Building Community Power to Achieve Health and Racial Equity: Principles to Guide Transformative Partnerships with Local Communities

June 13, 2022

This three-part series highlights learnings from Lead Local: Community-Driven Change and the Power of Collective Action, a collaborative effort funded by the Robert Wood Johnson Foundation that convened well-respected local organizations and leaders in the fields of community organizing, advocacy, and research to examine the relationship between health and power building. Building on the National Academies of Sciences, Engineering, and Medicine’s Roundtable on Community Power in Population Health Improvement workshop in January 2021, priority areas for action are shared to make progress toward, and further an understanding of, community power building for health and racial equity.

The opening commentary unpacks how and why community power building is more durable than community engagement for transforming local community conditions and advancing health and racial equity (Vaidya et al., 2022). The discussion paper shows how the power-building ecosystem works in practice, showcasing examples of state and local power-building organizations and campaigns nationwide and reflecting on how actors who exist beyond the organizing ecosystem (e.g., researchers) can play a critical role in advancing movement aims (Pastor et al., 2022). This commentary, which closes the series, reinforces the essential principles and values for effective and authentic partnering with the field, emphasizing the intersections between health, structural racism, and power.

Introduction

Leaders and practitioners across industries—including public health, health care, and clinical settings; local, state, and federal government agencies; and academic institutions—are asking hard questions about what it will take to achieve health equity. The COVID-19 pandemic, the 2020 uprisings for Black liberation, the January 6 insurrection, and increasing state and local restrictions on voting illuminate how high the stakes are for Black, Indigenous, and other People of Color (BIPOC). Previously quiet conversations about “advancing health equity” and “moving upstream” are evolving into more public debates about the need to center racial equity in institutional efforts to achieve health equity. As of October 2021, the American Public Health Association tracked more than 220 jurisdictions that had named racism a public health crisis, and organizations across various sectors are making visible commitments to transform their practices, programs, and policies to achieve racial equity (American Public Health Association, n.d.).

What should go hand-in-hand with efforts to achieve racial and health equity are efforts to share and shift power with communities affected by health and structural inequities. For example, more health institutions and funders, such as the Robert Wood Johnson Foundation, National Association for County and City Health Officials, and The California Endowment, are making this commitment—looking for opportunities to help build community power, as an outcome in and of itself, in their sphere of influence.

In this commentary, the authors discuss why this emerging emphasis on building community power is essential to achieving health and racial equity and highlight a set of values and principles to guide practitioners, researchers, and leaders in transforming how they work with communities to build their power.

Building Community Power as an Antidote to Health and Racial Inequity

People and communities who bear the brunt of broken, inequitable systems—those who are receiving poorer health care, incarcerated, living in lower-quality housing, working in high-risk jobs and without adequate protection, attending lower-resourced schools, and living with pollution and climate impacts—are often the furthest from formal centers of power (Givens et al., 2018; NAM, 2017). Power manifests in how decisions are made, the people and networks involved in making decisions, how problems and solutions are framed, what ideas are considered in the process, and how to measure success. Power shows itself in the form of resources, access to decision making, alliances and networks, the capacity to organize and reproduce community power, and the dominant stories society chooses to tell about the United States and its people.

Building community power is about transforming this reality, which is often racialized, leading to untold inequities in the social, economic, environmental, and political conditions that create health. Community power, built and exercised by low-income and BIPOC communities, affirms an understanding, grounded in research, that those experiencing the worst health outcomes are in the best position to contextualize, design, and implement solutions that will work in and for their communities (University of Southern California Equity Research Institute, 2020). But these communities need the platform and resources to do so.

A commitment to sharing power means widening—and ultimately shifting—the circle of people, communities, and networks making decisions and reprioritizing the problems and solutions to focus on. Given the many ways in which power hoarding has led to systematic oppression of communities of color and inequities across myriad determinants of health, the process of power-sharing sets a new paradigm within the systems that need to change (Hannah-Jones, 2021; Rothstein, 2018; Alexander, 2010). Transforming systems requires transforming the balance of power and relationships among people who shape and experience these systems.

As described by the University of Southern California’s Equity Research Institute (2020), “Community power is the ability of communities most impacted by structural inequity to develop, sustain and grow an organized base of people who act together through democratic structures to set agendas, shift public discourse, influence who makes decisions, and cultivate ongoing relationships of mutual accountability with decision makers that change systems and advance health equity.” In this understanding, building community power is an approach to shaping the conditions needed for healthy and equitable communities via the development and implementation of policy, practice, and structural change.

Community Power Building Organizations as Natural Allies for Practitioners, Researchers, and Leaders across Sectors

Grassroots community organizations, also known as community organizing groups or community power-building organizations (CPBOs), are among the most effective organizations to build power, as they work closely with those most impacted by structural oppression to transform the rules, policies, systems, and structures that underlie inequities and poor health (Robert Wood Johnson Foundation, n.d.). CPBOs raise political consciousness about pressing conditions among community members, develop strategic campaigns that build on research and experience to address priorities, and organize and lead collective action to transform the policies, structures, and systems for long-term sustained improvements to health and racial equity. CPBOs often focus on improving the social, economic, and environmental determinants of health inequity—even if they don’t use those words. Importantly, they also seek to transform the underlying power imbalances and systems of oppression, advantage, and privilege that drive those determinants (i.e., the determinants of the determinants).

Partnering with CPBOs is inherently a commitment to shifting and sharing power. The health system, for example, is in an exciting period of experimentation—and hopefully transformation—in advancing racial and health equity and ultimately building community power. Although partnerships between governmental public health and CPBOs constitute a relatively new field of practice, there are numerous examples to build from (Farhang and Gaydos, 2021; Human Impact Partners, n.d.). These collaborations have tangible impacts both on improving the conditions of people’s lives and transforming governance in enduring ways.

Working Principles for Health Justice and Racial Equity

To address the United States’ most persistent challenges, where sectors, industries, and people with deeply entrenched power defend the status quo and keep reproducing inequities (e.g., the fossil fuel industry and climate change, banking and real estate and the housing crisis, the sugary drink industry and preventable chronic diseases), more and stronger partnerships between health and racial equity advocates and CPBOs are necessary. However, given the differences in methods of advocacy, interpretation of the political and economic contexts in which inequities persist, the role of history and culture as a precursor to action, and how success is defined, the potential for early missteps are real. These missteps can be avoided if greater intentionality and focus are placed on understanding how to work across cultures, politics, capacity, and infrastructure, and especially how actionable knowledge is produced and operationalized.

In that spirit, the Praxis Project has organized a set of Working Principles for Health Justice and Racial Equity to partner with and center community interests in the design, promotion, implementation, and evaluation of policies and initiatives that support health justice and racial equity for everyone (The Praxis Project, 2020). The Praxis Project uses “justice” to denote the authentic collaboration between institutional advocates and CPBOs to transform the systems and policies that underlie inequity. The principles help envision a society in which CPBOs, affected communities, advocates, and policy makers move from addressing inequitable outcomes to focusing on the structures and systems that lead to inequity and transformation through initiatives centered on community organizing and community power.

Guiding Principles

Act with Care — Be thoughtful, be deliberate, seek to understand, build trusting relationships, and lead with love.

As a direct reaction to the recent trend of “moving fast and breaking things” (Taplin, 2017), this principle emphasizes the need to work at the speed of trust and an understanding that wrong steps can lead to irreparable negative consequences for the communities that practitioners and leaders seek to support. As communities are engaged, practitioners and leaders need to understand the different manifestations of privilege and account for each.

Inclusivity — Those most affected by inequities are in the best position to define the problem, design appropriate solutions, and define success.

Solutions should reflect the community’s priorities and the context in which they will be implemented. There is no one-size-fits-all solution. Local experience and wisdom should heavily inform evidence-based interventions. Communities have developed a wealth of knowledge and ways of collectively healing, even in a context of general disinvestment and oppressive practices and policies. These experiences and lenses will help make any collaboratively designed intervention more impactful.

Authentic Community Collaboration — Collaborations should build dignity and integrate all perspectives, and solutions should be co-designed, co-implemented, co-measured, and co-evaluated.

Collaboration should not reproduce past traumas where the community has been done to, rather than done with. Authentic collaboration centers the wisdom and context of those who are closest to the issue being addressed. This approach requires balancing what practitioners and leaders know from research with what the community knows from experience. Supports should be provided to transcend typical obstacles to participation, including compensation, transportation, child care, translation, and accessible meeting times. Authentic collaboration should build trust, capacity, and infrastructure for future partnerships.

Sustainable Solutions — Solutions should be community-driven, build community capacity and resident knowledge, deepen relationships, increase programmatic capacity, build lasting infrastructure, and ensure respect for all.

Policies should seek to address health equity and racial justice by prioritizing healing; developing community leadership; raising community consciousness about the historical, political, and economic roots of issues; developing community capacity to implement programs and activities to address issues; and increasing the infrastructure of organizations in a manner that transcends an engagement, grant period, or collaboration. Solutions should address the direct issue at hand and increase local capacity to transform other systems, structures, and policies that underlie inequity.

Commitment to Transformation — All participants can learn from one another, reflect on their own structures and practices, and find areas to continuously improve their respective organizational cultures and practices.

Approaching collaboration with a learner mindset will open up the opportunity to improve assumptions and understanding of the root causes of inequity and also recognize how to be better partners in transforming the systems, policies, and structures that underlie inequity.

Calling in Leaders, Practitioners, and Researchers Whose Decisions Affect Community Health: The Time to Invest in Power Building Is Now

There is a wide ecosystem of actors responsible for creating space for centering community power and equity. There is no question that leaders, practitioners, and researchers and those who influence and make decisions affecting communities—including myriad health system actors—should be part of that ecosystem, doing the hard work of relinquishing their power and privilege and establishing mutual and interdependent models of working with and centering communities.

The Working Principles for Health Justice and Racial Equity provide a framework for how to accomplish this. The BIPOC communities most affected by racial and health inequities can continue to cultivate and harness local power to transform harmful systems. The benefit of bringing these communities and system actors together around the goals of equity and racial justice has never been greater. Transforming decision making is itself a strategy to remedy historic and ongoing injustices. In addition to this reparative effect, shifting how leaders, practitioners, and researchers partner with communities will catalyze, create, and sustain conditions for healthy communities in ways that create lasting change. In that sense, community power building is not just a strategy to achieve social change but is also a concept representing social change in and of itself.

Funding Statement

The views expressed in this paper are those of the authors and not necessarily of the authors’ organizations, the National Academy of Medicine (NAM), or the National Academies of Sciences, Engineering, and Medicine (the National Academies). The paper is intended to help inform and stimulate discussion. It is not a report of the NAM or the National Academies. Support for Lead Local was provided by the Robert Wood Johnson Foundation. The projects described in this commentary were not all funded by the Foundation, and the references cited here do not necessarily reflect the views of the Foundation.