Building Health Communities: Interview with Tony Iton (Part 1)
Building Healthy Communities (BHC) is a 10-year, $1 billion program of The California Endowment (TCE) to help 14 low income communities across the state take action to improve health in the places they live. The following interview explores the initiative’s inception, progress, and lessons for the field with Tony Iton, Senior Vice President of Healthy Communities at TCE.
Dan Rinzler: How did The California Endowment’s Building Healthy Communities initiative come about? What were the main objectives?
Tony Iton: The Building Healthy Communities effort stems from The California Endowment’s recognition that over the first ten years of our existence, we had failed, really, to make much of a difference in some of the big health status indicators for people in California—issues like obesity and many of the measures of chronic disease.
After TCE’s first decade of work, it was clear that while there were programmatic and policy successes—and certainly individuals had benefitted—there weren’t many instances of substantial improvement in some of the big trends in disease, in health status, particularly for low-income Californians. That was of great concern to the board. So it started to look for other ways to move the needle on some of these big outcomes and came to the notion of doing comprehensive, place-based efforts over a decade, as opposed to the kind of shorter term, project-level type interventions.
DR: When did it launch?
TI: The planning for it took many years, as you might imagine. The actual launch was in 2009.
DR: What was the theory of change? Or was it intended to be more of a learning process?
TI: There was a relatively coherent theory of change at the outset. And the theory is that the things that shape people’s health are related to opportunity, and despite this, the dominant American narrative about health is focused on two things—access to health care and personal behaviors. The hypothesis behind BHC is that that is too narrow a conceptualization of health, particularly at the population level, and that there are also important policies that shape people’s environments, and that environment influences not just health status directly but also the behaviors that people engage in that would ultimately influence their health status.
So the theory is that there are certain aspects of the environment in many low income communities that are adverse to people’s health, and that by changing those environments, to make them more health-protective, we would see improvements in the health status of the populations living in those environments. Furthermore, by enlisting the active participation of those community residents that are most impacted by these adverse environmental conditions, we would be helping to build more resilient communities that will continue to sustain and defend these health protective environmental changes.
And so the only question was: How do you meaningfully change those environments? And that’s what BHC set about trying to find out and then prove—what would ultimately have a substantial impact on health status.
DR: Would it be fair to say that while intention was to address the social determinants of health that you described, the specific mechanisms for doing so were somewhat unclear, and there was a learning process understood from the start?
TI: Yes, I think there was a kind of skeletal set of strategies and tactics, but fundamentally the actual approach was designed to allow for evolution and continuous learning after significant interaction with community partners who would not only shape the priorities but shape the strategies.
DR: What was the strategy—staffing, tactics, that sort of thing—at the beginning?
TI: The idea was to select a handful of low-income California communities that were experiencing significant health disparities, which started with 200 and then whittled down to 14.
And the belief is that within those communities you’ve got resources that are not being optimized, and the goal is to figure out how do we invest in such a way to optimize those resources that will ultimately lead to the greatest degree of community resilience.
So let me just take a half step back here and say the theory is that communities that are disorganized, that lack infrastructure, that face enormous challenges, also have assets within them, and those assets are undervalued. And the approach is essentially to organize those communities in such a way that they optimize the use of the resources that they have at their disposal.
We approached this work by investing in what we call the “Drivers of Change” in those 14 communities, which are basically five things:
One is “people power,” which is building social, political, and economic power in a critical mass of people so that they can have more influence on the environment in which they live, including the policies and the politics that shape the resources to which they have access.
The second is youth leadership and youth development, because young people can be a major liability if they’re idle and underinvested in. If they’re not in school, or essentially not occupied, they tend to get engaged in crime, which tends to drive people’s health down very quickly in low-income communities. And if they’re not acquiring the skills they need for 21st century workforce participation, then they essentially become a liability in terms of the tax burden on society.
The third (collaborative efficacy) is bringing together all the various sectors that represent the social determinants of health—the land use agency, education, law enforcement and the larger criminal justice enterprise, social services, health—and forging the kind of relationships that are necessary for them to work together to improve overall quality of life.
The fourth is leveraging the resources of the private sector to harness the power of private- sector investment, which led to things like our fresh food financing initiative (FreshWorks).
And finally, we sought to change the narrative around what produces health, which had been focused on individual responsibility and access to doctors— we wanted to broaden that narrative so that people think about health when they look at a park or a grocery store or a bike path or a good school.
Today, we fund organizations that work in each of those five Drivers of Change to try to bring about new policies and practices and systems.
Here’s an example of how the process works:
If the community had prioritized healthy food, we would invest in organizing people to start participating in processes that shaped the decision-making about where the grocery stores are established or where the fast food restaurants or the liquor stores are located, and how those things were regulated and managed in the local communities.
We would invest in youth leaders that would learn about healthy food, learn about things like community gardens and advocate, within their schools or in various different decision-making bodies for improved healthy food offerings.
We would get the system’s leaders together that were responsible for making decisions on this topic—and that’s pretty much all of the system’s leaders, because all of these systems have institutions associated with them, and those institutions serve people food at a minimum. Many of them procure food—the jails, the schools, the city parks and rec department. So we would organize them and get them to focus on: how do you optimize the access to healthy food in the community?
We would leverage private dollars, and that’s what our FreshWorks fund is again, bringing in private capital to try to build grocery stores.
And then we would change the narrative. Work on trying to increase people’s awareness and understanding of how what we eat has a profound impact on our health. And it’s not just people’s personal choice; it’s also what choices they have available to them. The choices we make are the choices we have.
DR: What was the decision making process in establishing priorities in each of these communities? It sounds like a very participatory process—which is great—but was there any back and forth with subject area experts (such as yourself) where you think, “Oh, well what will really move the dial on health is if we can have a grocery store here,” and the community says, “We want better policing.” What was that process like?
TI: This is Tony Iton’s opinion—and it’s probably a little extreme—but I don’t think it matters what you decide to work on, all I think that matters is that you work together on it.
The organizers will tell you that you have to meet community members where they are and work on the things that matter to them. It may be a stop sign, or it may be cleaning up the dump. And so even if you’re a health agency that’s interested in obesity, if you try to impose an agenda around obesity on them, they’ll not likely be willing to work with you on that, unless they see it as their own agenda.
Your question is also asking about competing agendas at the local level. And that’s a fact of life, a fact of any kind of political process. You get people together to find consensus. So our strategy is to support and facilitate consensus building around priorities, but to avoid imposing our agenda or anyone else’s agenda on people that live and experience those environments on a day to day basis.
DR: What legitimacy did TCE have coming into these communities and playing what sounds like a pretty substantial convening and quarterbacking role?
TI: It’s a great question. TCE is the largest health foundation in the state of California and we have been in relationships with many of these communities since we were created. So I think that we’re known, and we’re not just an outsider. There’s legitimacy there—we’re not an outside entity, we’re not a for-profit entity. We’re owned by the people that we’re serving, and I think that there’s a modicum of understanding of that.
But I think the more important legitimizer is that we work primarily with local health departments as our government entrée into communities. And unlike some other aspects of government, like planning agencies and law enforcement, health departments tend to be very trusted. Health departments and schools tend to be the most trusted government agencies, particularly among low-income people, including immigrants, because those agencies provide services to populations regardless of their ability to pay or immigration status, and tend to be perceived as welcoming and inclusive organizations. We get some cover coming in with schools and health departments. Our communities recognized relatively quickly that we could be trusted.
DR: What are your measures of success? Are there particular health outcomes you are targeting and tracking?
TI: When we set out at the beginning, we said there would be four big results or indicators of healthy communities that we would track: obesity, youth violence, school attendance, and health insurance enrollment.
We figured that in healthy communities these numbers should look fairly robust, in the sense that the positive ones should be high—health insurance enrollment, school attendance—and the negative ones should be low—youth violence, obesity. And we know that throughout California when you look at communities, wealthier and healthier communities tend to have numbers that reflect those outcomes, that basic direction of outcomes.
But we quickly realized that those were kind of a traditional, medical kind of approach and when you define the problem as obesity or health insurance, then the solutions tend to be narrowly focused around those and we wanted broader solutions. We wanted more root-cause solutions focused on the social determinants.
And so we offered people ten outcomes from which to select their priorities. Those outcomes were written quite broadly and focused on three different environments in the community: school settings, neighborhood settings, and health care settings.
People chose from amongst those ten outcomes and prioritized their local plans accordingly. Our theory of change is that we would work with communities using the Drivers of Change to build capacity, to build this notion of resiliency in the community, so that the community was both much more capable to defend its needs and to assert and advocate for its needs.
And our belief was that that would translate into a new set of policies and practices at the community level that were more conducive to health. And that those policies and practices would yield improvements in health status.
So if you imagine an arrow leading from capacity to policy to status (Increased Community Capacity–>New Policy Implementation–>Health Status Improvement), that’s basically the theory of change. And so our notion was that we’d have to have metrics for the capacities that we were building—primarily the Drivers of Change; metrics that track the implementation of key local policies that are important health-protective policies (we believe that there are 12 key local policy clusters-the Transformative Twelve); and then third, metrics for the health status of the population over time.
That’s still the basic idea. We’ve recognized that some of the data that you need to collect is quite subjective which requires surveys and also collecting narratives. There are also independent objective data sources for various health status measures.
DR: Interesting. And so just to clarify health status, you mean particular health outcomes like obesity?
DR: Are you actually doing longitudinal tracking? How are you collecting that data?
TI: We have good sources of data, fortunately. We have things like the Fitnessgram in California schools through which all 5th, 7th, 9th graders get tested annually and weighed and measured, and a body mass index is calculated. We can track that longitudinally and it’s the best source of data we have.
We also use the California Health Interview Survey or CHIS, which is an extensive California health survey and BRFSS, which is Behavior Risk Factor Surveillance Survey that’s conducted by the Centers for Disease Control. They get sample representatives for regions of the country, and we can pay either of these groups to over sample if we choose to within our 14 BHC communities.