(Baltimore, MD) I am here for a panel on “Systems Change and Culture of Health” at the Robert Wood Johnson Foundation’s Culture of Health conference. My great fellow panelists were Sonal Shah (Georgetown), Derwin Dubose (New Majority Community Labs), and Karen Matusoka (Centers for Medicare & Medicaid Services). The audience seemed to be composed mostly of health practitioners and policymakers who were already strongly committed to three goals:
- Doing a better job of understanding the needs, priorities, and circumstances of truly diverse people by engaging them in influencing health interventions and policies. For instance, instead of telling a specific group of new immigrants how to improve their health, pay attention to what they already know and want.
- Supporting solutions that require collective action by residents. Dubose brought up a situation in which individuals couldn’t exercise in a local park because it was too dangerous, but a group started tai chi exercises there every day at noon. Only a coordinated strategy would work, and coordination requires organization, trust, leadership, and skill. This point is related to the previous one, because community members would be the first to know about the danger of the park and the popularity of tai chi. Not only is a coordinated strategy essential, but only the participants are likely to be able to invent it.
- Recognizing and enhancing the civic capacity of whole communities to achieve better health. For instance, Robert Sampson’s major book Great American City shows that Chicago neighborhoods achieve better outcomes for their children if the adults are organized and active in civic life.
Several participants noted that these were shared principles in the room–but none of the ideas are really new. In fact, a roughly similar discussion could have occurred 50 years ago, during the 1960s movement to make health (and research) more “community-based.” That impulse still remains marginal, which can be discouraging.
I would note that some relevant practices and networks have grown and strengthened over the past half century. (See, e.g., Community-Campus Partnerships for Health and the networks it represents.) But I would also acknowledge the powerful hold of a technocratic model in which solutions are developed at the “bench” and implemented at the “bedside.” That model is deeply rooted in modern epistemology and reinforced by the prestige of technology. It serves both governmental and corporate bureaucracies. So it is not easy to shake, and may even be worse than it was in the 1960s.
Policy changes can help. If–as one example–the National Institutes of Health funds community-based research, we get community-based research. But even the best-intentioned policies don’t implement themselves. They require dedicated and persistent work, everywhere from the national or state agency to the street level.
Civic engagement by communities can help. Why do Chicago neighborhoods get better outcomes–regardless of race and class–if they are organized and active? I would propose that this is partly because they support and compel local institutions, such as schools, police districts, and hospitals, to engage with them better. Every Chicago neighborhood has the same police chief, school superintendent, and mayor, but some neighborhoods receive more responsive government at the local level. Note that residents are not organized in specific policy domains, such as health or public safety. They are organized in multi-purpose civic and religious associations and networks. Those are essential for driving change through institutions.
Finally, we need effective organizing within the professions, a strategy that my friends Harry Boyte and Albert Dzur have advocated–and practiced–effectively for years. Like any good organizing effort, this strategy begins with recognizing the assets and interests of the people in question. Physicians, health administrators, and academic researchers are people, too. Lecturing them that they should be less arrogant and more sensitive to diversity may fail for the same reasons that it usually fails to lecture people to eat more vegetables.
But health professionals have interests that can be tapped–for instance, interests in getting better results and escaping social isolation. Most of all, they can develop genuine skills for engaging the public better. That is hard, complex, challenging work. It requires evidence and analysis. When we tell professionals to be less professional–to diminish their sense of expertise and authority–I think it goes over like asking people to eat their broccoli. Even if they want to comply, all the incentives work against it. But when we reward them for exercising advanced professional skills in community engagement, we treat them as assets and give them ways to excel. Combined with policy changes and grassroots pressure from outside, this organizing effort within professions may begin to change systems at a large scale.