Prescription for Well-Being

Efforts to improve health focus on helping neighborhoods

As a blazing sun bears down on her on an early fall afternoon, a woman named Tong walks among rows of cilantro, mint, sugar cane, Chinese long beans, and some

vegetables native to Southeast Asia that, she says, have no English names — cucumbers the size of small watermelons, small orbs halfway between being tomatoes or peppers.

The garden sits beside a neighborhood where 9 in 10 of the Hmong refugees in this town of 12,000 live in poverty. It provides 114 Hmong families with food when their welfare checks or meager earnings can’t — and links them to their past as farmers in Laos.

Organizers and supporters of a foundation-backed collaborative group that encompasses Marysville and five other poor Northern California towns hope that it can also link the Hmong to better health. Part of a 10-year, $20-million effort in 30 towns by the Sierra Health Foundation, in Sacramento, the three-acre garden was given to Marysville’s Hmong four years ago.

The early yields are promising. While tending to their plants, Marysville’s Hmong have also fulfilled part of the effort’s overarching goal: to improve the health of the residents and to help them voice concerns about obstacles to their health and well-being. When the local government threatened to turn off water to the garden, the Hmong and their children talked them out of it. Now, Hmong residents use a steering committee they formed, with the help of a local collaborative group, to deal with county officials.

But, organizers say, the neighborhood-growing work involves more than vegetables and herbs, and is far from over. It will take time — and money — to make the Hmong full partners in the doings of their town.

“The garden really hasn’t connected the Hmong to the rest of the community,” says Jeanie M. Young, co-coordinator of the Yuba Community Collaborative for Healthy Children, which oversees the program. “That’s the next step for them.”

Broad Definitions

Marysville’s example echoes both the hopes and the challenges that nonprofit groups cite when they discuss such programs, which generally are referred to as “community building” in the name of improving health. Buttressed by studies that show that 70 percent to 80 percent of a person’s health is affected by one’s environment and way of life, and evidence that joining groups can improve health, proponents say programs with far-ranging approaches will ultimately do more to help neighborhoods prevent illnesses than the medical-services programs that foundations typically support.

Grants focused on community building typically go to groups of residents, not necessarily established charities. Such efforts have been based on poverty and problems other than health, but what all community-building programs have in common is that they encourage residents to work with government agencies, charities, and business groups. While some efforts have succeeded, others have failed because they often involve ambitious goals and involve a wide range of groups that have disparate approaches and cultures.

Marguerite M. Johnson, vice president for programs at the W.K. Kellogg Foundation, in Battle Creek, Mich, which has spent $55-million in recent years on health-focused community programs, says it can be difficult to persuade grant makers “that there can be concrete outcomes that result from a lengthy community process and that to do it well, bringing people together can be quite costly.”

Health programs designed to gather neighborhood strength haven’t been the most likely of foundation grantees, but they are hardly new. More than $100-million has been applied to health programs that focus on neighborhood involvement during the past two decades collectively by the Annie E. Casey Foundation, in Baltimore, the Robert Wood Johnson Foundation, in Princeton, N.J., and Kellogg.

Early pioneers of collaborative health programs say the efforts have paid off. The lure of foundation grants has helped to create alliances, such as those among races and between neighborhoods and police departments, says Paul Jellinek, vice president of the Robert Wood Johnson Foundation.

Programs that focus on health can help build neighborhood strength, “because people will come to a meeting about addictions or getting drugs off the street, but not one about community building,” says Mr. Jellinek, who adds that such programs appear to be growing.

In the past five years, foundation-supported programs designed to help neighborhoods deal with the causes of bad health have gained a foothold in the Midwest and in poor agricultural towns and fading industrial areas in California, where some foundation efforts are supplemented by proceeds from a state tobacco tax. Among the problems neighborhoods are encouraged to devise solutions for are asthma, drug addiction, teenage pregnancies, and obesity. But other issues, such as jobs and safety, are sometimes included as well because they are considered vital to residents’ physical health.

Much of the movement lacks form, as program leaders and foundation officials continue to search for the best ways to start collaborations and measure their effects. But proponents point to some early signs that those programs are working, such as:

• Safer neighborhoods. A Sacramento collaborative group persuaded city officials to change 160 burned-out street lamps on crime-ridden streets. “The Centers for Disease Control says that childhood obesity is a national epidemic, but many inner-city kids can’t go out their doors because it’s not safe,” says Dorothy Meehan, vice president of the Sierra Health Foundation, which supported the effort. “Some of our collaboratives have made it safe for kids to get out and exercise.” A major benefit of the foundation’s program is that it turns grant money over to residents in 26 areas in Northern California. “The beauty of these collaboratives is that residents decide what a health issue is, not agencies or foundations,” says Ms. Meehan.
• Growth in leadership. The Kansas Health Foundation, in Wichita, has spent $1.2-million in the past three years to put 1,200 people through leadership training in 17 Kansas towns. In Dodge City, trained leaders have gone on to start child-rearing classes taught by Mexican-Americans for Mexican-Americans and programs that get information on health-care access to non-English speakers. Carol Meyer, president of Leadership Garden City, a nonprofit group connected to the town’s chamber of commerce, credits the Kansas Health Foundation with helping to develop programs that bring disparate cultures together. “We can get any grant we want from anyone because of our demographics and poverty rates,” says Ms. Meyer. “But we’re very careful about what grants we take. This isn’t about getting big money. It’s about getting people to understand our community and to care enough about it to make a difference.”
• Improved transportation. Troubled by traffic congestion and poor air quality, members of Healthy Mountain Communities, a collaborative group in Carbondale, Colo., determined in the mid-1990s that they should focus on the future of the area’s transportation. With help from grant money from the Colorado Trust, in Denver, the group devised and lobbied to enact legislation to expand an underutilized transportation authority with the power to start bus lines. The Roaring Fork Transportation Authority, the largest in rural Colorado, now carries 4 million passengers per year.
• Increase in vaccination rates. Another Sierra Health Foundation-supported group, the Children First-Flats Network, in Sacramento, recently reported that the number of immunizations in two neighborhoods had risen 300 percent since 1995. Because of its success, the vaccination program has been used as a model by nonprofit groups and government agencies in four other Sacramento County locations.
• More political power for residents. A collection of residents’ groups in West Fresno worked with government officials and businesses to open a supermarket in an area where there hadn’t been one for 30 years, thanks partly to support from the California Endowment, in Woodland Hills, and the Rockefeller Foundation, in New York. In Richmond, Calif., poor and working-class residents now sit on a group designed to improve health by enhancing the job prospects of those living in the city’s four poorest neighborhoods.

“The bottom line for all of us is doing something about community health, but there’s more to it than that,” says Larry D. Hill, executive director of Partners for Health, a nonprofit group in Richmond backed by the California Wellness Foundation, in Woodland Hills. “Some of our poorest, most disenfranchised people end up sitting next to representatives from the these collaboratives. That’s a sign of major progress right there.”

Social Connections

Some proponents of creating neighborhood groups for the sake of health take their cue from Robert D. Putnam, a Harvard University professor of public policy and the author of Bowling Alone: the Collapse and Revival of American Community. Mr. Putnam argues that a decades-long trend away from joining groups has deteriorated civic life and, in some ways, health.

“People who are not connected to their communities run a higher risk of death,” Mr. Putnam says. “Your chances of dying within the next year are cut in half if you join one group. Not joining brings the same level of risk to your health as smoking.”

But others who have studied the subject say that the Putnam model is passé, and that those who follow it by attempting to create “social capital” in the form of collaborative neighborhood groups are misguided. Neighborhoods are too fluid and dynamic in most places to form the same types of old-fashioned groups that Mr. Putnam lauds, his detractors say.

“We’d do better to find new ways of connectedness than try to return to what some foundations see as a golden era of togetherness,” says Richard Florida, an economics professor at Carnegie Mellon University, in Pittsburgh, and author of The Rise of the Creative Class.

Others argue that without financial capital, either in the form of national health insurance or other guarantees of health care for everyone, groups will make only piddling gains in overcoming inequities in health.

What’s more, some critics see efforts as futile and emblematic of some foundations’ desires to impose their values on neighborhoods.

“The rhetoric of community building is so vague as to be meaningless,” says Heather Mac Donald, senior fellow at the Manhattan Institute, a think tank in New York, and the author of The Burden of Bad Ideas, in which she criticizes foundations for pouring money into ineffective programs.

She adds that some efforts by grant makers, such as an Annie E. Casey Foundation program designed to help neighborhoods come up with solutions to teenage pregnancies in five cities, espouse values that might be insensitive, a charge that foundation officials deny. “There was maximum openness in discussions of sexuality, which was forced on immigrants who don’t share those values,” Ms. Mac Donald says.

Even the best-designed programs don’t last long enough to make any kind of difference, she adds.

“These things tend to peter out,” says Ms. Mac Donald.

Proponents of community-building efforts add that the skepticism of residents can work against them, and that foundations should be involved in programs for the long haul to counteract that. “There is a lot of wait-and-see on this,” says Paul Bauknight, president of the Northway Community Trust, a group looking to involve residents in solving health problems in north Minneapolis. The group will receive $14-million over the next 10 years from the Northwest Area Foundation, in St. Paul. Maintaining residents’ level of interest can also be tricky, he adds. “It’s very difficult to keep whatever initial enthusiasm you have going. Foundations that want to get involved have to factor that into their plans,” Mr. Bauknight says.

Even when foundations do keep the momentum going, measuring the effects street-level collaborations have on health can take several years.

“We need to be a little less ambitious about outcomes,” says Marion B. Standish, senior program officer at the California Endowment. “We need to look at where neighborhoods are right now and see whether people have more healthy food to eat and whether there are fewer asthma triggers, for example.”

She urges other foundations to be patient with collaborative health efforts, but adds that too few grant makers see neighborhood-centered groups as viable. “We haven’t climbed that mountain yet,” she says.

Maintaining Momentum

Leaders of programs aimed at amassing neighborhood strength concede that they face a mound of challenges, but that money remains the No. 1 worry. Without it, momentum can stall. Some program leaders credit foundations with helping them afford paid staff members to keep things moving forward when the volunteer involvement of residents wanes.

When foundation backing ends, a new level of anxiety kicks in for program directors. In some areas, such as Baton Rouge, La., and Kansas City, Mo., community foundations have picked up some of the slack when private foundations’ commitments to health and community-building programs have ended.

Sometimes, other private foundations step in.

The Yuba Community Collaborative for Healthy Children, faced with the imminent loss of the initial Sierra Health Foundation grant, will benefit from a commitment by the Dyson Foundation, in Millbrook, N.Y. The foundation recently announced a $500,000 five-year grant to community building and children’s health in Northern California.

But for others, the challenge of persuading grant makers of the need to support such programs remains a daunting one.

“It’s hard for us to explain to foundations what we do, because they are so used to dealing with groups that provide direct medical services,” says Peggy J. Tapping, formerly executive director of the Children First-Flats Network, in Sacramento. “This is soft stuff, and it’s a hard sell.”