LISC-NPQ Series: Changing the Health System: A Community-Led Approach Rises in Rhode Island
Ana Novais, acting secretary of Rhode Island’s Executive Office of Health and Human Services, describes how neighborhood-rooted Health Equity Zones are tackling gaps in wellbeing and life expectancy that plague communities of color and people living on low incomes. Listening to people’s stories, she explains in this essay for the LISC-NPQ series Community Strategies for Systemic Change, is a key to the success of these transformative health collaboratives.
The excerpt below was originally published on Nonprofit Quarterly:
Changing the Health System: A Community-Led Approach Rises in Rhode Island
By Ana Novais, Acting Secretary for the Rhode Island Executive Office of Health and Human Services
The culture I come from relies a lot on storytelling to cement our learning and culture. I was born in Cabo Verde (Cape Verde) and started working in public health there as a clinical psychologist. I was responsible for mental health in what was, at the time, one of the world’s poorest countries. Because many of my patients were without homes and had been brought to the police station following their involvement in some type of public disturbance, I often found myself talking to police, people in the court system, and businesspeople.
I could see those patients in my office, give them some medication, and see them again at their follow-up appointment a month later, their situation basically unchanged—or I could do something different. I began to think about how, starting with those community conversations and partnerships that developed, public health officials might work with neighborhood residents to build a system out of nothing.
From Cabo Verde to the United States
Fast forward to my family’s move to Portugal, where my mother was born, then to the United States, where, in 1998, I found a job with the Rhode Island Department of Health (RIDOH) as an education and outreach coordinator. There I was, talking to parents about lead poisoning, doing what we do so readily in public health: telling people what to do.
Every day, after educating them about the dangers of lead poisoning, I sent families back to homes full of lead paint, because at the time, our public health response did not include necessary environmental changes, like home repairs. Nor did it include asking people what they thought were the sources of their health problems—let alone listening to their stories. I found myself in a country with so many resources and so much expertise, experiencing the same challenges I had faced in Cabo Verde, where I had almost no resources whatsoever.
A few years later, I worked as a minority health coordinator, focusing on racial and ethnic minority populations in Rhode Island—on people like me, who come here with dreams and hopes to do better but often find themselves without the resources or opportunities they need. Along with my team, I was still telling people what to do. We provided information on how to be healthy but never challenged ourselves, as public health professionals, to create the social and environmental conditions that alleviate structural barriers to health and allow people the opportunity to act on that information.
If you don’t have decent, affordable housing, a livable income, places to safely walk and exercise, or access to affordable fruits and vegetables, what opportunities do you have to make healthy choices? Yet, we continuously tell people to be healthy in the face of structural barriers—we tell them that their health is their individual responsibility, without making the structural changes needed to enable people (and their community members) to overcome systemic barriers to health.
By the early 2010s, when we looked at the metrics produced by Healthy People, the federal government’s data-driven blueprint for public health goals, the numbers showed us that, for the first time in public health history, life expectancy for children had dropped; it was lower than when we were children. How did we have it so wrong? And how could we be so complacent about the status quo?
Developing a New Approach: The Health Equity Zone Concept
So, we challenged ourselves to do something different. We asked ourselves, “What else can we do if indeed we fundamentally believe that positive health outcomes—positive life outcomes—result from good jobs, good education, safe housing, healthy, affordable foods, and safe, prosperous communities? How can we develop an intentional strategy to realize such outcomes—strategies that empower communities to actively improve their quality of life?”
At the time, ideas were percolating about how to promote health outcomes in a radically different way, and related movements were building in other parts of the country and the world. Public health professionals and community developers—along with community activists—were having “aha” moments about the linkage between social determinants of health and terrible, systemic health outcomes for people of color and those living on low incomes. The passage of the Affordable Care Act in 2010 also pushed public health officials to think about these connections.
All this fed into the vision for Rhode Island’s Health Equity Zones (HEZ). Launched by the state in 2015, HEZ is an approach to prevention that leverages place-based, community-led solutions to address social determinants of health. Each of 15 designated zones is a contiguous area—ranging in geographic size from a few city blocks to an entire county. Each is designed to address public health needs in communities with higher-than-average health risks.
The populations of these zones range from 5,500 people to 178,000 in the largest HEZ, the capital city of Providence. Some zones overlap. For example, two smaller HEZs are neighborhood based and also part of the larger Providence citywide HEZ. Each HEZ has a “backbone” community organization—a trusted, local group that people can turn to and which is responsible for promoting HEZ’s approach and assessing how effective the interventions are.
Lead partner agencies vary because the needs of different HEZs vary. One HEZ lead is a community health center with multiple sites. Other lead organizations include a domestic-violence survivor support nonprofit, a city government, an affordable housing developer, and a school district.
This system requires the state government to honor and respect the expertise of those who live and lead in each community. Rhode Island’s Health Department isn’t alone in this kind of thinking and commitment. At about the same time that Rhode Island launched the HEZ initiative, Maryland began implementing its own health empowerment zones. Connecticut and Delaware have also created similar community-rooted collaboratives.
In Rhode Island, we were also inspired by a new model of public safety work being carried out in Providence. These were “safety partnerships” of residents, local community development organizations, and community-minded law enforcement staff (with financing support from the Local Initiatives Support Corporation), who were effectively collaborating to brainstorm and carry out strategies to reduce the crime rate.