In 1835, Alexis de Tocqueville defined a community as a self-generated gathering of people who assumed the power to decide what was a problem and how to solve it and could then act to consummate the solution. Like an individual, a community’s health depends on learning and responding to challenges that change over time.
The World Health Organization defines a healthy community as “… one that is continually creating and improving physical and social environments and expanding community resources that enable people to mutually support each other in performing all the functions of life… ” A healthy community is fluid, not a defined goal, rather it is diverse groups of people connecting and interacting similar to Jane Addams’ principles of the settlement house, encompassing the practice of cooperation and egalitarian social relations across class lines.
A healthy community does not necessarily have high health outcomes but places health high on the social and political agenda, and it strives for equitable access to such basic prerequisites for health as peace, balanced diet, shelter, clean air and water, adequate resources, education, income, a safe physical environment and social supports.
For a community to function at the level defined by the World Health Organization and approach the lofty goals of Tocqueville and Addams, it requires people with power, citizens, instead of clients or consumers. The Greek roots of these two words demonstrate a profound difference in meaning. A client is controlled, and a citizen holds power. A community magnifies the power of citizens, and it is social involvement and participation that improves a person’s perceived control, individual coping capacity, health behaviors, and health status.
These dynamics between the federal healthcare system and community healthcare providers suggest at least four values that will enhance cooperation of community members within a federally funded healthcare project.
First, Project Directors respect the wisdom of stakeholders in community organizations. To this end, the Project Director does not train, expect, or pay community organizations to do the work of the system. The main job of the system is to provide information and feedback about progress to shared goals. Produce standardized practices and outcomes. Other components of the system within the federal government require this production of bureaucratic reports. While the main job of the community healthcare providers is to identify and solve problems related to the care of the community.
Second, Project Directors share useful information in understandable form. They are not the source of the analysis or solutions; rather, they are the source of information not easily discovered by local stakeholders. For example, they might prepare a map that shows where people diagnosed with diabetes live. They ask for local stakeholders in their associations reasons diabetes might be prevalent in those areas and how the local stakeholder organizations can help. The Project Director provides information that mobilizes the power of local stakeholder associations to develop and implement solutions.
Third, Project Directors use their capacities, skills, contacts, and resources to strengthen the power of local associations. Instead of trying to gain space, influence, credit, or resources for their system, they ask how the system’s resources might enhance the problem-solving capacities of local organizations. They listen for opportunities to enhance local leadership, strengthen local associations, and magnify community commitments.
Fourth, Project Directors escape the ideology of the medical model. For all its utility, the medical model always bears a hidden negative assumption that what is important about a person is his or her injury, disease, deficiency, dilemma, need. Yet, the capacities of people, not the deficiencies, establish communities. Project Directors must invert the medical model and focus on capacities instead of needs and deficiencies.