People’s power over themselves and their communities became the theme of a Tuesday afternoon Annual Meeting session on “Transforming Local Communities to Achieve Health Equity.”

“Building people power is the most important thing that we can do to advance health equity and create the type of inclusive democracy that we’re all seeking,” said presenter Sandra Witt, program director of Healthy Communities-North Region at the California Endowment. “Building power isn’t just a means to an end. It’s actually the goal.”

Powerlessness is associated with poor health outcomes, and structural imbalances in power “are not just passively replicated but actively maintained,” Witt said.

The California Endowment’s Building Healthy Communities initiative is a 10-year, $1 billion place-based initiative aimed at tackling the root causes of poor outcomes and transforming communities that have historically been disinvested in into thriving communities. Witt highlighted three key health equity-promoting principles of Building Healthy Communities, summed up as the ABCs: agency, belonging and changing underlying conditions.

Agency is the power or control people have over their own lives and communities. Belonging is being seen, heard and valued by others. Belonging means supporting people in telling their own stories, sharing their dreams and hopes, and challenging the status quo.

Changing underlying conditions means developing policies and systems changes to improve the political and socioeconomic conditions in place, which will improve health outcomes over the long-term, Witt said.

“What we’re trying to do here is change the odds for people, rather than expect people to beat the odds,” she said.

With that in mind, some success stories from Building Healthy Communities in California over the past eight years include:

  • more than 4 million residents becoming newly insured through the Affordable Care Act;
  • more than 1 million Californians being eligible to have their felonies reduced to misdemeanors, thereby removing barriers to housing, employment and other areas;
  • over 300,000 fewer school suspensions and expulsions; and
  • over 800 policy and systems changes at the local level on issues such as healthy land use, community safety, police violence, access to health care, criminal justice reform and education reform.

Cardiologist and public health professional Garth Graham, president of the Aetna Foundation, illustrated the idea of using one’s narrative power by telling session attendees two stories about his teen years. When he was about 15 years old, he was chasing his sister down the hallway; the next thing he knew, emergency personnel were working on him. He had collapsed while running, suffering a severe asthma attack from mold in his home. His experience was not unique in his Miami neighborhood, and several people were already leading efforts to find solutions to the asthma problem in their community.

About five years later, as he was starting college, Graham was running around with friends when he again collapsed. But this time it was because police officers saw the racing boys who fit the description of young black men they were looking for in connection to a crime. A police officer had knocked him out.


“There was this extreme feeling of disempowerment; I didn’t have any control over what happened next. They could have done anything,” Graham said. If he had given into that feeling of loss of control, he might have gone down a more negative path, not finishing college, not going to medical school, he said.

But his mom told him, “People can only disempower you if you allow them to. The power that we have is still the power to determine our own destiny and to determine our own future.”

The concept of power and agency has often been absent from public health efforts and research, said Donald Schwarz, of the Robert Wood Johnson Foundation, which is undergoing a shift in which it’s placing health equity “front and center.”

The foundation is taking up issues such as residential segregation, which includes a discussion on how money and resources don’t flow into underserved communities. The foundation is partnering with organizations such as community development financial institutions — institutions he said everyone in public health should know about — to help them advance health equity in their community work.

Community development financial institutions are large nonprofits or banks that provide credit and financial services to underserved areas. The national trade organization that represents these institutions has diversified its board and is improving in other areas as well, Schwarz reported.

For its part, the Robert Wood Johnson Foundation now requires grantees to include health equity as part of their work. The foundation is on a journey, “and we’re open to ideas,” Schwarz said.

“At front and center is what is going to be the path to change the narrative in this country so that we have narrative that embraces equity?” he asked.

Read more about this story in the January 2019 issue of The Nation’s Health.