Health Systems: Empowered Communities

In a 2000 article, I wrote:

The aim of public health is not to make people healthy, but to assure the conditions in which people can be healthy. The well-being of a population is the collective judgment of its members about their quality of life. Their quality of life is largely determined by the quality of their political, social, economic and other institutions. There is growing evidence through recent studies that social capital is to communities as wellness is to individuals. And social capital cannot be given to a community like a vaccination. It must be grown from within.3

I see the empowering of communities to participate in their health improvement as key to realizing the greatest improvements in population health. This is far from being a new idea. Two generations ago, it was one of the principles guiding the War on Poverty, but the political will to address such issues has long left the national scene. The preamble to the Public Health Service Amendments of 1966 stated that “the Congress declares that fulfillment of our national purpose depends on promoting and assuring the highest level of health attainable for every person….”

However, a key resource for this is alive and well: community health centers. The first proposal of a community health center to the Office of Economic Opportunity stated that its purpose was “to intervene … in the cycle of extreme poverty, ill health, unemployment and illiteracy by providing comprehensive health services, based in multidisciplinary community health centers, oriented toward maximum participation of each community in meeting its own health needs and in social and economic changes related to health.”4 The centers were intended to “emphasize the formation of community health association … to stimulate change in family and community knowledge and behavior relating to the prevention of disease, the informed use of available health resources, and the improvement of environmental, economic and educational factors related to health.5

The opposition of organized medicine together with Reagan era politics caused the centers to neglect community development and concentrate on providing medical services. The program was no longer seen as an avenue toward health reform, but as health care for the poor, i.e., a welfare program, and not as advancing consumer empowerment.

Thirty years ago, establishing "community trusteeships" for health care in communities across the nation was a goal for national health planning.6 Health systems agencies were created to mirror their communities and to exercise the decision making powers derived from that legitimacy. They succeeded in providing new roles to consumers as having equal rights vis-à-vis medicine, and established the precedent for consumer participation in policies for health care delivery. For that very reason, they brooked the same opposition as community health centers, and were denied federal support after 1986.

The community is the health system for improving its members’ health, and health improvement requires community development as the catalyst for the social changes that can result in greater empowerment. Public health’s mission here is the one so well described by Rudolph Virchow in his “Report on the Typhus Epidemic in Upper Silesia” (1848) in which he counseled physicians to be radical in promoting the advancement of the entire population, adding that “the people must acquire what they need by their own efforts.”

It is encouraging that now, some 45 years after the War on Poverty gave rise to community health centers, community-public health partnerships are working toward some of the same ends: empowerment of community members, healthier environments, improved access to services, increased focus on health by local governments, and better health education resources.7 To better address social determinants, public health practice is shifting from communicable disease control and treatment to community based primary prevention. The ultimate goal is empowered communities able to take ownership of their health and well-being.  

I concluded my article with an observation that I think may be better appreciated today:

This is what I see to be health planning's signal contribution to public health: Giving voice to community as a means toward improving not only health care, but all the other upstream conditions for our quality of life. Our aim as health planners should be to elicit a stronger sense of community, and through it, a stronger sense of belonging, cohesiveness and trust among community members. Then we can see the social solidarity of a community as its immune system and see that we all have the same vital interest in supporting it for our common benefit.