During the 1980s, efforts to improve health focused on changing the behavior of individuals. The public was cautioned to quit smoking, eat low fat diets, exercise more, and adopt other lifestyle changes that medical researchers had proven to lower health risks. Unfortunately, a focus on individual behavior change did not translate into appreciable improvement in the health of Americans, especially those with disproportionate risk for disease, disability, and premature death.
In California, several key leaders in public health and the Healthy Cities movement, drawing on their professional experience as well as research suggesting that people who feel well connected to others tend to enjoy healthier lives, decided that something different was needed to improve the public s health. As the World Health Organization was starting its Healthy Cities campaign in Europe, these leaders decided to bring
Identifying a starting point. The California Healthy Cities and Communities Program (“the Program”) has its origins in the California Healthy Cities Project (“the Project”), which began in 1987. The strategic direction for the Project was shaped by key political, economic, and structural factors and challenges, including:
• An emerging public health interest in focusing on the broad determinants of health, that is, education, income and living conditions, for community health improvement.
• The emergence of the Healthy Cities model, which was largely unknown in the United States and had only recently been initiated in Europe and Canada.
• A need to popularize what creates health while simultaneously countering the traditional and prevailing notion equating health with medical care.
• The absence among many local public health departments, which held legal and fiscal responsibility for community health, of organizational relationships, resources, and staff necessary for policy development or expertise in content-specific areas related to health determinants.
• Extremely modest resources for a statewide program—$249,000 for the first 18 months.
Given these factors, the Projects founders decided that the most advantageous initial entry point would be cities. Cities were the level of government closest to the people; they had responsibility and resources for many health determinants such as safety, housing, and economic development; and they had the ability to rally broad constituencies, including the business sector and residents, based on civic pride and a sense of place. Even though there were 447 municipalities in California at the time, they provided a discrete, identifiable audience with whom to start a movement. The League of California Cities, based in Sacramento, the state capital, offered opportunities for partnership.
Initiating the Project. In the late 1980s, California s harsh economic times, combined with the view that health and social services were budgetary “black holes,” made many city leaders wary of experimentation. These factors implied a strategy to attract those municipalities for which being at the forefront of change had great appeal.
The initial strategy involved:
• A competitive process by which the Projects steering committee would choose 10 cities for a demonstration program. Cities were required to submit applications to the Project that: profiled their city; identified areas for community improvement; detailed staff involvement; described the convening of a broad-based steering committee; detailed a work plan and evaluation process; and demonstrated city council commitment via passage of a supportive resolution. While some technical (and minimal financial) assistance was available once cities were selected, there was no direct funding to implement initiatives.
• Promotion of the Healthy Cities concept and approach in ways that related to municipal functions. The Project sent out more than 3,000 newsletters to political, community, and public health leaders. This literature emphasized improving “community liability” and “quality of life” using familiar examples such as literacy programs, ordinances limiting alcohol use in parks, and the development of master plans.
• Products and services offered by the Project on a continuing and regular basis to all California cities, the public health community, and interested others to raise awareness and garner support.
The Project accepted 10 applicants based on their commitment to innovation, interest in lowering social inequities, and commitment to involvement of various sectors of the community. In 1992, these first 10 participants were designated “Charter Cities”—a title they continue to use proudly—to recognize their pioneering spirit and their willingness to share their experiences with others.
Expanding the Project. As interest grew, the Project shifted from a demonstration phase to accepting applications on a “rolling” basis, with extensive technical assistance provided for proposal development. This approach was more responsive to the organic nature of community development. As additional resources were secured, seed grants were made available. Over the next several years, 33 additional cities participated.
With a solid track record of providing quality services and a decade of success elevating the profile of cities in prevention-oriented programs, policies, and plans, the Project was eager to work more directly with other “lead” organizations, for example, community-based organizations and other nonprofit groups. In 1998, the Project entered its next major phase with a grant from the California Endowment. With these new resources, grants were made available to 20 qualifying communities that encompass neighborhoods, unincorporated areas, and multijurisdictional regions. With this expansion, the Project changed its name to California Healthy Cities and Communities (referred to here as “the Program”).
Creating an organizational structure. Consistent with the Healthy Communities philosophy, the Program grew through cooperation between public and private entities. When the Project originally began in 1987, the California Department of Health Services (DHS) and the Western Consortium for Public Health had established a partnership to lead in the planning. Later, in 1996, the Center for Civic Partnerships was established to provide an “umbrella” structure for the Project and similar community building efforts designed to reach different constituencies. In 1998, the Center became part of the Public Health Institute, a private nonprofit organization.