Initiatives based in communities can have widespread effects. Not only can they transform the communities in which they are located, but they can act as seedbeds for similar programs elsewhere. Three presenters at the workshop described such initiatives and their potential to reduce health disparities.
Parks After Dark is a program that uses Los Angeles parks to prevent violence, transform communities, and promote health equity. In 2011, Los Angeles County had 611 homicides, approximately 37 percent of which were gang related. Parks After Dark started in 2010 as part of Los Angeles County’s Gang Violence Reduction Initiative. “Over the years we saw the program grow,” said Kelly Fischer, staff analyst for the Injury and Violence Prevention Program at the Los Angeles County Department of Public Health, adding “We saw how it had the potential to improve health, chronic disease, and mental health, as well as build community trust through cross-sector collaboration, and give the government an opportunity to interact with the community in a more positive way.” In its fourth year, the program includes nine parks and in 2014 received an award from The California Endowment for advancing health equity.
Parks and Recreation Director Russ Guiney and CEO William Fujioka conceived of Parks After Dark after the success of Summer Night Lights, a program that kept 32 Los Angeles parks open late during the summers. Other community-based organizations have used similar models, but Parks After Dark has “a real opportunity to sustain and expand in local gov-
ernment and probably in private business,” said Fischer. The program was originally funded through a community transformation grant by the Centers for Disease Control and Prevention. When Congress cut the budget, the program’s success prompted board supervisors to make an unprecedented decision to fund it out of the county budget on an ongoing basis.
The Parks After Dark model is simple, said Fischer—the summer evening hours at parks are extended on the weekends, and varied programs are offered to community members. The program focuses on areas of high crime during times when youths have less social and recreational opportunities because schools are closed. While the program was initially conceived as a violence-prevention strategy, it has grown into a model for health promotion. Programming includes organized sports like basketball, baseball, soccer, golf and tennis lessons, martial arts, dance classes, Zumba, bike rides, and access to community pools and gym facilities. Parks After Dark offers classes on topics from healthy cooking to computer skills. Free concerts, movies, and talent shows provide evening entertainment, and resource fairs connect community members with health and wellness, economic, legal, and social services.
The Parks Department leads the program with support from the Public Health Department. Deputies patrol the parks during the evening hours but also engage in activities with community members. Each year at Roosevelt Park in South Los Angeles, for example, the deputies organize a basketball tournament with the teens. The first 3 years, the teens easily beat the deputies, so the fourth year the deputies decided to have a kickball tournament to try to even the playing field. Through such efforts, the tournaments offer a bonding opportunity for all participants. Although Parks After Dark is a summer program, park staff are able to build lasting relationships with the community, community organizations, and government agencies. “We saw a great cross-sector collaboration develop during the planning and debriefing meetings,” Fischer said.
In interviews, deputies said that enhanced safety was not caused by their presence, but rather by “the mass of people enjoying themselves, getting to know their neighbors, and creating a positive vibe and a positive image of the community,” according to Fischer. Deputies have been able to establish relationships with youth and build trust in communities where they could not before. The program allows the park staff to become community liaisons and public health ambassadors who can provide a safe and welcoming space with strong community support.
One thing that helped the program is the gang injunction that exists in Los Angeles County, where designated gangs are not allowed to congregate in certain areas. However, the program also worked with the sheriff’s and probation departments to encourage the members of multigenerational gangs in the community to participate with their families.
A significant part of the budget for the program has been used for law enforcement, since they are paid extra, as they would be for special events. But much of the support has been in the form of free time from parks staff, youth and community volunteers, and other government programs that do outreach during the events. Money also has become available for youth hiring programs. “We’re hoping that this can turn into a pathway to full-time jobs, at least in the parks department,” Fischer said.
Parks After Dark has been successful on multiple levels. Between 2009 and 2013, serious and violent crime dropped 32 percent near the three original parks in the program versus an 18 percent increase in comparison parks that did not have a similar program. By 2014, violence fell 48 percent, although recently crime rates have slightly increased, so there is still room for improvement, Fischer acknowledged. On average, the immediate vicinities of the initial participating parks averaged 14 fewer serious and violent crimes per summer. In response to a question about whether crime overall has declined or whether it has just moved away from the parks, Fischer said that crime in nearby neighborhoods, where it would be expected to increase if it were just moving away from the parks, also has been going down. “We’d love to claim credit for it, but it’s honestly hard to tease out what the impacts are,” she said.
The Parks After Dark program has affected not only violence but also community health, Fischer added. Parks After Dark received funding to do a health impact assessment report in 2014 that examined physical activity and violence in the park communities. The assessment found that 80 percent of participants engaged in physical activity in Parks After Dark. Compared with their previous levels of activity, these increases in activity level could translate to a 5 percent decrease in the burden of diabetes, dementia, and heart disease in these communities, she explained. Expanding Parks After Dark to 16 sites could save three premature deaths from cardiovascular disease each year, Fischer said.
Parks After Dark is also cost effective. “We estimated we saved the county nearly $1 million in criminal justice and health care costs,” said Fischer. The estimated annual criminal justice savings at the original three parks alone were one and a half times the cost of implementing the program, including the costs of incorporating recommendations that would make the program “world class,” such as two full-time staff to coordinate the program, gang interventions, administrative overhead, and outside evaluations.
Parks After Dark offers a flexible model to advance the interests and missions of many different sectors, Fischer observed. In the future, the program hopes to partner with mental health and health services to do more onsite screening, provide more onsite services, and use the parks as the hub for year-round activities in the community. Parks After Dark provides a
model at both the local and national level for using community support and engagement to improve crime-laden neighborhoods across a wide range of outcomes, Fischer concluded, adding that “The community loves the parks, and it’s a great starting point for something bigger.”
Today, diversity is central to the excellence of any organization, said Trisha Tillman, the public health director at the Multnomah County Health Department in Oregon. Work on health equity is of comparable importance to that of work on quality improvement or company efficiency, she added.
In 2007, Tillman was tasked with starting the Health Equity Initiative in Multnomah County to create a common understanding of the root causes of racial and ethnic health inequities and their possible solutions. Funded by the county’s general fund, the Health Equity Initiative was created to improve the health of all county residents by considering the ways that societal conditions in which people live, learn, work, and play affect health. This was during a period when the National Association of County and City Health Officials was beginning to move away from the term health disparities to the term health inequities, which addresses health conditions that are avoidable, unfair, and unjust, Tillman noted, adding that “Our work on the initiative was to raise the visibility of health inequities and also reframe the experience that people were having from an individual shortcoming to a systems failure.” The program aimed to help people understand that unnatural suffering was caused by more than just personal failures.
In 2008 the leaders of the initiative held conversations across the county at various public venues to produce a set of recommendations. Based on screenings of the PBS video series Unnatural Causes, community members and Multnomah County employees discussed the connections among social and built environments, policies, and health outcomes. These conversations led to recommendations for actions that could be taken by local governments, which were reviewed and prioritized by the community and given to the health department. While some of the community’s concerns were so large that it was difficult to know where to start, Tillman noted, the program was able to generate some initial steps toward equity. Ultimately, Tillman pointed out, major advances will have to include more jurisdictional partnerships and private–public partnerships.
Based on the community conversations, the county is working to address inequities in a wide variety of areas, including
- addictions and mental health,
- the built environment,
- community safety,
- investments in social capital,
- criminal justice and corrections health transitions,
- early childhood,
- the economy,
- emergency planning,
- food security,
- health impacts,
- health promotion,
- human services access,
- health care,
- physical activity and nutrition,
- racism and equity, and
- workforce development.
The county’s strategic plan includes
- eliminating health inequities,
- working on organizational trauma,
- taking a healing approach to racial equity,
- funding the community-led development of the Community Health Improvement Plan,
- developing a culturally specific public health strategy,
- staging a Health Equity Initiative community forum,
- generating racial and ethnic disparities reports and supplements, and
- sparking organizational assessment through culturally specific equity strategies.
As an example of its success in improving the built environment in the county, Tillman pointed to an initiative to work with a local community to weatherize homes, thus combating displacement and gentrification. People had been coming into the community and attempting to buy decrepit homes for cash. By weatherizing the homes, residents were less likely to sell.
Initially, the program experienced difficulties in tackling housing, since programs run through the public health department traditionally do not deal with housing policy. However, as a result of community conversations, leaders discovered the effect of housing on environmental health. For example, residents complained of lead, mold, and mildew in their homes, as well as the feeling of being ignored and disempowered by their landlords, some of which are local governments. The Health Equity Initiative is now
working with the City of Gresham, a city outside of Portland where many people of color and low-income families are being pushed by gentrification to conduct proactive inspections of multiunit housing sites to identify environmental health problems. Gresham differs from Portland, where inspections are triggered by a complaint, but people are unlikely to complain when that could trigger an eviction. In this way, the Health Equity Initiative has allowed the residents of Gresham to benefit from environmental health prevention without the threat of eviction.
Another major focus has been improving community health and safety. Through community building, the program hopes to decrease youth violence and unhealthy behaviors. For example, the initiative has worked with Native American community members who are interested in learning how, as a community, they can organize and partner with the county and child welfare system to decrease the prevalence and effects of fetal alcohol syndrome.
In Multnomah County, different communities have been working together to achieve shared goals. For example, the Coalition of Communities of Color started organizing in response to the perception that communities of color were being pitted against each other in competitions for resources. In addition, the Oregon Health Equity Alliance has been organizing across communities to identify health equity policy priorities and act as a collective to move county and state policy. For example, the coalition worked on access to health care for undocumented individuals and were successful in making prenatal care available for all undocumented Latina mothers in the state, which had previously been a county-by-county patchwork.
The actions taken by the Health Equity Initiative to reframe the conception of minority health, multicultural health, and health disparities have broadened the conversation around health equity from Multnomah County to the state of Oregon, which created an Office of Equity and Inclusion in 2009, Tillman reported. In 2010, Multnomah County started an Office on Diversity and Equity, which extended much of the work of the Health Equity Initiative, followed by the City of Portland’s introduction of an Office of Equity and Human Rights in 2011. In 2012 a regional governing system called Metro created its diversity, equity, and inclusion program. “The initiative opened the door, and created permission, for all of these various governmental jurisdictions to start to figure out how they could take on equity as a core part of their mission,” Tillman said.
The Health Equity Initiative hopes to continue to expand in the future. “Many of the offices that exist around equity, diversity, and inclusion are one-person, mom and pop shops,” said Tillman. To change policy, practice, and systems, a serious investment and commitment is needed by all parties, she observed. As part of the development of its strategic plan, the initiative
is moving all of the dollars for the planning process to a community-led, equity-focused project.
In addition, the Health Equity Initiative will continue to build its capacity to collect data to aid in continuing improvement. Culturally specific health equity policy analysis has proven to be the initiative’s most important investment. Applying a socioecological model to health equity work helps dictate the delivery of individual services and acts as the basis for organizational change.
The initiative aims to support the community through two venues. First, the program hopes to help partners address their own priorities through funding and data support. Second, it aims to provide staff support while allowing community-based organizations to lead the way. The key is “practice-based evidence, more so than evidence-based practice,” Tillman said. The initiative continues to look for ways to work in partnership with the community to mobilize and change policies.
Tillman concluded with a quotation from Albert Schweitzer:
No ray of sunlight is ever lost, but the green which it awakens into existence takes time to sprout, and it is not always granted to the sower to see the harvest. All work that is worth anything is done in faith.
The Health Equity Initiative has planted the seeds for change, Tillman concluded; now it needs to support the soil from which those seeds can sprout, grow, and thrive.
The Dudley Village Campus is a community located in the North Dorchester and Roxbury neighborhoods of Boston. It has a population of 26,560 people, with 8,738 households and 5,145 families. Forty-one percent of the households identify a language other than English as their primary language, and 34 percent live below the federal poverty level. Thirty-one percent of the neighborhood’s inhabitants are African American, 14 percent are white, 28 percent are Latino, and 25 percent are Cape Verdean, a small island off the West Coast of Africa. In the 1980s, this area, referred to as the Dudley Triangle, was deemed the area with the highest concentration of vacant lots and disinvestment in Boston. The 62 acres in the Dudley Triangle had 1,300 vacant lots.1
The Dudley Street Neighborhood Initiative (DSNI) started as a community-based project. “Our mission statement is to empower Dudley
residents to organize, plan for, create, and control vibrant, high-quality, and diverse neighborhoods in collaboration with community partners,” said Travis Watson, DSNI’s communications manager and senior organizer. The three primary languages in the neighborhood are English, Cape Verdean, and Spanish. All of the major print materials are translated, and interpretation is available for both Spanish and Cape Verdean at meetings. Drawing on its base of volunteers, the initiative has even been partnering with other organizations to provide interpretation.
The first major DSNI initiative, started in the early 1980s, was called Don’t Dump on Us. During that time, a typical block in the Dudley Street Triangle had many vacant lots, and many of these lots were filled with dumpsters. In total, 96 dumpsters were located in the neighborhood and being used as illegal trash transfer stations by general contractors and neighborhood businesses. In addition, at night, companies from inside and outside Boston would come into the neighborhood and dump their waste on the vacant lots. “It was a toxic waste site,” said Watson. To combat this problem, the Dudley Triangle residents organized DSNI and worked with city officials to padlock the street. By blocking access, residents were able to prevent trash dumping in their neighborhood.
The next major campaign was called Take a Stand, Own the Land. While the neighborhood had experienced success with Don’t Dump on Us, community members were looking for a way to be more proactive and take control of the land in their neighborhood. During that time, Boston was working with consultants to formulate a master plan for the Dudley Triangle with no resident input. DSNI responded by looking for ways to have a voice in decisions regarding land use. After considering many different models, a community land trust was selected as the best fit for community members’ carefully crafted vision. Through the community land trust, the neighborhood has gone from 1,300 vacant lots in the early 1980s to a little under 150 today, Watson said.
The community land trust, started in 2015, created 95 units of permanently affordable homes. This included 77 cooperative housing units, 53 rental units, a playground, a small orchard and garden, a community greenhouse, 1.5 acres of urban farm land, a community nonprofit office space, and a commercial space. The greenhouse is on the site of a former chop shop and is operated by a community partner called the Food Project. About 10,000 square feet in total, half of the greenhouse is used to grow produce to sell at local markets and restaurants and the other half has plots available for local residents at very low cost, and often no cost, to grow produce for themselves.
Today, residents in the Dudley Triangle are advocating for a campaign called Dudley Grows. Part of this campaign calls for partnership with the Food Project and local merchants, particularly the bodegas, to offer
the produce grown at the greenhouse for sale at very reduced prices. Other priorities include building a home supply chain for healthy foods and securing vacant land to designate it for growing food.
One challenge was to sell the produce before it rotted. DSNI has worked with foundations to add appropriate refrigeration units for local bodegas so that produce lasts longer. It also has relied on youth, especially in the summer, going to festivals, farmers markets, and other gathering places to sell healthy, locally produced foods on the streets. Not only does this provide healthier foods for people in the community, but it introduces young people to the effects that food has on the body. As a result, “We’ve seen a spike in the young folks going for the healthier food options,” Watson explained.
School meals are a huge issue for the community, since the offered meals are often not nutritious—“tater tots, cheeseburgers, and french fries,” according to Watson. DSNI is working with neighborhood partner schools to grow produce at the greenhouse and in neighborhood farms and make that food available at local schools.
DSNI also wants to expand the existing food access points for low-income residents. In conjunction with the Food Project, the initiative runs a farmers market for 4 months of each year where the produce is inexpensive and food stamps can be used. One dollar gets 2 dollars worth of produce. “So if you go there and spend $10 for produce, they’re going to give you an additional $10 worth of produce,” Watson said.
Finally, DSNI aims to advocate and plan for additional physical development to support neighborhood food systems. For example, the program is working with young people during the school year, and particularly in the summer, to build raised-bed gardens. These gardens overcome the problem of toxic soils, since the soils in the raised-bed gardens come from elsewhere, and older residents are able to participate without having to stoop so low to the ground. In the past 2 years, 175 raised-bed gardens have been built in the community.
DSNI is the only community-based nonprofit in the United States to be granted imminent domain authority over abandoned land, Watson observed, which it has used to transform more than half of the area’s 1,300 abandoned parcels of land into schools, parks, community buildings, urban agricultural plots, and affordable housing. By creating a community-based, community-led program, the initiative has given the neighborhood a chance to improve on its own terms.
An interesting issue that arose in the discussion session involved building the levels of trust necessary to get all three of these initiatives off the
ground. In the case of Parks After Dark, the first challenge was that the parks department had to be convinced to keep the park open later during the summer. “They were afraid, to be honest. But we saw the change immediately,” said Fischer. Another major challenge was getting people to see a summer parks program as transformative for broader systems. “But once people went to the parks and saw and experienced the program for themselves, it really shifted their thinking,” she commented.
Trust was also a major issue in Multnomah County, said Tillman. Addressing inequities meant acknowledging, even if implicitly, that other approaches were not working, even if people were comfortable with them, she said, adding that “The trust part comes in when you say, ‘We’ve been doing this. It hasn’t worked. How would you like to handle this?’” Program practitioners have to trust the community to provide input and act as partners, even if data are not immediately available to build trust, community members do not have the educational credentials, or community procedures are different than governmental procedures. “The hardest part was getting people who represent dominant cultural strategies to step back and trust that the communities knew what they were doing and that their solutions would be effective,” she concluded.
DSNI faced a similar issue, but with funders rather than government officials, said Watson, adding that the agenda was led and driven by residents, “so it was a huge challenge to sit with the funders initially when they thought that they knew what was best for our community.” Another interesting challenge, he said, was identifying exactly who owned the many vacant lots in the neighborhood. “Often the city did not know which lots they owned or did not own. Many of the lots had absentee landlords left in trust. . . . The eminent domain process took many years, and once you put something into foreclosure it takes a year or a year and a half to take ownership of it,” he explained.
Building trust is part of a broader effort to engage communities in programs such as the ones described by the presenters, and all three programs have made special efforts to foster this community engagement. For example, DSNI is governed by a 34-member board of directors that meets monthly, with community elections held every 2 years. Made up of residents, the board has four seats for each of the four major ethnic or racial groups in the neighborhood, as well as seats for representatives of businesses, churches, nonprofit organizations, and youth (including 15- to 17-year-olds). “Those monthly meetings guide and lead all of the work we do,” said Watson.
As an aside, Watson noted the importance of getting young people involved in the governance of the organization. At first, the board of direc-
tors did not include youth seats, but a strong group of young people in the neighborhood made the point that the neighborhood was being rebuilt for future generations, not just for the adults in it now. Young people “pushed their way into the organization, with some resistance at first, but all of a sudden it flipped the script and people started to realize the value of having young people at the table,” he noted.
The health equity initiative in Multnomah County did not start with much community engagement, but the organizers quickly realized that they needed to get community members involved, Tillman recounted. Today, culturally specific programs, such as a healthy birth initiative focused on African American infant mortality, have community advisory boards. A collaboration focused on Native Americans is run by a Native American rehabilitation recovery association and a Native American youth and family center. As part of an ongoing organizational restructuring, work on equity, planning, and strategy is being elevated to include a partnership strategy. “How do we engage with community partners to be able to track how many of our country dollars are moving out to the community over time?” she asked. Multnomah County is also part of an ongoing research project that has been studying public health departments that are institutionally embedding health equity, Tillman noted.
Fischer noted that Parks After Dark is trying to become a more community-driven program, with more funding for community organizations and youth to drive a comprehensive violence prevention and community revitalization initiative. On a regular basis, the park staff convene community members to plan the kinds of programming they would like to see. In addition, most of the parks have teen clubs in which the teens themselves plan activities. Many activities have arisen spontaneously from the communities, Fischer observed, such as a bike ride between two parks in South Los Angeles that were rival gang territories, or an evening where young people could come to the parks to get free haircuts, adding “We want to find a way to harness that to make this about civic engagement and community building.”
A final focus of the discussion session was how to involve the private sector in the activities described. In Multnomah County, the Portland Business Association has committed to a goal, initiated by the United Way, of cutting childhood poverty in half by 2025. As part of this goal, the United Way has been working with corporate philanthropies to address the ways out of poverty, including school success, family stability, and connected communities.
Tillman and her colleagues also have been working on ways to engage the business community in policy advocacy. Policies that help families
and children include paid parental leave, paid sick leave, increases in the minimum wage, and increases in the earned income tax credit, all of which have been targets of the City of Portland and Multnomah County. The goal, she said, is to convince businesses that “you can’t service your way out of health inequities. A policy shift is required.”
Finally, she mentioned an interesting effort to bring healthy eating opportunities to a north Portland neighborhood that was formerly a food desert. A community corner store was established with the agreement that it would not sell tobacco or alcohol. Because most such stores are profitable from sales of these products, the county government fills in the gaps so the store can remain open.
Parks After Dark also is seeking ways to partner with the private sector. For example, some of the parks have been partnering with local businesses to provide donations or services. One model is a private–public partnership developed by the City of Los Angeles to support the gang reduction and youth development initiative. Another is a program in Sacramento in which community members are organizing to help improve the business district while the business district is investing in park programming and other initiatives. “There are a lot of great models out there,” Fischer said.
DSNI has launched an innovation center where local entrepreneurs can get technical assistance on bringing their businesses to markets. The role of the initiative in this effort is to make sure that whatever comes out of this process is something that residents need and provides an opportunity for residents, said Watson.