Pathways to Healthy Communities

The following comes from a presentation on, “Developing a Systems Thinking Perspective of a National Deliberation Project on Healthcare Costs” as part of the “How Can We Reduce Costs and Still Get the Care We Need?” Kumu project which was featured in the last blog post, “Using Deliberation and Systems Thinking to Address Healthcare Costs”. They are the three concluding statements arrived at after the completion of a systematic inquiry into the NIFI forum on healthcare costs.

1. We should not approach issues of Healthcare Costs in terms of "Cost Savings". Instead, we should approach it in terms of "Reinvesting and getting a Better Return”.
2. We should endeavor to bring Healthcare concerns, both health, and costs, closer to community-based approaches. The positive aspect of such an approach is that there are already numerous efforts going on. These need to be prioritized to a far greater degree. (and made to have a Collective Impact)
3. Community-based efforts should focus first on health then find cost-efficient means of implementing programs, not the other way around. 

The salient point for this post is, “The positive aspect of such an approach is that there are already numerous efforts going on. These need to be prioritized to a far greater degree.” This means moving our attention away from the deliberative process of deciding issues of healthcare costs to creating and implementing programs in a community based on those decisions.

This then would be a part of a process of creating what will be called Healthy Communities (wiki-tag). Below are several new websites recently added to the New Community Paradigms Wiki, all of which have some focus on health and community.

Healthy Communities involves building Healthy Cities (wiki-page) as well as focusing on Community Design (wiki-page), Geographic Based (wiki-page) community change agencies, and rethinking our Streets (wiki-page).

Healthy Cities approaches working toward community health from a variety of different perspectives and levels. Some are more functional and could be applied in a variety of settings, like a toolbox. This particular Community Tool Box | Table of Contents is a service of the Work Group for Community Health and Development at the University of Kansas.

“The Community Tool Box is a free, online resource for those working to build healthier communities and bring about social change. Our mission is to promote community health and development by connecting people, ideas, and resources.”
Others like the Gallup-Healthways Well-Being Index provide important health data.

“The Gallup-Healthways Well-Being Index® is the first-ever daily assessment of U.S. residents' health and well-being. By interviewing at least 1,000 U.S. adults every day, the Well-Being Index provides real-time measurement and insights needed to improve health, increase productivity, and lower healthcare costs. Public and private sector leaders use data on life evaluation, physical health, emotional health, healthy behavior, work environment, and basic access to develop and prioritize strategies to help their communities thrive and grow. Journalists, academics, and medical experts benefit from this unprecedented resource of health statistics and behavioral economic data to inform their research and reporting.”

Another similar site is Rankings | County Health Rankings & Roadmaps, sponsored by the Robert Wood Johnson Foundation, which "allows you to Look up your county’s Rankings, learn about their methods, and download the data you need."

An example at a local city level of a community focusing on health is Davidson Design for Life.

“Davidson Design for Life (DD4L) is an initiative of the Town of Davidson to foster healthy community design through the use of health impact assessments (HIA), public participation, and collaborative efforts in Davidson, the Charlotte-Mecklenburg region, and North Carolina.”
Even though a small community of 11,750 people (2013) with Davidson College nearby with 1,920 students, the site provides information on Health Impact Assessment: What is it?, for the surrounding region and information on HIA in the US.

At a state level for Minnesotans is Alliance for Healthy Homes and Communities.

“All Minnesotans should have the opportunity to make choices that allow them to live a long, healthy life, regardless of their income, education, or ethnic background. Everyone wants good health to be productive at work and to succeed in school and to have affordable medical and housing costs. To make this opportunity a choice for all Minnesotans, we all have to do our part in creating and maintaining healthy homes and communities. Every person and every organization have a role to play, small or large.”
Closer to home is LA2050 - Shaping the future of Los Angeles, which involves though a major city with a population of over 3.8 million and a focus that expands beyond healthcare concerns to other areas, so it has been placed under Geographic Based community change agencies.

“LA2050 is a community-owned mechanism to create a shared vision of success for Los Angeles in 2050 and to track progress toward that vision.”
At a state level is The California Endowment which is also involved in the Creating Health Collaborative and in the related Stanford Social Innovation Review presentation on “Organizing Communities to Create Health”.

"The California Endowment was established in 1996 as a result of Blue Cross of California's creation of its for-profit subsidiary, WellPoint Health Networks. Since then, we've invested in health broadly, from strengthening the safety net for families struggling with poverty to diversifying the health care workforce. The lessons learned from early investments were the genesis for Health Happens Here and the 10-year, $1 billion Building Healthy Communities plan, in which residents in 14 places are working to transform their neighborhoods."

The sites cited above involve data and organizations. There is also a need to consider at a more foundational physical level in the promotion of health through design, which is what the Center for Active Design does.

“The Center for Active Design is a nonprofit resource for design professionals, policymakers, real estate developers and community advocates, committed to promoting and expanding the Active Design Guidelines published by New York City in 2010. We maintain a multi-disciplinary perspective in the translation of health research into design solutions that amplify the role of architecture and urban planning in improving public health and well-being.”

"Rethinking the Automobile", a project created to raise awareness around the negative impact of the automobile on our world by livable streets advocate Mark Gorton no longer seems to exist. The presentation, associated with the site, still exists on Vimeo. 

Elsewhere, from a more creating health perspective, is the StreetFilms video Carmaggeddon Averted as Broadway Comes to Life, in which "Mark Gorton takes us on a tour of Broadway's car-free squares and boulevard-style blocks, where conditions have improved dramatically for pedestrians, cyclists, and, yes, delivery truck drivers," putting forward the counterintuitive truth that taking away space for cars improves traffic and makes the city safer and more enjoyable for everyone on foot, based on established theories like traffic shrinkage and Braess's paradox that help to explain why this happens.

These are not the only websites in the NCP wiki related to health or healthcare, in fact, most can be related, at least indirectly. They are the most recent and have not been featured previously.

Laying out a few possible pathways to creating Healthy Communities does not lay out the entire required journey. Moving from the primarily deliberative process to actual implementation of programs still, means overcoming any fundamental differences in perspectives or mindsets within the community (which will exist even if everyone is familiar and adept at systems thinking) and crossing the Knowing-Doing Gap by Jeffrey Pfeffer and Robert I Sutton as discussed in previous posts. There is still lots more work to do but this does make it all the more possible. 

The Failed Olmsted 1930 LA Plan points to Complex Challenges for Today and Opportunities for Disruption Tomorrow

In the last post written on attending ‘A Place for Us: Re-imagining and Reclaiming’,' lessons learned from the past regarding the process behind the failed 1930 Los Angeles Playgrounds, Parks and Beaches Plan of the Olmsted Brothers, were discussed. This post will attempt to bring some of those lessons up to the present by connecting concepts previously considered on these pages with the concrete examples provided by history.

One lesson in particular is that even if there are surface similarities between then and now, this does not mean that the underlying premises and perspectives, or agendas are the same.  We sometimes pick the lessons from history or criticize mistakes of the past to fit our own current agendas. There are some aspects of popular initiated community building and development though that do seem to stay the same. Los Angeles in 1930 had its Hollywood stars has it has today and businessmen on the Chamber of Commerce could be swayed as they can today. Los Angeles had cars back then, more cars than most cities, and was concerned about water.  However, what they saw and what we see as the fundamental challenges and the visionary goals are very different.  This is not to point out that they were wrong but that they had different system wide challenges and came up with a different set of solutions based on the knowledge and resources that they had.  Although the perspectives and approaches may change, Los Angeles, as a community defined by geography, history and natural resources, is still continually trying to redefine, even create itself anew. 

Besides looking at the past, the panel for the ‘A Place for Us: Re-imagining and Reclaiming’ discussion also provided more abstract but still useful perspectives on the continual regeneration of cities over time. Cities overall, William Deverell pointed out, provide for the most efficient utilization of resources on a per capita basis and succeed far better as social engines compared to other versions of built community. Two newly learned and important metrics in the organizing of humans within a constrained geography were urban metabolism and friction of distance. A closer look at urban metabolism is provided by this slide presentation by Stephanie Pincetl and Paul Bunje of UCLA.   

While these are not the type of numbers that would be included in a city’s end of year report, they do help in the configuration of placemaking on a broader scale to optimize community ecology.  Community ecology is chosen as a more appropriate term, rather than the word environment, because it can be associated with a greater biological orientation to the concept of community and the process of relating to the environment. Placemaking, according to the Metropolitan Planning Council of Chicago, “is both an overarching idea and a hands-on tool for improving a neighborhood, city or region. It has the potential to be one of the most transformative ideas of this century.” 

This effort, in its initial stages, saw placemaking as dealing with the built environment but from an interactive social perspective by which the built environment became the canvas upon which the creativity of the community was manifested, and was in turn also transformed by that creativity to the point at which the canvas became the art. 

The use of these terms serves to define the system of community as one of adaptive complexity. Under a complex adaptive system we can assume that there are elements making up the neighborhoods that in turn make up the city that is part of the region.  It is at the level of elements that design thinking has its focus, that disruptive innovation seeks the job-to-be-done and that, as the moderator Claudia Jurmain challenged the panel, supports Paola Antonelli’s assertion that design allows for the negotiation of change.

We, as a rule, though create artificial systems of complicated mechanistic algorithms imposed by top down management in an attempt to control the complex systems of nature or those arising through our interactions with nature or which then subsequently result.  The business world is already coming to the realization that the complex challenges of the twenty-first century cannot be addressed through twentieth century means of imposing solutions.  The public sector is though, in many cases, falling behind. 

The 1930 Playgrounds, Parks and Beaches Plan was based on the aspirations of the community of Los Angeles or at least that part of the community that had aspirations. This is different from the norm according to Tom Gilmore of Gilmore & Associates, who during the panel discussion asserted that most substantial forms of community transformation were based on some form of crisis.  This is aspiration that emerged through what is considered by this blog as a complex system of community.  Certain creative elements or a vanguard within the community saw a need to make the future more coherent. The actual creation of the 1930 Plan though was done through what can be imagined as being the complicated application of algorithms gathered and developed by the Olmsted Brothers over their impressive career.  They also incorporated local expertise of the territory and fauna but they did not seek general public input maintaining strong top down control over the process. 

The Olmsted's were also savvy enough to know though that the politics of the Plan had to be addressed before hand.  The community likely thought that it had but did not realize how, what this blog terms as ‘entrenched‘, the Los Angeles Chamber of Commerce or its inner sanctum was, allowing it to be the bottleneck that killed the efforts of the vanguard of the larger community.  

Entrenched power should be operationally defined as it is arguably the biggest obstacle to optimizing the system. The term ‘entrenched’ for New Community Paradigms, usually found as ‘entrenched’ city halls, refers to political institutions, usually local, that through an evolution of community culture have created subsystems of political and economic power that become entrenched regardless of any form of democratic intervention.  Surface changes of exchanging one clique of politicians for another might occur but there is no longer any real broad based democratic participation in the mode of the top tiers of Sherry Arnstein’s Ladder of Citizen Participation.  The label ‘entrenched’ was used to make such entities analogous to incumbent business entities that through their own successes had become myopic in their understanding of their own market and failed to see or appreciate the impact of competitors being empowered through disruptive innovation. Entrenched cities are not similarly successful, often quite the opposite, but they are myopic and they restrict or squander resources to hold on to power and often a past in which they had greater status.  New Community Paradigms is exploring whether disruptive innovation can, in some form, be applied to the public sector. 

Entrenched city halls and their like have been a target for this effort from its start.  It has also been said before that not all city halls are entrenched. That, however, is not enough. What should also be made clear is that if a city is not entrenched then it may likely be ‘adaptive,' as in existing as a manifestation of a complex adaptive system.  How adaptive would still be a question, adaptive enough to maintain the system until the environment changed too drastically or adaptive enough to recreate the system?  Furthermore, no community is wholly at any one particular stage.

The larger community or system had developed what was likely a complex resolution to meet a community need but without getting formal, explicit democratic agreement from the majority of the community.  It found a seemingly effective means of addressing that challenge which would have been likely adopted by the larger community if the opportunity had arisen. This system or community, however, had no means of addressing the entrenched power of the few members of the LA Chamber board once they turned on the Plan.  Another 'if' question for the future is whether getting formal and explicit democratic approval for the Plan from the larger community before and during its creation would have also derailed implementation of the Plan, not up or down approval but the crafting of the plan to the same level of widely accepted excellence. 

Another new area of exploration for this blog has been systems thinking. Communities are systems and it becomes increasingly difficult to meet new challenges facing these community systems. This is not “The System” of secret, behind closed doors political power and chicanery, but the larger, ‘living’ complex social system which encompasses civil society and economics extending from the local to the global.  This system endeavors to create components of itself through self organization and agent intervention that ideally functions to meet the ‘metabolic’ needs of the community effectively, efficiently and sustainably while meeting a desire for greater democratization by its residents while trying to get past the bottlenecks often created by that other “the system” of entrenched political and economic power.  These three components of the system can move in and out of conflict, usually because of different agent agendas, making the system potentially chaotic. 

A conflict or disfunction between entrenched power and greater community democratization or even between entrenched power with a truly well functioning system could be understood and appreciated.  A potential conflict between a well functioning system and community democratization might not be so obvious and its resolution not so apparent. Adding an entrenched entity to this last configuration only makes it, well more complex. However, even if entrenched power is successfully addressed, there is still a potential (though expectably resolvable) conflict between creating a well functioning system that addresses wicked challenges and full community democratization that could move the system back to control by entrenched powers. 

Reimagining and Reclaiming a Place for Us: Olmsted 1930 LA Playgrounds, Parks and Beaches Plan, Lessons from the Past

This last Sunday afternoon was spent in attendance at the Rancho Los Alamitos, Long Beach, CA, to listen to presentations and a panel on the 1930 Los Angeles “Playgrounds, Parks and Beaches” Plan as a basis for a discussion of “A Place for Us: Reimagining and Reclaiming”, which was written about in advance of the event by this blog a couple of posts ago. 

The participants presenting and serving on the panel included from an academic perspective, William Deverell, Chairman of the USC History Department and Director of the Huntington-USC Institute on California and the West, who co-authored Eden By Design: The 1930 Olmsted Bartholomew Plan for the Los Angeles Region, and Stephanie Pincetl, Director of the Urban Center for People and the Environment at the UCLA Institute of the Environment.   

From a media perspective, Frances Anderton, radio host of DnA: Design and Architecture on KCRW and KCRW.com, and Jon Christensen, an Adjunct Assistant Professor in the UCLA Institute of the Environment and Sustainability and the Department of History, as well as nationally published freelance environmental journalist.  

From the brick and mortar development perspective, Alan Pullman, AIA, founder of Studio One Eleven, a division of the international firm Perkowitz+Ruth Architects, who also serves on the Urban Land Institute’s Inner City Council, and Tom Gilmore of Gilmore Associates, who began in 1998 to acquire and rehabilitate underutilized historic properties in the Historic Core of downtown Los Angeles. Noted by the event’s promotional material as a risk-taker and animating force behind Los Angeles adaptive reuse development, his revitalization of the Old Bank District has served as a model for other developers.  

The moderators were Claudia Jurmain, Director of Special Projects and Publications and founder of Conversations in Place at Rancho Los Alamitos and D.J. Waldie, historian, cultural commentator and author of Holy Land — A Suburban Memoir, who also served as a presenter and panel member.

Saying who presented the ideas is important because there weren’t any Powerpoint presentations and the exchange of ideas was plentiful and very fluid.  As usual, this was a new venture with little previous knowledge, even more so relative to the deep knowledge that the panelists brought to the discussion. The issues that were dealt with, whether from the past or today were also more concrete than some of the issues that have been dealt with recently by this blog.  There was both new knowledge acquired and the checking of previous ‘knowledge’ wrongly acquired providing enough to create two posts, one looking to lessons for the future and one, this one, looking to lessons taken from the past. 

The presentation and panel discussion provided more substance to the the 1930 LA Playgrounds, Parks, and Beaches Plan story. The Olmsted Brothers were asked a number of times before they agreed to create the Plan and they warned the good people of Los Angeles Olmsted that it was essential that the political work needed to be done before hand to avoid, what W. Deverell termed, a naive environmental idealism versus politics.  

The actual process of bringing the 1930 LA Plan to realization was not that different from today.  The Hollywood big star of the day, Mary Pickford, wooed the LA Chamber of Commerce resulting in a large number of paid prescriptions from private wealth to fund what was to be conceptually similar to the Emerald Necklace of Boston.  The Olmsted Plan focused around Elysian Park combining landscape planning with traffic planning with the underlying premise that nature or the environment was endless. That myth is now gone. 

The Olmsted Brothers had local input into the creation of the Plan but from local experts familiar with the fauna and territory, not so much from the public it would seem. The Plan was to be paid for by bonded debt and governed by a newly created government entity.

The best intentioned outcome of the Plan was that the LA Chamber was to accept the report and then send out thousands of copies but instead they sent out only 150 copies. The inner Board killed the project creating a power shift by a small group.  Demonstrating as a past example of what has been termed entrenched power by this blog, one LA Chamber member was quoted as having said, “Los Angeles has enough parks.” 

It may have been the realization that the newly proposed government institution would seriously diminish the influence of the LA Chamber’s inner circle of power that was the motivation to kill the Plan. In the tradition of Greek tragedy, that happened anyway with the coming of the Great Depression, making the squandering of a potential resource all the more ironic. S. Pincetl of UCLA spoke of ‘foiled desire’. 

This brings us to two erroneous assumptions that were made the previous Paradigms Lost - Olmsted Brothers and the 1930 L.A. Plan post.  First that the Olmsted Brothers foresaw the problems that would arise from automobiles because they recognized at the time that Los Angeles “has a far wider and thinner spread of population than any other metropolis, and a far greater use of automobiles.” W. Deverell explained that the Olmsted Brothers had a far different perspective of the automobile and its relationship to nature to what we have today. 

They envisioned what has become the rush hour packed freeway system as a series of parkways to which one could escape.  The second assumption, arising from the first, was seeing the past as a far too idyllic reality.  It was pointed out that in the early part of the twentieth century cities, particularly large cities, were still seen as being insalubrious. The automobile, rather than being the source of greenhouse gases was seen in the early twentieth century as a means of escaping the infectious diseases lurking in the cities.  Many of the urban issues we face today would arise a few decades later when the federal highway system would be created and expanded by Eisenhower, starting the Growth Ponzi Scheme that Strong Towns rails against today. 

The negative effects of past acts of either omission or commission cannot be ignored but we need to be careful with putting ourselves or our favorite aspects of the past into too favorable of a light. Cities have faced various system challenges over the years and have come up with a variety of solutions. However, the vast majority of man-made solutions created have been based on mechanistic, usually top down, complicated management structures as opposed to more complex oriented systems, and all at some point in time begin to fail if for no other reason than changes in the environment (total environment not just natural). This includes any that we make today; trouble is that they will likely fail faster. 

S. Pincetl pointed out that the older cities of Europe were built by beasts of burden rather than by machines powered by fossil fuels as were the American cities of the Twentieth century.  Early ages were not only in a different relationship with nature, they also saw their cities as serving different functions from today.  While we work to develop sustainable cities, they sought to built sanitary cities which had an essential function of evacuating waste even if that meant using waterways to do so. 

Water was also seen in a very different light in the earlier history of Los Angeles. The Los Angeles River was once a principal source of water. The Olmsted Brothers seem to have basically ignored it or, as some asserted during the panel discussion, realized that it wasn’t much of a river.  LA River would later though become a source of flooding in 1938 providing the rationale for the building of the Los Angeles Flood Control System.  At the same time Los Angeles was looking for new sources of water to meet growing demands.  The city has celebrated the 100 Anniversary of Los Angeles Aqueduct. Today, our perspective on water has changed and our primary concerns are scarcity and pollution. 

The event at Rancho Los Alamitos began to come to a close when the opportunity to ask one question from the audience was offered.  I was chosen, and though I had at least a dozen, asked a what if question which has no real answer but can still provide a good deal of insight.  What if questions provide a hindsight perspective of what went wrong.  This can be useful when trying something similar and applying it to an unknown future. 

What would have happened if the inner board of the Los Angeles Chamber of Commerce had not stopped the distribution of the Plan?  W. Deverell believed that because of the paid prescriptions and public support of notables such as Mary Pickford that the Plan had a good chance of being implemented. So one lesson that could be taken is to find ways to break up instances of entrenched power that serve as bottlenecks to beneficial change within the overall system in which we live.  That, however, is a longer term or at least more difficult endeavor.  Leaving the question for a future post, what other lessons can we take from this particular piece of Los Angeles history to use in creating our future.