⁵⁵ and led to the city being forced to update the parks and open space element of the General Plan with enforceable commitments to investment and maintenance. This was the first of several major victories for the Parks4All campaign.

Other victories soon followed. For instance, community residents packed a budget hearing and won $450,000 to create a Parks Master Plan for Fresno. Soon after, the city committed to creating a new skate park and BMX facility in South Fresno. Ongoing intensive organizing and advocacy also led to the creation of the Southwest Fresno Specific Plan, a prerequisite for eligibility for state park bond money, which positioned the community to draw down up to $70 million in state bond funding. Parks4All also positioned Fresno to receive $6.6 million to renovate a park in Calwa, an unincorporated and impoverished area populated by undocumented Latinx workers.⁵⁶ The park had not been renovated since the 1950s.

In 2018 Parks4All continued its momentum and helped gather the 35,000 signatures required to place a ballot measure on the November 2018 ballot, asking voters approve a three-eighths-cent sales tax in the City of Fresno to support improvements to Fresno’s parks and trails. Despite opposition from the city’s mayor, police chief, and fire chief and the Fresno Chamber of Commerce,⁵⁷ the measure received 52 percent of the vote. The city, however, insisted that implementation of the measure required two-thirds of the vote, even though that requirement applied to special taxes proposed by governing bodies, not citizen-led initiatives. The organizers raised money for a lawsuit, and ultimately the California Supreme Court sided with the residents. The measure was certified into law in July 2021⁵⁸ and raised $58 million in its first year.⁵⁹ It is projected to raise more than $2 billion for parks in Fresno over the course of its thirty-year duration.

Through Building Healthy Communities, the fourteen communities have won more than 1,700 new policies, changes in systems, and other tangible benefits by holding policy makers and institutions accountable for greater equity.⁶⁰ For instance, in the Eastern Coachella Valley, residents forced the Coachella Valley Unified School Board to end its contract with the sheriff for school resource officers and instead institute restorative justice practices, with the goal of interrupting the burgeoning school-to-prison pipeline. And in the City Heights neighborhood of San Diego, residents convinced San Diego County to create a new policy to enroll eligible individuals and their families in health insurance before their release from county incarceration facilities, leading to five thousand enrollments in the first two years.⁶¹ In Building Healthy Communities there is a special emphasis on youth in the hope that they will become lifelong advocates for social justice (with the skills required to do so). This strategy is beginning to bear fruit. For instance, a former participant in Building Healthy Communities activities went on to become the mayor of Arvin, in Kern County, and fought to prevent energy companies from drilling for oil within 300 feet of hospitals, parks, and schools.⁶²

Our experience with Building Healthy Communities is not the only example of a democratic approach to community health improvement. As previously stated, the field of environmental justice provides numerous examples. For instance, in Harlem, New York, an environmental justice organization called WE ACT used community mobilization to force the city’s Department of Environmental Protection to conduct a full environmental review of a new waste treatment facility, purchase fewer polluting buses, and distribute bus depots more equitably around the city—all helping reduce exposure to air pollution and the rates of diseases associated with it.⁸ In Calumet City, Illinois, economic justice organizations convinced voters to recommend a $15 minimum wage to the city council, aided in part by data from the Collaborative for Health Equity Cook County that showed the link between low wages and infant mortality.⁶³

Implications For Practice And Research

Given the clear limitations of the technocratic approach to health improvement and the theoretical, empirical, and experiential evidence that community power can protect and improve health, we believe that population health strategies must become democratic. This applies whether they are delivered by public health, philanthropy, or health care. This transition must start from a candid recognition that current approaches—those that focus on individuals’ behavior, genes, or access to health care—are failing to appreciably move the needle on entrenched health inequities.

From this recognition must come a radical change in how population health improvement is funded. At present, federal, state, and private funding is largely directed toward organizations in health and narrowly focused on specific diseases or risk factors. In addition, funding is generally short term and occasionally even precludes policy-focused approaches. This is incompatible with the democratic approach to health improvement, which requires a greater focus on policy change and which, by implication, requires funds to be directed toward power-building organizations and to be longer term.

Embracing the democratic approach to health improvement will require organizations in health to change.

Embracing the democratic approach to health improvement will also require organizations in health to change. Returning to our definition of community power, they will need to learn how to partner with and facilitate power-building organizations, develop processes to be accountable to communities, and be open to change in the pursuit of health equity. Indeed, local health departments, as local government agencies, are part of the administrative arena of democracy and should be accountable to communities. Tax-exempt hospitals have a similar imperative.

There is no doubt that this will be new and challenging work for leaders in health, especially for those who have come to assume that their skills and knowledge afford them primacy over community organizations and community members. This does not mean, however, the abandonment of expertise. Rather, leaders must learn to work alongside community organizations by sharing what is known from practice and research that might advance a community’s attempts to influence policies and improve its socioecological conditions. Furthermore, leaders in health understand how public systems operate from a budgetary and programmatic perspective, something that is often opaque to community organizations and community members. Sharing that knowledge can sharpen communities’ efforts to bring about change.

Some health entities already make themselves accountable to the communities they serve through community engagement. This practice, ubiquitous in population health strategies, is highly variable, however, with some communities merely being informed of strategies and others having significant roles in designing, implementing, and assessing them.⁶⁴

We draw on the evidence summarized in this article to propose a new model linking community engagement and health improvement and creating conditions conducive to communities building or channeling their power. We build on a model proposed by Jennie Popay in 2006, which illustrated that the type of outcomes possible from community engagement depend on the depth of the engagement.²⁸ At the shallow end, only service and health outcomes are likely, but as engagement deepens, other, more social outcomes become possible, such as greater social capital. In our new model we call these outcomes “community outcomes.” Based on our review of the literature, we separate these outcomes into those that concern the people involved in the work and those that concern the social space between them. Deeper forms of community engagement—those that go beyond informing and consulting communities to involving, collaborating with, and deferring to them—have the potential to build people’s skills, confidence, and sense of power and enhance trust, social cohesion, and a community’s sense of their combined power. These community outcomes are conducive to communities building and channeling their power. In other words, a community with skills, confidence, trust, social cohesion, and a sense of their individual and combined power is more likely to develop, sustain, and grow an organized base and act together through democratic structures to set agendas, shift public discourse, influence who makes decisions, and cultivate ongoing relationships of mutual accountability with decision makers—our definition of community power.

The online appendix contains an illustration of this model and a more detailed discussion.⁶⁵ We hope that the model can be a tool to help leaders in health critically assess their approach to community engagement and consider whether they can do things differently to better contribute to the democratic approach to health improvement.

In addition, research needs to change. Instead of continuing to focus on individuals’ behaviors, genes, and access to health care, the research community should focus on community power and democracy as key factors in health equity. This refocusing is long overdue, given that leading researchers were positing the importance of power more than thirty years ago, in the late 1980s. But instead of proposing new projects that keep funding in the hands of researchers and academia, researchers should offer their expertise and access to funds to community-led projects seeking to build power to improve socioecological conditions, of which there are many across the United States. Part of the challenge for the research community will be to find new measures for community power and deepen the understanding of its link to health.⁶⁶

We have learned that optimizing local democracy is an effective population health intervention.

In Building Healthy Communities we have learned that optimizing local democracy is an effective population health intervention. This means communities having the power to hold policy makers and institutions accountable through the electoral, legislative, judicial, and administrative arenas. Doing so requires an ecosystem of local base-building organizations connected to sources of regional and statewide influence. The infrastructure of this ecosystem, including the formal and informal alliances and coalitions within it, needs to be supported as much as any of the organizations within it. In our experience, it is this infrastructure that enables health equity movements to operate at the scale required to hold policy makers and institutions accountable, although precisely what is required is influenced by the social position,⁶⁷ networks,⁶⁸ culture,⁶⁹ and political context⁷⁰ of community members and how open entities within systems are to change.⁴⁷

Health Equity And Democracy

As the COVID-19 pandemic vividly illustrates, the root cause of many community health problems is primarily social, rather than behavioral or biological. Policy-mediated conditions, such as poverty, lack of health insurance, lack of paid sick leave, and inadequate wages, create social vulnerability that translates into higher rates of preventable disease. Despite this, population health improvement efforts remain technocratic in nature. It is our contention that this represents a fundamental misdiagnosis of the problem. If it continues on this path, the US will certainly face further decades of widening health disparities and further relative decline in health status.

At its core, much of health inequity in the US is a product of racism and its policy legacy. Undoing health inequity will require uprooting and dismantling policies and systems that have been denying certain groups health-protective resources and opportunity. This is an unjust status quo. These communities must have the power to hold policy makers and institutions accountable for equitable outcomes. Ultimately, the work of health equity requires enhancing the quality of democracy to change the status quo power balance in communities throughout the US.

ACKNOWLEDGMENTS

Pritpal S. Tamber received support for the research that underpins this article and the drafting and revising of the article. That support was part of a grant from the California Endowment to the Insight Center for Community Economic Development (Grant Agreement No. 20202262.2). The authors thank the nine key informants who helped them find research on the link between community power and health (listed alphabetically by surname): Michael Little, Sir Michael Marmot, Mahasin Mujahid, john a. powell, Shannon Sanchez-Youngman, Rebeca Sandu, Paul W. Speer, Nina Wallerstein, and Margaret Whitehead. The authors also thank the other key informants who helped them deepen and broaden their understanding of the link between community power and health: Renée Canady, Brian Castrucci, Reena Chudgar, Abdul El-Sayed, Lili Farhang, Nick Freudenberg, Sandro Galea, Megan Gaydos, Rosa Gonzalez, Jonathan Heller, Phyllis D. Meadows, Jennie Popay, Geoff Wilkinson, and Kirsten Wysen. In addition, they thank Richard Smith for his advice on how to approach the health literature; Alex Desautels, Meredith Minkler, Sandra Witt, and Hanh Cao Yu for feedback during drafting; and Brad Caftel of the Insight Center for Community Economic Development for overseeing the administrative and funding details involved in this work. This is an open access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) license, which permits others to distribute this work provided the original work is properly cited, not altered, and not used for commercial purposes. See https://creativecommons.org/licenses/by-nc-nd/4.0/.

NOTES

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