Supporting a Movement for Health and Health Equity: Lessons from Social Movements: Workshop Summary (2014)

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Lessons from Health-Related Movements

Building on the theoretical foundation laid by Polletta and Ganz, a diverse panel of speakers experienced in organizing and participating in health-related social movements next provided a range of strategic perspectives and thoughtful interpretation of the meaning of “health improvement” and “health equity.” Moderator Mary Pittman of the Roundtable on Population Health Improvement introduced the session by stating its objectives: to highlight lessons that could be adapted to a broader movement for health and health equity and to discuss challenges and potential solutions.

Pittman also noted that the European Union (EU) has made significant strides toward health and health equity by identifying social conditions linked to the existence of avoidable social inequalities in health, documenting health disparities, and using this information to drive health strategy. Thus, the EU could serve as an example and a source of lessons learned as we attempt to encourage similar thinking in the United States, she observed.

SUPPORTING HEALTH EQUITY

Mildred Thompson, director of the PolicyLink Center for Health Equity and Place and co-chair of the Roundtable on the Promotion of Health Equity and the Elimination of Health Disparities, described PolicyLink’s role in supporting health equity as part of its mission to foster social and economic equity. Within the context of health, PolicyLink

has focused on promoting health food access; she described the organization’s work with the Pennsylvania Fresh Food Financing Initiative as a model of such efforts.

From Models to Movements

The Fresh Food Financing Initiative is a public–private partnership that supports economic development by supporting new grocery stores offering healthful food choices to Philadelphia inner-city neighborhoods that have become “food deserts.” Because this initiative offered multiple benefits—including health—to underserved neighborhoods, it was an attractive investment for PolicyLink, Thompson said. To present this model to the Obama administration in hopes of scaling it up, PolicyLink worked in partnership with the Food Trust and The Reinvestment Fund; together they assisted in creating a federally funded National Healthy Food Financing Initiative that supports new grocery stores, converting neighborhood stores to offer healthier products, and promoting farmers markets that offer access to healthy food. This process exemplifies how PolicyLink supports valuable ideas through networking, outreach, and engagement at many levels, she said.

Similarly, PolicyLink supports the Harlem Children’s Zone in its efforts to provide a path for inner-city children focused on a “cradle to careers” framework. “These are just two examples of how you can take an idea to scale and it begins to be a part of a movement,” Thompson said. An idea is not a movement, she said, but if it can be connected to relevant issues and nurtured through shared interest, an idea can fuel a movement. PolicyLink also serves as partner and advisor to The California Endowment, helping it to invest strategically in healthy community initiatives, she said, and, in so doing, it coordinates with grassroots, community-based, and government organizations to change school meals, neighborhood environments, and health care institutions—and, ultimately, to shift mindsets.

Anticipating the Demographic Shift

By 2040 people of color will no longer be “minorities” in America, Thompson noted. “We don’t even use that term anymore because we are not minorities in California,” she said. “There are four states which are a majority of color: California, New Mexico, Texas, and Hawaii. Right now, 48 percent of all children under the age of 18 are children of color.”¹ Pre-

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¹ U.S. Census Bureau, 2012 National Population Projections. www.census.gov/population/projections/data/national/2012/downloadablefiles.html (accessed October 6, 2014).

paring the nation for this important demographic shift is an overarching goal for PolicyLink, she said. It aims to raise awareness of this phenomenon and to mobilize people to make changes in policies, practices, and research in order to build an equitable economy.

This challenge is the subject of the recent book All-In Nation: An America That Works for All (Cárdenas and Treuhaft, 2013), a joint project of PolicyLink and the Center for American Progress. In addition to presenting the case for economic justice in an appealing, attention-getting format, the two organizations were interested in knowing how Americans were responding to the demographic shift, Thompson explained. Although most people seem to welcome the changes to come, according to a survey conducted as part of the project, some respondents expressed some reasonable concerns. For example, they expressed concerns about job security, government responsibility for the needy, and their identity as Americans in this changing context. “As long as we have conversations about those things, as long as we talk about them openly, it continues to build the sense that we are all in this together,” she said, and the best way to build a movement for equity will be to include as many people as possible through such opportunities.

This project reflects PolicyLink’s approach to advancing economic and social equity. “It always involves partnerships,” she said. “It is about building capacity. It’s about looking for opportunities for growth because inequality is not good for our economic growth.” “There is urgency in this work,” she continued. “It does require a movement, and we must each figure out what our role is in shaping this new tomorrow.”

THE ROLE OF PHILANTHROPIES IN SOCIAL MOVEMENTS

The Robert Wood Johnson Foundation’s (RWJF’s) vision for the future is of a nation striving “to create a culture of health enabling all in our diverse society to lead healthy lives, now and for generations to come,” and in which “health is the outcome,” said speaker Michelle Larkin, the assistant vice president of the health group at RWJF. This is not a vision that the foundation can achieve on its own, she emphasized; rather, the role of foundations such as RWJF is to help shape public dialogue and thereby build demand for change, to invest directly in the people and projects that propel social movements, and to advocate for policy changes that support movement objectives.

Building Demand for Change

Shaping public dialogue begins with getting people engaged with an issue, Larkin said. In the case of health, this can take the form of

supporting existing organizations and networks whose mission encompasses health; as an example of such an organization, Larkin pointed to MomsRising (http://www.momsrising.org), which engages mothers to advocate for all aspects of family well-being. Research—including marketing research and big data—is needed to inform the framing and communication of critical issues, she continued. “We need to provide clear, accurate, and usable information [and to] truly understand what individuals want and need and what excites them and what motivates them to take action.” This is especially important given the nation’s growing diversity, she added. “If we really want to empower people, and we want them to take part in creating this society that we hope for, we have to help them see where they fit, and we have to listen to them and understand how we can create demand for change.”

Several ingredients are essential to building this demand, Larkin said. Organizations, people, leaders, elites, and, most importantly, communities can be brought together around an issue through networks such as parent–teacher associations, professional organizations, and communities of faith. Demand for a healthier and more health-promoting nation can be grown through highlighting success in innovation and engaging and influencing the actions of others. She encouraged health professionals to reach beyond their circle of peers to engage and influence other sectors, such as education, transportation, housing, and business, which truly represent communities and workforces.

Examples of Movement Building

Larkin offered three examples to illustrate the development of health movements. Nearly 50 years ago, the first Surgeon General’s report on tobacco use shaped national dialogue by presenting scientific evidence on the harmful effects of tobacco products, sparking a demand for change which continues to shape legislation at all levels of government. Similar momentum has gathered around the issue of childhood obesity over the past decade, a cause in which RWJF has been involved. The foundation has gathered evidence on effective strategies for reducing childhood obesity through both individual choice and policy initiatives, and it is beginning to see signs that the issue is gaining attention in diverse communities and populations throughout the United States, she said.

RWJF is also involved in research to support efforts toward health improvement and equity by raising awareness of the social determinants of health. For the past 5 years, in partnership with the University of Wisconsin Population Health Institute, RWJF has compiled an annual ranking of almost every county in each of the 50 states, ranking health outcomes and predictors of health, including healthful behaviors (i.e.,

tobacco use, obesity), access to and quality of clinical care, socioeconomic factors (i.e., education, employment, housing and environmental factors). Rankings are helping people understand the social determinants of health, highlighting successes, and showing where improvements are needed. “Those are powerful strategies that get people excited,” Larkin observed.

RWJF considers the County Health Rankings and Roadmaps initiative to be a platform for the culture of health that it hopes to cultivate, Larkin said. Much as a shopping mall gathers diverse shops and shoppers under one roof to the advantage of all, she said, the County Health Rankings unite civic leaders with concerns about health determinants. “Schools, business, law enforcement, community developers, and funding agencies (e.g., United Way) that care about the communities they are part of . . . don’t often work together or see their issues as having shared or common opportunities. The Rankings [and Roadmaps Initiative] provide[s] that opportunity and stimulus for our conversation and—we are happy to say—more action.”

Influencing the Actions of Others

A key aspect of RWJF’s work in building demand for change involves influencing others’ actions, Larkin said. She described five elements of this process: (1) building relationships with sectors outside of health; (2) becoming an influential contributor to the goals of those sectors; (3) bringing ideas and innovations into the movement; (4) sharing credit (without being co-opted or co-opting); and (5) raising the visibility of solutions. To engage other sectors in a movement toward health improvement and equity, she said, “we need to be asking ourselves how we can become an influential contributor to their goals and the strategies that they are pursuing and where are opportunities for us to work together”—and also how to bring their ideas and innovations into our own movement. In order to avoid the problem of co-optation, it is necessary to cooperate on shared solutions, acknowledge contributions, and together publicize the results, she explained.

The notion of a “culture of health” is both inspiring and daunting, Larkin said, much as were the ideas that launched the civil rights and marriage equity movements as well as specific health initiatives such as seatbelt use and efforts to counteract childhood obesity. To establish a culture of health, she said, it will be necessary to connect the vision of a culture of health with the dreams and aspirations of individuals, to build engagement and partnership across broad sectors of society, and to set concrete, meaningful targets to gauge progress. “It will take time to get there,” she acknowledged. “I hope that we will be more and more

creative about how we find, solicit, engage, and influence allies because this is a heavy lift. It matters to us and me and my family, and I hope it matters to you.”

LESSONS FROM THE HEALTHY CITIES AND COMMUNITIES MOVEMENT

Joan Twiss, executive director of the Center for Civic Partnerships within the Public Health Institute, offered the following four points of advice based on the center’s 25 years of supporting initiatives to improve health in more than 100 cities and communities in California and in other parts of the United States:

1. Leadership and community participation that are diverse, broad, and deep
2. Geopolitical context and history matter
3. Home-grown and locally driven networks
4. A regional “fishbowl” that provides incentives

Leadership and Community Participation: Diverse, Broad, and Deep

To be effective, movement leadership should be diverse in every way, Twiss said: It should be representative of a community’s full lifespan spectrum, its racial makeup, and gender and sexual orientation—and also should be diverse in terms of the functions its leaders perform. “We need people who want to plan and implement, and who want to be the spokespersons,” she said. “We need to cross-fertilize across [disciplines] and cultivate stakeholders from all walks of life be they planners, engineers, civic organizations, faith-based groups. These are the model coalitions that we see and support in our work.”

Twiss also stressed the importance of establishing and maintaining political support without being tied to a single administration or political party. She acknowledged, however, that policy making is critical to the work, and her organization has formed productive alliances with respected associations and organizations who have the ear of those in power and who can link them to governmental agencies involved with issues such as sustainable communities, transportation, climate change, and environmental justice.

Geopolitical Context and History Matter

“If we are trying to influence policy makers, we need to be most concerned with their concerns, which is their sphere of control,” Twiss said.

Thus, it is important to supply policy makers with information that is relevant to them, easily accessible, and ready to use. “Learn how local government is organized and appreciate the current context,” including the relationship between public and private sectors, she advised. “Don’t just go ahead with your agenda and hope that it will be embraced by others.”

Rely on Homegrown and Locally Driven Networks

Twiss emphasized the importance of relying on homegrown and locally driven networks. “This is where the most potent strategy comes in,” she said. “Networks are organic and inherently self-serving. That’s a good thing. Connect them versus direct them.” She noted that nationally orchestrated “top-down” movements have not, in general, been as successful as those that came up from the grassroots. “Build on what works and resist the temptation to brand it as your own,” she warned. “Locals really resent that.”

Professionals armed with data about the problem at hand or with likely solutions may face challenges and need to be open to various alternative scenarios, Twiss said, recalling Ganz’s example of the New Zealand community that had a problem with childhood diabetes, but in which young people were most concerned about suicide. She recommended going with where the community’s interests lie. Recently, she said, a community with which the Center for Civic Partnerships has worked for decades announced that it wanted to comprehensively reorganize the city from a health standpoint rather than go from initiative to initiative, without any external resources. This is a breakthrough of the sort that only comes with time, patience, and sustained involvement with a community, Twiss added.

The Regional “Fishbowl” Provides Incentive

Diffusing innovation is important, Twiss said. “Find the 10 percent that will embrace the work and embrace the initiative, and help them to advocate among their peers,” and then showcase the successes that emerge. Phenomenal work in healthy communities has been achieved through the health departments of Los Angeles County and San Diego, which have been recipients of federal grants, such as Communities Putting Prevention to Work and Community Transformation. In Los Angeles, the county worked with cities that would not have been competitive in a standard competition for funds, she said. Often such successes hinge on finding one influential person, such as the smart growth developer in Southern California who in turn influenced superintendents of schools, champions of industry, and leaders of universities. “Sometimes one indi-

vidual can be your Johnny Appleseed that can really get some things going,” she said.

What a national organization such as the IOM can do to stimulate a social movement is to provide “glue” to connect activity that is already taking place, Twiss said. Twenty years ago, she recalled, 1,600 people from around the world attended an international Healthy Cities conference in San Francisco, sponsored by her organization and many others—an experience that many in attendance now say changed the way they viewed their life’s work in public health. “Maybe it’s time to think about something like that again,” she suggested.

BUILDING PUBLIC WILL TO ACHIEVE HEALTH EQUITY

Ned Calonge, president and chief executive officer of The Colorado Trust, described four frameworks of social movements and focused on the process of building public will in support of a cause. For The Colorado Trust, that cause is health equity, an issue that the organization has embraced relatively recently and around which it is maturing. The frameworks Calonge presented have provided critical guidance in this process, he said, having allowed the Trust to organize its work and develop a strategy to move this issue forward.

Community Wealth Partners’ Steps to Social Transformation

The first of four experience-derived frameworks that Calonge shared consists of the following set of 10 insights to achieve social transformation, developed by Community Wealth Partners²:

1. Be bold and believable
2. Discipline is key
3. Create shared leadership
4. Open your circle
5. Communications is strategy
6. Change the conversation
7. Build public support
8. Live in the market
9. Experiment, learn, and evolve
10. Build culture, intentionally

“This is a roadmap of how to be successful in social movements,” Calonge said. Focusing on the third and fourth insights, which concern leadership,

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² See http://communitywealth.com/transformation-insights (accessed June 13, 2014).

he observed that shared leadership requires humility, as Ganz pointed out, and that by opening one’s circle, the number of possible stakeholders in a cause can be increased significantly. “We need to work with everyone we can who is interested in trying to reach the goal of improved population health or health equity,” he advised.

A Framework for Building Public Will

The Metropolitan Group’s framework of five phases for building public will provides important guidance for this crucial process, Calonge said. The first phase, “framing the problem,” requires research to build a knowledge base on the causes of a problem and its cultural context and to identify entities that can have an impact on it. These steps lead to an assessment of current work, the players involved, and gaps to be addressed. In the case of framing the problem of health inequity, he said, a body of research exists on this issue, and government agencies and foundations are already recognizing the importance of the social determinants of health. On the other hand, he added, the cultural context of a dialogue about equity may present challenges, given foundational economic values that can obscure the uneven playing field upon which health inequities operate. This makes it necessary to learn who can make a difference, build on others’ successes, and invest wisely to further the cause of health equity.

The second phase of building public will, Calonge said, focuses on raising public awareness of the problem by using information to raise the sense of urgency around the issue. This requires an understanding of the audience for the message and recognizing that something that worked elsewhere may not move the current target population. Calonge illustrated this point with the example of the RWJF health equity slogan, “Your zip code is more important than your genetic code.” Although it may have resonated in some parts of the country, he reported that it fell flat in rural Colorado, where people simply countered, “I can’t change my zip code.” Conveying the meaning of health equity to that particular population required that they understand that some people are unfairly denied access to a healthy life. “Opportunity and fairness play a little bit better than equal in rural Colorado,” he said; in order to build public will there, one must recognize that attitude and connect the issue of health equity to opportunity and fairness.

People cannot change the personal values of others, Calonge said, but they can change attitudes by building and delivering tested messages through traditional communications as well as through advocacy and grassroots outreach. “You take social marketing and grassroots outreach

and movement building and stick them together, and that is public will building,” he said.

The IOM has a key role to play in the third phase of public will building, which involves the sharing of information. Through the collecting and dissemination of information on an issue, Calonge explained, such communities of experts can engage politicians, health care systems, and foundations and thereby promote policy changes.

In the fourth phase, Calonge continued, the creation of personal conviction leads to action by individuals and organizations that actively champion the issue. Furthermore, successful movements create aspirational community expectations and publicly celebrate their successes in order to encourage more widespread participation.

The fifth and final phase focuses on evaluating and reinforcing progress, including examining whether or not messages succeeded in building public will for a cause. The Colorado Trust recently discovered that one of its two key messages, “Your health care is too important to leave up to others,” was successful, while the other, “You should be able to get the health care you need when and where you need it,” proved ineffective with health care organizations, which constitute an important segment of the Trust’s audience, Calonge reported. “We are learning from that and building new messages going forward.”

A Framework for Change

Figure 3-1 depicts The Colorado Trust’s equity theory of change as a flow chart, connecting strategies with intermediate and long-term outcomes, together with the group’s vision of healthy and productive lives for all Coloradans. To achieve this goal, Calonge said, the Trust is investing in evidence-based policy and advocacy in order to build public will in favor of healthy communities. In particular, he noted that the Trust supports community-based participatory grant-building, a process that encourages the growth of authentic partnerships that can serve as the foundation for a movement for health equity.

Bill Moyer’s Eight Stages of Social Movements

The fourth and final framework Calonge presented was created in 1987 by Bill Moyer (Moyer, 1987). It comprises eight stages through which social movements transition on their way to establishment (see Box 3-1).

“I think we are in the three-to-four range,” Calonge observed of the movement for health equity. The conditions are right, and the movement is starting to take off, he said, but he warned against the next stage: iden-

FIGURE 3-1 The Colorado Trust health equity theory of change.
SOURCE: Calogne presentation, December 5, 2013.

tity crises in the form of “movement fatigue.” Ironically, he observed, such challenges often arise just as a movement is starting to gain traction.

LESSONS FROM THE WALKING MOVEMENT

In introducing his presentation, Raymond J. Baxter, senior vice president for community benefit, research, and health policy at Kaiser Foundation International and president of Kaiser Foundation Health Plan, invited the audience to join a social movement in development. “It is a movement that is about health and meaning and happiness, and it doesn’t really have a demon,” he said. “It’s about walking as a way of life.”

Five Features of Successful Social Movements

Before presenting the case for walking, Baxter noted that the walking movement shares several key features with other successful social movements, including the health-related movements that shaped his career: the institutionalization of mental institutions and nursing homes, tobacco control, childhood lead poisoning, and AIDS. “Those movements drew on different core constituencies for support and succeeded with seemingly different strategies,” he said. However, at their core, they had at least five things in common, and Baxter listed the following:

1. Everyone was invited. These movements were grounded in concepts of equity, drawing in and representing multiple interests and including unlikely allies. They organized broad-based coalitions—and coalitions of coalitions—to extend the reach of what otherwise could have been perceived as a narrow interest group.
2. They worked on multiple fronts. These movements launched comprehensive attacks that changed practices, behavior, policies, and cultural norms. To do this, they built on small successes to create bigger ones which ultimately reshaped societal expectations.
3. They had clarity of purpose. Each movement was able to articulate a clear set of values, not just goals. Those values drove activities and served as a rallying point and a magnet to bring in more supporters and participants.
4. They provided meaningful points of entry for individuals and for organizations, offering many ways for people to join and many levels of participation. They understood the value of action, and so provided ways to engage people either as individuals or collectively or as members of an organization, as well as ways to form and strengthen personal and organizational relationships. Those actions positively reinforced participation because they helped people see how they benefited from the movement as well as how they could contribute to it.
5. They engaged in distributed action. Successful social movements have always been messy. Rather than rely on a linear plan, the leaders of these movements relied on and built relationships and capacity and capabilities, embracing opportunities as they emerged. They achieved success through distributed, shared, and often unpredictable and unpredicted action—and they continue to do so because such movements are never-ending.

The Walking Movement

Walking—which has had a powerful role in many social movements—merits one of its own, Baxter argued. The most direct benefit of walking is its ability to reduce the growing burden of chronic diseases, which currently account for 80 percent of health care costs in the United States and 65 percent of deaths worldwide. Risk for cardiovascular and lung diseases, diabetes, and cancer can be substantially modified through exercise as well as through other behavioral changes. “If you could cut your risk of cardiovascular disease or diabetes or chronic lung disease or some cancers or dementia by 40 to 60 percent, would you take that action?” Baxter asked. “Walking 30 minutes a day, 5 days a week, can cut the risk of premature death from those factors by that much.”

To grow a constituency of support for walking, Baxter’s group launched an awareness campaign that consisted of speeches, modeling behavior, a social media campaign, and a website³ offering a range of resources, including publications, a free smart phone app, and a 30-minute documentary, The Walking Revolution. The group has also been helped by a pre-existing “backbone organization,” America Walks,⁴ that is a coalition of hundreds of organizations united in their support for walkable communities.

From this foundation, Every Body Walk! shifted toward movement building by hosting a summit in October 2013 in Washington, DC, that drew more than 200 advocates from about 150 national organizations, including doctors, policy makers, developers, realtors, employer groups, foundations, and elected officials. The summit participants discussed how to reshape behavior, policies, practices, and social norms to encourage both walking and walkability. Baxter concluded his presentation with a video clip that showed the summit.⁵

In the discussion session following panel presentations, Terry Allan asked what lies ahead for the walking movement. Baxter responded that in the quest for distributed leadership, Kaiser Permanente downplayed its brand, focusing instead on funding and supporting various initiatives and on building relationships and social networks. Now, in order to support the walking movement to maturity, there is a need to define the role of the national group of organizations involved in Every Body Walk! in the context of many successful local initiatives.

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³ See http://everybodywalk.org (accessed June 13, 2014).

⁴ See http://americawalks.org (accessed March 28, 2014).

⁵ See http://www.youtube.com/watch?v=XfXx7rKlLIc (accessed March 28, 2014).

PANEL DISCUSSION

A lively discussion followed the panel presentations, sparked by questions from in-person attendees and webcast participants. Although the questions, as described below, addressed a variety of topics, most threads of the discussion ended up touching on the overarching issue of the language used by movements and its potential to “open the circle,” uniting a broad spectrum of constituencies in support of a cause.

From “isms” to Equity

Winston Wong, medical director of the Kaiser Permanente Community Benefit, Disparities Improvement and Quality Initiatives, noted that none of the panelists made direct mention of the “isms” (e.g., racism, sexism, ageism, homophobia, etc.). Is that framing of the issues antiquated, he wondered, or is there still a case to be made for calling out issues that have driven the major social movements?

Thompson replied that while she often specifically mentions issues of race in her presentations for PolicyLink, she rarely uses the term “racism.” There is a balance to be maintained between careful use of language and confronting tough topics, she observed, and the term “equity” may help maintain that balance.

Larkin noted that in the course of conversations on the county health rankings that have taken place in communities around the country, the “isms” issues have come up as challenges to improving those rankings. These moments have provided useful opportunities for community leaders and members to openly discuss issues that might otherwise have been avoided, she said, and they have also raised awareness of the often invisible, but significant, divisions that exist within communities.

Terry Allan argued in favor of a collective, community understanding of “the narrative around issues of the ‘isms.’” In Cleveland, he reported, eliminating racism as a social determinant of health emerged as a central theme of the city’s health improvement plan as a result of discussion with community groups. “That term requires a lot of dialogue and discussion, a lot of emotion,” he observed; thus, a developing movement for public health will need to grapple with the question of addressing racism and other “isms” directly.

It is not a question of whether to address the role of racism in health inequity, but when, Calonge said. “You are going to have to address it, and you will call it racism at some point. The issue is, where is that tipping point?” In addition to the personal journey of recognizing one’s own biases, there is a need to publicly acknowledge the impact of race throughout the history of any community. When and how should that process occur?

Thompson responded to Calonge’s query with an example from her experience working with a social justice initiative in Seattle–King County, Washington. After considerable discussion, the community decided that eliminating racism would be the focus of their efforts. At the time, she said, she wondered how the group would approach this daunting goal and how they would measure their efforts. But out of this resolve, she reported, they were able to create a public health department initiative on racial equity after shifting their frame from eliminating racism to social justice. In so doing, she said, “they were able to get the entire department to buy into the idea,” having made the terms of change inclusive, while not compromising their primary issue.

The language of shared values is key, argued Jeff Levi of Trust for America’s Health. Raising the example of gay marriage, he noted that the tide of public opinion in the United States turned “when we stopped talking about being anti gay marriage as being homophobic and we started to present it as freedom to marry and marriage equality.” By reframing that issue in terms of personal freedom, the marriage equity movement connected with values shared by a majority of Americans rather than challenging personal beliefs regarding marriage.

Changing Values Versus Changing Attitudes

Sanne Magnan, president and chief executive officer of the Institute for Clinical Systems Improvement, contrasted Baxter’s contention that successful movements rest more on values than on specific goals with Calonge’s observation that while movements can change attitudes, they are unlikely to alter values. Is the walking movement articulating a clear set of values, she asked. Is it really possible to change someone’s values?

Values, like relationships, are very powerful and motivating, Baxter responded; there is great opportunity to build support for a movement around those elements, even among people who have divergent, even opposing, interests. People less often behave according to their interests than to their values, he said; therefore, it is important to be aware of the values of the people one wants to engage in a movement and to show how they align with what movement builders are trying to achieve.

Calonge agreed with Baxter’s remarks and noted that shared values represent the common denominator of people committed to a social movement. For example, he said, in Colorado the concepts of fair opportunity and personal choice were initially raised in support of smokers, but eventually they were interpreted as favoring the right to breathe smoke-free air. These kinds of connections with values propel public health movements forward, he said.

The Role of States in Health Movements

A member of the webcast audience asked what roles state health departments and governments could play in a movement for public health improvement and equity, as compared with the roles of national entities such as the IOM.

Twiss responded that two recent initiatives in California, the Office of Health Equity and the Strategic Growth Council, could provide examples for other state-based entities. In general, she advised, states “need to support, but then get out of the way” of community-driven approaches to improve public health. State participation in public health initiatives is shaped by the party in power, Calonge said. However, despite shifting ideologies at the state level, movement momentum can be maintained by connecting with local health departments on issues that matter to them.

George Isham remarked on the contrast between Twiss’s nonpartisan approach and Calonge’s single-party focus. He also observed that political parties have mastered the art of changing attitudes, which has divided the country to its detriment and made consensus building around public health a difficult challenge. So, he wondered, “what are the values for population health and how do you get to them?”

“I don’t think what Ned and I said was all that different,” Twiss replied, noting that they had both found windows of opportunity in any state government scenario. If one is partisan, she continued, one risks losing everything one might gain with a particular administration when times change. Instead, it is better to take a long-term view and build the case for population health on core human values rather than on partisan postures. This, she said, was her group’s approach to introducing a Healthy Cities resolution in the California legislature, which eventually garnered support from both extreme liberals and conservatives. Similarly, Colorado’s Office of Health Disparities was created by a Republican governor, a fact Calonge noted may or may not seem unusual, but fits the political context of the time.

Opening the Circle

Pittman applauded Levi’s example of how the language of equity and freedom “opened the circle” to allow more people to support gay marriage, and she commented that this lesson was one she learned by working in the early days of AIDS activism. It is important to portray an issue in ways that make sense to people with different points of view, she said; narrow framing shuts out people who could contribute to and support a movement.

Indeed, Baxter added, the AIDS movement provides a great example of the power of an open circle. Although there was tension between

scientists and activists as to how to address this problem, the National Institutes of Health and ACT UP (AIDS Coalition to Unleash Power) resolved to work together to figure out how to accelerate vaccine research and other interventions. “I view that as a great moment rather than a problem,” Baxter said, and he suggested that it can serve as a valuable example for those who are looking to create change in population health.

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