By Laura Senier and Boris Templeton
Since the founding of our discipline, sociologists have decried the urban living conditions that produce poor health. Friedrich Engels described in heartbreaking detail how the working poor suffered in Manchester, England, and W.E.B. DuBois used statistics to paint a vivid picture of the burden on African-American communities in the Philadelphia Negro. Urban health inequalities have persisted, and over the past decade, policymakers, community health advocates, and private philanthropies have begun to demand multilayered interventions to address health inequalities comprehensively. Community health partnerships have sprung up in neighborhoods around the country, and healthcare providers, business leaders, charities, and community nonprofits are working redefine a healthy community as one where residents can not only access health care, but also purchase nutritious foods, exercise in safe and attractive recreational spaces, and work in family-supporting jobs. Because these partnerships bring together diverse stakeholders, they resemble cross-movement coalitions—an understudied phenomenon in the social movements literature.
Previous scholarship on cross-movement organizing has shown both that overcoming ideological differences is a serious stumbling block, and that coalition brokers—individuals with ties to multiple movements—have potential to bridge frames and thus allow cooperation. More recent work has also shown that organizations can also fill this brokering role. In our research, we have identified a particular kind of organization that is particularly well suited to recognizing the multifaceted nature of urban health problems, and especially well positioned to build partnerships to address them—federally qualified health centers (FQHC).
The Sixteenth Street Community Health Center (SSCHC) is an FQHC on Milwaukee’s south side. For more than 30 years, they have provided high-quality affordable primary care to un- and underinsured families. In the United States, the community health center movement began as part of LBJ’s Great Society program. The early FQHCs provided primary care but also stocked food pantries, dug wells and privies to control spread of mosquito-borne illnesses, and offered job-training programs. Today, the US Department of Health and Human Services continues to support a national network of 1,200 FQHCs, annually serving approximately 20 million patients in medically underserved communities. Importantly, FQHCs are required to have patients or consumers comprise 51% of their boards, ensuring that they are responsive to the needs of the communities they serve.
As an FQHC, SSCHC recognized that social determinants of health are as influential in shaping community health as medical care. In the 1990s, they established an environmental health department, which conducted home visits to identify at-risk children and to connect tenants, landlords, and homeowners with lead abatement services. As they crisscrossed the city visiting patients and families, they witnessed firsthand how poverty, unemployment, and the disinvestment and contamination left behind by deindustrialization were colliding to magnify the health problems of the clinic’s patients. They pressed the city to include community health concerns in redevelopment plans of two neighborhoods: the Menomonee River Valley, an industrial area that collapsed in the 70’s and doomed the surrounding neighborhoods to unemployment, and the Kinnickinnic River Corridor, where the city was proposing to remove 150 low-income families in a project to control flooding. Each site had different stakeholders with different interests and ideological perspectives to be reconciled. In both sites, redevelopment was complicated by historical and material conditions patterning the physical characteristics of the site and the social location of its residents.
Our research shows that the SSCHC’s coalition brokering activities operated at two levels. First, they convened a diverse group of stakeholders who were concerned with three overarching goals for redevelopment: economic revitalization, environmental restoration, and social justice. At this stage, the health center staff translated the concerns of different constituents and did some crucially important work in frame alignment and frame bridging. Second, they helped found anchor organizations to continue the work of maintaining the coalition frame. These anchor organizations (Menomonee Valley Partners and the Kinnickinnic River Implementation Coalition) were established as public-private partnerships, with leadership from the city, the health center, and the business community, but which also included stakeholders whose interests ran the gamut from environmental protection, to economic revitalization, to social justice. The existence of the anchor organizations ensured that the shared frame would reflect diverse perspectives.
The SSCHC also brought their commitment to democratic decision making to debates about redevelopment. In both the Valley and the Kinnickinnic, they sponsored community meetings and did intensive door-to-door canvassing to maximize the opportunities for residents to comment on the evolving plan, and to express their preferences for what they would like to see happen in their communities.
The SSCHC has been a powerful coalition broker because they were able to transcend the ideological barriers that often hinder sustainable redevelopment projects. Rather than allowing stakeholders to square off in zero-sum debates about which goal was more important (e.g., job creation or environmental cleanup), they showed how economic redevelopment could benefit multiple parties. They were especially important in championing the needs of low-income patients and making sure that communities had input on which problems were most pressing, rather than allowing the city or the business community to drive decision making alone.
Because they embody such a broad mission to promote community health and because they have a long tradition of democratic governance, we expect that health centers elsewhere will be critical to improving community health in the 21st century.