Q&A with California Endowment’s Tony Iton: Building power to improve community health: Initiative offers opportunity for people to tell their own stories

How has community input influenced the priorities of the Building Healthy Communities campaign?

One of the best features of Building Healthy Communities is that we weren’t rigid about what we asked people to partner with us on. One of the biggest examples of that is the school discipline work.

When we sat with our communities in the first year of Building Healthy Communities, several of our communities raised this issue, saying that particularly for boys and men of color, that these kids are being pushed out of school into the criminal justice system and that that was essentially marking them for their entire lives, and that the systems were discriminating against kids of color.

We talked to policy experts, we looked at the data (and) we found that 800,000 kids were being suspended and expelled from school every year — more than the number of kids that graduated — and we knew that if a kid is suspended once after the ninth grade, their chance of graduating high school on time declines by 30 percent.

It’s been the most successful campaign that we have had, that and the health insurance campaign. We have cut suspensions and expulsions across the state of California in half.

How did the endowment decide on its 10 outcomes for community health, including providing health coverage for all children and narrowing health gaps for young men and boys of color?

They were basically constructed by three sources of input: One was research, seeing what the literature said, what was out there in terms of health-promoting policy change and health-promoting outcomes that we thought we could have some sort of influence over. Two was expert interviews, including members of the (Centers for Disease Control and Prevention), members of the public health academic community, local public health practitioners as well as health foundations. And three was really talking to communities, community leaders, and getting a sense of what they prioritized as the issues that they felt were holding them back.

Iton

Why is it so important to bring young people into conversations about improving health outcomes in their communities?

We recognized fairly early on in our work that youth were the rocket fuel of change…You look around and look at the Parkland youth, you look at Black Lives Matter, you look at marriage equality movements — these are driven by young people. And what we recognized is that our role is really to organize them and kind of stay out of the way, and also that the kinds of changes we were looking for to promote health in California required a social movement, that they weren’t just technical policy issues, they are political issues.

We realized that we needed to essentially help catalyze a social movement, that these issues were fundamental to politics, and if you want to change politics you’ve got to bring power to the table, and that meant we needed to organize people. And when you study the history of movements, you recognize that it means you have to organize the youth.

What does it mean to change the narrative surrounding investments in community health, which is central to the campaign?

(The Bay Area Regional Health and Equities Initiative) framework starts with this notion of narrative, and it describes this ongoing battle between narratives in this country: one narrative of exclusion and the other narrative of inclusion.

Those narratives have shaped policies since the beginning of this country, and those policies create conditions for people. You look at what is happening on the border today and you see, for instance, the president talking about how the people that are being stopped at the border are “infesting” our country, that they are criminals, that they are invaders. So there is an intentional effort to dehumanize that population, to make them seem like an other, an undeserving other that is trying to take from us.

What flows from that narrative is a set of policies, like the zero-tolerance or family separation policy…It’s a perfect example right now of how an exclusionary narrative creates policy that steers resources away from needy people. And so our argument has been that we have to change that narrative.

The narrative has to become one of inclusion, and a narrative of inclusion actually is focused on humanizing the populations that are most vulnerable, letting them tell their own stories, and to the extent that they can tell their own stories, we see them as sort of sharing humanity with us in this idea that we are them, they are us, as opposed to us versus them.

What flows from that are policies that seek to essentially share benefits and resources more equitably across populations, which, as a consequence, improves their condition.

The example in California that we did very intentionally around (undocumented immigrants) in our Health for All campaign was that we used social media, billboards, television (and) a scripted drama series…to essentially let undocumented people tell their stories about who they are, how they came to be here, what their lives are like, so that their humanity was sort of elevated and people could see that they are us.

Another great example is really the school discipline work. When we started this work, there was a zero-tolerance policy in schools that was pushing kids out, and it was indiscriminate. Ninety-plus percent of the infractions had nothing to do with weapons or fights, it had to do with what was called defiance, where kids were not listening to the teacher or putting their heads down on their desk and the teachers had an enormous amount of discretion over how to use that kind of cause for a suspension.

Our advocate partners working with researchers and with the U.S. Department of Education (Office for Civil Rights)…changed the narrative around how significant this issue was and allowed young people who have been suspended and expelled to tell their own stories, to humanize themselves.

What lessons can public health practitioners learn from the success of the campaign?

You’ve got to build people power, you’ve got to change the narrative and you’ve got to foster multi-disciplinary cross-sectoral collaborations that are enduring.

Public health can’t do this alone. You have to do this in conjunction with folks that can build power. These are folks that are organizers, these are folks that spend their time in close communication with people living in communities that are experiencing adversity. You have to find ways to partner with those people. You cannot do this as a purely technocratic enterprise.

I like to say that the big debate of public health is technocracy versus democracy. And I think that democracy wins. This is a fundamentally democratic enterprise, and if you believe in democracy, you can make these kinds of changes.

–Interview conducted, edited and condensed

For more information, visit www.calendow.org.

A child smiles at a Sacramento event for residents and youth. Sacramento is one of 14 communities benefiting from the California Endowment’s Building Healthy Communities initiative.

Photo courtesy the California Endowment

Robert Ross, MD, MPA, president and CEO of the California Endowment, will be discussing findings from the Building Healthy Communities campaign at APHA’s 2018 Annual Meeting and Expo in November. Session 3114, on Monday, Nov. 12, will focus on the future of health equity.