Community Power and Health Equity: Closing the Gap between Scholarship and Practice
Introduction
The last few decades have seen an upsurge in research linking health outcomes to the “conditions in the environments in which people are born, live, learn, work, play, worship, and age,” commonly referred to as the social determinants of health (Cash-Gibson et al., 2018). These conditions include “economic stability, education, social and community context, health and health care, and neighborhood and built environment” (Office of Disease Prevention and Health Promotion, 2014). More recently, many in the public health field are recognizing the need to analyze (and transform) the structural determinants of health that are at the root of inequities (Baum et al., 2018). Such structures include government rules and regulations, institutional policies and priorities, cultural norms and values (for example, racism, sexism, xenophobia, homophobia, and ableism), and disparities in the power and influence of different communities to change those structures.
This consideration of “community power” has acquired special salience in the wake of the widespread and devastating impacts of the COVID-19 pandemic in 2020–2021. The pandemic brought to broad public attention what communities of color and low-income communities have long known: that underlying inequities by race, income, and geography put their communities at higher risk of contracting the virus and with lower levels of access to vaccines (Ollove and Vestal, 2020). Simultaneously, protests swept the nation and the world in response to the tragic deaths of George Floyd, Breonna Taylor, and Ahmaud Arbery, continuing to highlight the role of deep-rooted racial differences in treatment by the police and other social institutions. Together, these crises have accelerated long-overdue conversations across the country about how racism is a public health issue (Vestal, 2020).
All of this has created an opportunity to bring together policy makers, public health professionals, equity-oriented advocates, and researchers to understand approaches to addressing powerlessness and racial equity as root causes in health outcomes. The authors of this paper have decades of experience studying and partnering with organizations with the primary mission of building power with communities disproportionately impacted by health and racial inequities. In 2018, the authors came together on a collaborative project, Lead Local, supported by the Robert Wood Johnson Foundation (RWJF), to examine community power and community power-building approaches to advancing
health equity.
In this discussion paper, the authors share our understandings of community power and its fundamental relationship to health equity, drawing from our collaborative and individual scholarship conducted in partnership with community power-building practitioners, emphasizing examples from the field. Despite working in university cultures that tend to reward and recognize academic achievements that result in publications in peer-reviewed journals, the authors have found that collaborative knowledge production and exchange between scholars across different disciplines and in partnership with practitioners can advance both the conceptualization of theory and empirical analysis. Therefore, the authors conclude by turning the lens on ourselves as community-engaged scholars and how the study of community power has transformed our scientific methods and outcomes in ways that can close the gap between scholarship and practice.
A Collaborative Effort to Examine Community Power and Health Equity
From 2018 to 2020, Lead Local, an RWJF initiative, brought together leaders of community organizing, advocacy, public health, and social science to examine the relationship between community power and health. The core partners were Caring Across Generations, Change Elemental, Human Impact Partners, Right to the City Alliance, Johns Hopkins University SNF Agora Institute, University of Southern California (USC) Equity Research Institute, and Vanderbilt University. Each research and action group brought a set of theories of community power building as well as relationships with local community power-building organizations. This discussion paper is coauthored by university-based academics who have decades of direct experience in engaging communities in their research.
Four of the core partners are non-academic institutions. Caring Across Generations is a national campaign that brings together people impacted by the care economy to transform the U.S. caregiving industry. Change Elemental partners with individuals, organizations, and networks to co-create and catalyze transformative approaches for justice. Human Impact Partners is a national nonprofit organization that uses capacity building, advocacy, and research to challenge and transform the barriers caused by inequities that harm the health of our communities. Right to the City Alliance is a national alliance whose member organizations build a movement for housing, land, and development justice through grassroots local policy advocacy campaigns.
As for the academic institutions, the P3 Lab is a project of the SNF Agora Institute at Johns Hopkins University and is dedicated to making the participation of people across race and class possible, probable, and powerful. USC Equity Research Institute conducts research with and for community-based organizations working on issues of social justice and studies how social movements make sustained change over time. Human & Organizational Development at Vanderbilt University works with communities on applied problems with a particular focus at the community scale, supporting solidarities that can alter material conditions within communities and, via movements, larger social scales.
The collaborative nature of this research endeavor is an unusual one. It challenged the notion of traditional academic research that usually studies community efforts from afar rather than working with them directly. In Lead Local, the community organizing, advocacy, and public health groups were actively engaged in research design, including selecting the cases eventually studied. In short, the collaborators sought to center community power as well as community-led insight in the research process.
Lead Local partners also incorporated the knowledge and expertise of 40 local on-the-ground organizations working in 16 locations across the United States. The communities and organizations were selected through an iterative, data-driven process to ensure diverse representation by geographic region, political context, and demography. Place selection was also informed by mapping organizations that have been successful in building power for impact at local, regional, or state scales. This intentional selection process was to ensure that lessons from this project could be applicable and scalable in various contexts.
The 16 places of the study included nine small to mid-size cities (with populations between 50,000 and 500,000): Atlanta, Des Moines, Eau Claire, Miami, Minneapolis, Portland (Maine), Rochester (New York), Santa Ana, and Santa Fe. Three larger cities (with populations over 500,000) in the study were Chicago, Denver, and Detroit; and the four states included Kentucky, Oregon, Texas, and Washington. Staff from 40 organizations participated in interviews conducted between September and December 2019 and attended a Lead Local Symposium in November 2019.
Over 24 months, a series of papers were produced exploring community power (Pastor et al., 2020b); power- and capacity-building strategies (Mirsa et al., 2022) and campaigns (Caring Across Generations, 2020; Human Impact Partners, 2020; Human Impact Partners and Right to the City Alliance, 2020); theories underlying community power (Speer et al., 2020a); and questions to guide additional research on how to measure power (Speer et al., 2020b). While community power is complex, dynamic, and highly contextual, one agreed-upon conclusion is that community power is not just instrumental but fundamental to achieving health equity. That is, not only is it an effective approach to changing inequitable policy conditions, but it is also an end goal in and of itself in that it builds community confidence, capacity, and efficacy, all of which contribute directly and indirectly to health (Pastor et al., 2020a).
In what follows, the authors offer key concepts and tensions within the field of community power building, illustrating the points with real-world examples that can inform both the multidisciplinary study and multisector collaborative practice of building, sustaining, and strengthening the type of community power that can uproot the deeply entrenched conditions that hold structural inequities in place.
What Is Community Power? What Are the Features of Community Power Building?
Drawing from interviews with community power builders and existing literature, the authors have developed a working definition of community power as the ability of communities most impacted by structural inequities to develop, sustain, and grow an organized base of people who act together through democratic structures to shift public discourse, set proactive agendas, influence who makes decisions, and cultivate ongoing relationships of mutual accountability with decision makers that change systems and advance health equity (Pastor et al., 2020c).
This definition can be traced back to the “three faces of power” framework theorized by Steve Lukes (2005), operationalized by John Gaventa (1980), and adapted by grassroots organizing efforts (Human Impact Partners and Right to the City Alliance, 2020; Healey and Hinson, 2018). The contemporary conceptualization defined by Grassroots Power Project names the three dynamic and interrelated faces of power as observable, hidden, and invisible. In brief, observable power is the organizing of people and resources through policy campaigns, relationship building, and electoral work that is targeted at specific decision-making bodies. Hidden power lies in the long-term alliances and sometimes loosely connected networks of organizations aligned around a broad change agenda. Last, invisible power is about shaping people’s understandings and beliefs about society (i.e., public discourse, narrative, and mindsets).
While it may be tempting to think about community power through traditional social science probabilistic frameworks—that is, as a variable, X, that yields an impact on outcome, Y—it is best understood through a lens of possibility as opposed to probability. Community power is about fundamentally making possible what might not seem possible at the start because of structural inequity. Moreover, community power is not a singular attribute, condition, or variable; rather, it represents a dynamic, relational quality within communities.
Below, the authors discuss some of the key features of community power building. Before beginning, it is useful to consider what is meant by “community,” a somewhat amorphous term that could refer to an ethnic group, a neighborhood, or even a set of individuals tied together by a common interest. While the term has many meanings, recall that this discussion is connecting to groups of people who share a specific experience of systemic exclusion from resources and decision-making power that could positively impact their health outcomes.
Centering Directly Impacted Communities
If powerlessness is seen as a root cause of health inequities, then it is critical to build power in communities most impacted by those inequities. As one power builder states, this starts with those “on the ground feeling the most hurt,” such as caregivers and farmworkers working long hours for low pay, families displaced from their neighborhoods due to gentrification, voters purged from the rolls, tenants living in substandard housing, and immigrants who have been separated from their families. By bringing together individuals who are facing similar circumstances, these individuals understand that their problems are not unique and not due to any personal shortcoming or mistake—instead, they understand that these issues are impacting their entire community.
A key task of organizing is often to help shift someone from harboring (and maybe hiding) private suffering to taking a public stance based on common circumstances. For example, caregiving work can be isolating, so Citizen Action of Wisconsin brings caregivers in Eau Claire together and elevates their voices to people in power who would otherwise not realize how large of a constituency they are and what an important and widespread issue caregiving is. An organizer from the Maine People’s Alliance shared a powerful story of a farmer who felt embarrassment and guilt for going on Medicaid. But when he saw a video of another farmer describing the same struggles with health care, he realized his lack of access to adequate and affordable health care was not due to a personal failing but a structural problem facing all farmers—and low-wage workers. He would go on to participate in rallies and meet with the governor directly to protect Medicaid.
Part of fully embracing community power building as a strategy requires acknowledging that community members are themselves experts of their own experiences and conditions. As such, they should drive the design, implementation, and protection of policies and reforms that improve their day-to-day lives. It also means communities should drive shifts in priorities over time. For example, in Santa Fe, New Mexico, Somos Un Pueblo Unido started as a member-led immigrant rights organization. For over 25 years, they built a membership base and achieved an impressive list of victories: sanctuary city policies in 1999, driver’s licenses for undocumented drivers in 2003, and fighting family detention centers in 2014. After 25 years, members began to identify a need in their communities around workers’ rights—specifically regarding the vulnerability of immigrants in the workplace, including workplace
safety, wage theft, and discrimination.
When community members participate in, take ownership of, and see themselves as public actors in determining the future of their communities, they are best positioned to push for the deep structural reforms that are necessary and less likely to push for what is viable. Individuals with positional power have the responsibility to listen and to work in authentic partnership toward structural or procedural changes. Moreover, community members can hold community power organizations, academics, and policy makers accountable to the community and the change they want to see in the world. Often this is an important counterforce to the political calculations that may drive negotiations and compromises with decision makers. This begins to push against institutional tendencies to pursue incremental change rather than transformational change.
Developing an Organized Base to Act Together
Community power building is a long-term project that requires the development and sustained active presence of a strong and organized base of people—referred to in community organizing as base building. Across the ever-evolving theories of change and dynamic schools of organizing practice, a set of themes seem to be constant with regard to building a base: the need to develop an organized base of community members who are in a relationship and invest in each other’s leadership, who share a common identity shaped by similar experiences and an understanding of the root causes of their conditions, and who use their collective analysis to create solutions and strategize to achieve them.
Base building is different from mobilization—which is often about bringing those already convinced about an issue for an episodic action or protest versus the development of a leadership cadre that can both persist and pivot. Building a base is about building potential power. For communities that are underrepresented and historically excluded from public and private decision-making processes, building power starts with the on-the-ground, one-on-one work of organizing, recruiting members, and developing grassroots leaders.
At the same time, mobilizations are ways of exercising the sort of civic engagement muscles that sustain people in the long-term efforts of power building. In practice, there is a range of approaches and mechanisms for actualizing the potential power of an organized base into exercising community power (University of Southern California Program for Environmental and Regional Equity, 2019). Transformative approaches point to the most promising opportunities for advancing health equity.
Resilience OC in Santa Ana, California, takes a transformative justice approach by “changing what the systems around us are doing while also realizing and changing ourselves in that process.”
In leading a campaign, Resilience OC organizers place just as much importance on changing systems and practices as they do their own organizational systems and practices. That means eschewing a “superhero” or savior complex and instead taking the steps necessary to build trust with people in the community, including setting intentional time to listen and learn from them, engaging and centering people at every step in the work, and providing a space for empowerment and development of new skills. In contrast to tokenized participation, the goal is to create spaces for people’s self-motivated and authentic engagement in public life.
Establishing Democratic Structures for Collective Action
Historically, a large share of community and labor organizing institutions have often had strong top-down structures to ensure effectiveness in policy outcomes. Yet, a younger generation of organizers are challenging these power dynamics within the organizing world and insisting on the importance of healing from racial and class trauma and ensuring internal power is distributed equitably (Pastor et al., 2018). Within the field of community power building, there is an effort to avoid replicating oppressive decision-making processes within their organizations that they are fighting against outside their organization.
This is similar to how organizations establish alternative comprehensive programs to demonstrate what is possible. For example, Our Voice Our Schools is an organization that emerged to increase the decision making of students within Denver public schools, specifically in Aurora and Cherry Creek. It focuses on providing support for families navigating the public education landscape, connecting families with mental health supports, launching advocacy efforts, organizing the grassroots, and base building. Our Voice Our Schools has doubled down on Denver schools as places where Black and Latino families can be part of a community effort in transforming a school into the kind of supportive, loving, and nurturing place they want for their community.
Yet, in the process of establishing a “loving community school,” Our Voice Our Schools is also modeling processes of inclusive decision making. As a result, leaders learn the skills of inclusive decision making and democracy that they continue to hone and employ as they move up in positions of responsibility and authority like serving as a school board member. This is another way to shift systems from the ground up—by preparing leaders skilled to usher in new ways of working with others, especially with communities most impacted.
What does democratic and inclusive participation look like? Consider Kentuckians For The Commonwealth (KFTC), a group formed over 38 years ago in the mountains of eastern Kentucky to hold coal companies accountable for the wealth, resources, and power they have extracted from the people in the state. KFTC has since expanded its geographic reach throughout the state and broadened its focus to include multiple issues ranging from economic justice, tax and fiscal reform, access to quality education, and environmental justice.
But while it has upscaled in size, it has maintained decision making tethered to its local roots. Reflecting a core commitment to leadership development and local organizing, KFTC comprises 14 local chapters defined by a county or multiple counties. While they choose their own local issues and strategies, each chapter elects representatives to a statewide steering committee, which guides the work and sets the priorities of KFTC from year to year. Local representatives participate on issue-specific committees, such as Economic Justice and New Energy and Transition, and on governance committees, such as Finance and Leadership Development. They strive to balance the composition of the committee so that they are driven by the people who are most impacted, and thus have the most to gain, by the set of issues that the committee is focused on.
Advancing Structural Change to Shift Power Dynamics
Considering the role of community power in advancing health equity requires an expanded understanding of the types of change and impacts that power building ultimately seeks to produce. One frame for conceptualizing the types of change makes a useful distinction between tuning, incremental change, and restructuring (Seidman, 1988). Tuning change involves adapting and adjusting to existing systems rather than altering or replacing the standards, relationships, or mechanics within systems. Incremental change produces an increase in a valued resource—for example, health, wealth, and safety—but the relative distribution of resources is maintained or slightly altered such that distributional disparities remain. Restructuring changes the relative proportions for subgroups in relation to society as a whole. This more fundamental approach is consistent with “targeted universalism,” in which the attempt to achieve a universal goal, such as quality health care, housing, and healthy environments for all, is coupled with strategies that offer different populations differentiated resources to get there (Powell et al., 2019).
In some places, power-building organizations are not only strategizing around policies and institutional reform but also changing the composition of who sits in positions of authority. What this looks like, according to one community power builder, is “getting grassroots, everyday people from the [power-building] movement to run for [elected] offices,” as in Denver, CO, where three school board candidates aligned with Our Voice Our Schools were elected to the board, or in Washington State, where volunteers who had been trained by community power-building organizations helped to elect a local leader of an immigrant rights group, Pramila Jayapal, to state senate. Representative Jayapal then became a prominent member of the U.S. Congress. In Minnesota, a member of ISAIAH, a faith-based statewide organization, became second-in-command at the state health department, thus gaining influence over the state’s multimillion-dollar health equity budget. While one elected official cannot change the system, shifting the composition of decision makers can lead to more durable shifts in the way power is allocated within the system over time by acting on Lukes’s (2005) notion of the “second face of power.”
Other ways in which organizations are influencing who makes decisions include establishing task forces and committees that include community members or getting community members appointed to boards and commissions that oversee the agencies in charge of policy and program implementation. In Miami, Florida, Miami Workers Center and SMASH (Struggle for Miami’s Affordable and Sustainable Housing) organized tenants and succeeded in getting the city and county to assemble a task force to hold property owners accountable for deplorable housing conditions. As a result, a 21-unit building with overdue code violations worth more than the value of the property was eventually put into receivership with the city, which began repairs until a buyer who agreed to make repairs was found. In Chicago, the Grassroots Collaborative trained community members who were then appointed to the Community-Driven Zoning and Development Committee—and, as a result, the needs of workers and residents experiencing poverty are at the center of the conversations about zoning and development. Such task forces help democratize the set of voices who make decisions about how resources are allocated.
Yet it is not enough for elected officials and government agency staff to come from communities most impacted. Once on the “inside” of government, there needs to be mechanisms to be in ongoing communication with, and accountability to, these communities—mechanisms that are responsive as local needs change. In fact, when grassroots leaders successfully assume these types of insider roles, many express feeling isolated or disconnected from the community organizations where their leadership trajectory began. We see more and more interest and attention in the field given to developing sustained relationships of mutual accountability. This interest reflects a clear realization that access to decision makers and power brokers is not enough; community leaders must cultivate and maintain a strategic and sustained source of power that gives leverage and flexibility to promoting their interests.
It is important to note that much of the restructuring change that community power building seeks to bring out is not as apparent or visible as a program, policy, or election outcome or changing the composition of decision makers. Transforming the underlying terrain upon which such policy and election debates play out is also the work that results in shifts in power relationships between individuals, organizations, and networks of a place; shifts in what is politically possible as indicated in a legislative agenda that is actively debated and voted upon; and shifts in narrative. For more on making such shifts more visible and applying different research methods to measure such shifts (i.e., network mapping, analysis of legislative bills, and analysis of tweets), see Prisms of the People (Han et al., 2021).
Community Power as a Science
So what does this discussion mean for researchers seeking to understand and advance health justice? The first point seems obvious but bears repeating: excellent research on any health issue is important but is more likely to change policy when coupled with a strategy to shift the status quo balance of power. Expanding Medicaid, stabilizing rents, and providing local park space are all measures that are likely to close health inequities, but success in those dimensions only comes when organized constituencies challenge health providers, landlords, and political leaders.
If that is so, then a first step forward for health equity researchers is to go beyond identifying structural determinants and start building mutually beneficial relationships with community power builders who seek to change those realities. For the authors, the second step has been to understand large-scale social problems not merely as problems of a lack of individual or collective awareness or of faulty policies but also as problems of power imbalances that open up a whole new field of actors and approaches in efforts to advance health equity.
Taking community power building seriously as an object of study—as the authors of this paper have done in their respective disciplines—has made it clear that it is a science and not just an art. Victories for justice do not emerge from moments of inspiration, but rather are the result of long-term and disciplined planning and strategic power building. Data analysis on micro-practices, such as the breadth and depth of oneon- one conversations and what results in increased or sustained participation, has helped organizers improve their craft of organizing and base building.
This may also change the way research is done. Despite long traditions of community-engaged research, many social scientists are still trained to be detached as they gather data and make observations about how things work. What the authors are proposing is different. Akin to advocacy planning in the field of urban development (Clavel, 1994) and action research in the field of adult education (Fals-Borda and Rahman, 1991), the authors are proposing to subvert an interventionist model where academics are the experts and academics design the interventions. Community power-building organizations have a set of practices and capacities—and academics can build a relationship with those groups and bring to bear some of the skills academics have as partners and not just observers or experts, and not just as teachers but as learners. This also implies a different sort of “evaluation”: rather than standing apart from the groups, academics are often in a good position to provide data on what matters to the community, enhance what community organizations are doing, provide insights on how to capture the impacts at the community scale, and reshape research agendas based on goals and priorities of community power-building efforts.
This is not always an easy road to walk. Just as the community power builders need to figure out their inside-outside balance with political leaders and agency heads, community-engaged researchers—and, arguably, all organizations working toward health equity—need to determine how deeply to be embedded with communities and when it is best to step back and serve as an observer. The authors hope that our experience as Lead Local partners can help inform the field on how best to close the gap between the theory and practice of community power building, to offer more responsive and dynamic measurements of power, and to work with communities to shift fundamentally the social determinants of health in the direction of racial, economic, and environmental equity.
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Tweet this! Authors of a new #NAMPerspectives discussion paper describe how the study of community power has transformed their scientific methods and outcomes in ways that can close the gap between scholarship and practice. Read more: https://doi.org/10.31478/202206c #pophealthrt
Tweet this! “When community members participate in, take ownership of, and see themselves as public actors in determining the future of their communities, they are best positioned to push for deep structural reforms.” Read more: https://doi.org/10.31478/202206c #pophealthrt #NAMPerspectives
Tweet this! In a new #NAMPerspectives series, authors emphasize the promise of community power building for achieving racial &health equity, highlight examples from the field, &discuss essential principles and values for building community power: https://doi.org/10.31478/202206c #pophealthrt
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