measurable improvements in 24 categories, declines in 14, and no change in 157 (CDC, 2007).

A number of concerns underlie this restlessness:

  • Many initiatives do not embody the kind of community voice, support, and participation that is necessary for sustainable long-term results.

  • Many initiatives are divorced from other significant community-development strategies that have the potential to influence the known determinants of health disparities (e.g., housing, safety, education, and civic engagement).

  • Many initiatives are not built on a platform of governance, management, and adequate stable financing that assures a continuity of response from prevention, to early detection, to treatment, and to evaluation.

In simple terms, these initiatives have developed along two different paths. One broad approach to disparity reduction involves essential clinical services and interventions, generally developed by health status or diagnostic categories and supported by categorically clinical funding streams. Thus, a huge number of specific health disparities programs have emerged to address asthma, diabetes, breast and cervical cancers, cardiovascular disease, and other conditions. These programs have the advantage of being targeted to known disparities, can be tailored to provider and community resources, and have the potential to pursue evidence-based strategies. Often these programs are mounted by academic medical centers, health systems, or other provider organizations.

At the other end of the spectrum, an alternative set of community programs and policies proceed instead to address the socioeconomic “fundamentals” of community development and health. These initiatives, generally not on the radar of disparities researchers, are designed to enhance the strengths and assets that already exist in communities; to increase human, physical, and social capital; and to navigate complex processes of economic change (such as gentrification) in communities. These programs fall under the rubric of community building, community economic development, comprehensive community collaborations, and others in the so-called community-development field. Examples include the Local Initiative Support Corporation (LISC) and Community Builders.

For our purposes, however, many of these community-development approaches have significant health aspirations (sometimes explicit and sometimes implicit), often command huge investments and resources, as well as involve the same institutions—churches, schools, hospitals—and community leaders as community-based disparities programs. There is



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