How Community-Based Programs Improve Public Health

In recent years, some critics of public health have portrayed it as an example of government overreach, exemplified by pandemic vaccine, mask and shutdown mandates. It’s more properly understood as the state of health of the population at large, which can be affected by everything from access to food, basic medical services and housing to stress and environmental degradation.

Health has been defined as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” This definition illuminates the monumental scope of the public health mission, and what public health might really have to do with personal freedom.

There are about 3,000 local health departments in the U.S. More than a third have less than 10 full-time staff, and 17 percent have fewer than five. On their own, they can't resolve all the factors in their communities that prevent residents from achieving or maintaining good health.
Community-based organizations play a vital role in filling this gap in communities where they exist. Often, they reflect the activism and cohesion in a community that are preconditions for their creation.

The Institute of State and Regional Affairs at Penn State Harrisburg defines CBOs as “most often nonprofit organizations — particularly service organizations — that work at the local level to provide services to communities and specific target audiences which improve a community's health and well-being.”

Monica Valdes Lupi, managing director of the Kresge Foundation’s Health Program, has a long history of service in the public health community, ranging from executive director of the Boston Public Health Commission to deputy commissioner of the Massachusetts Department of Public Health.

Lupi co-chairs a Health Equity Workgroup that advises the Centers for Disease Control and Prevention (CDC). Earlier this year, it issued a report recommending that the CDC strengthen its relationships with CBOs in underserved communities, and even consider funding them directly.

During the pandemic, CBOs helped health departments deal with the burdens caused by staff shortages, says Lupi. “They became extensions of their public health agencies.”

Connecting with community members as friends and neighbors, these groups were able to break down walls and barriers that prevented residents from engaging with programs designed to slow the spread of the virus.

Lupi hopes to see these kinds of partnerships elevated and strengthened. The COVID-19 public health emergency may be over, but challenges that require an “all hands” approach remain in regard to chronic disease, opioid abuse, mental health and other public health issues.

Lack of access to nutritious food is a fundamental inequity with immediate health and social consequences. Collaborations between CBOs in San Antonio and the city’s public health department illustrate the kind of work Lupi hopes to see more of.

A Food Council

A healthy diet reduces risk for such chronic health problems as heart disease and type 2 diabetes, even certain cancers. Some Americans who have access to healthy foods choose not to make them dietary mainstays, but others live in “food deserts” where healthy options such as fresh produce are not readily available or affordable.

Using funds from a CDC grant, the San Antonio Metropolitan Health District (Metro Health) formed the Food Policy Council of San Antonio (FPCSA) in 2010. The FPCSA incorporated as a nonprofit in 2012; its all-volunteer board works with both community groups and policymakers to achieve food equity.

One of the programs originating from FPSCA is Healthy Corner Stores, which brings fresh produce to “food desert” neighborhoods by placing it in convenience stores. It got off the ground thanks to pilot funding from a city councilmember.

The council selected convenience stores for the pilot and raised funds to pay for refrigerators and shelving for produce. It organized outreach and marketing around the program, including cooking demonstrations, and worked with the city to create a subsidy to lower the cost of wholesale produce purchases.

Mitchell "Mitch" Hagney has been a member of the FPSCA board since 2014 and served as its president from 2017 until this year. He recently became director of food sustainability for another nonprofit, the San Antonio Food Bank.

Other cities have introduced similar programs, but Hagney believes San Antonio has been successful because the FPSCA board includes members who work in the food system. (He owns a hydroponic farm.)

“We had a nuanced understanding of what the food desert problem was, which is a question of infrastructure, distribution and supply chain rather than a question of marketing to households,” Hagney says.

Today, Healthy Corner Stores is administered by Metro Health, housed within its Healthy Neighborhoods program. It has grown from eight stores to 41, reaching nearly 30,000 residents, says Daniel Jimenez, special projects coordinator for the district.

The city continues to subsidize produce purchases and provides refrigerators that store owners can keep once they’ve completed a program contract. Convenience stores are targeted for participation using an FDA “food atlas” that identifies food deserts. The district is developing a rewards program to incentivize produce purchases by low-income families receiving food assistance.

Farms, Food Forests and Human Flourishing

The FPSCA’s impact has been wide ranging, from working with the city on changing codes to accommodate urban farms or more chickens in backyards. A 4-acre community “food forest” was created on county land, with city funding.

“We have a pecan and fruit orchard that anyone from the public is welcome to come and harvest,” Hagney says. The bridge that the council created between the city and the county was important to the project, both for political reasons and because it could bring in volunteer labor to create and maintain the forest.

Moreover, he says, community members feel more ownership of the space than if the city created it, participate at higher levels to access the opportunities for food, education and exercise that it provides.

While the FPSCA advocates for improvements in San Antonio’s food system, the San Antonio Food Bank — another nonprofit — is focused on distribution to those who have fallen through the system’s cracks. It provides fresh produce to 90,000 people a week at no cost to them, and helps residents sign up for SNAP benefits. It runs the kitchen of Haven for Hope, San Antonio’s largest homeless shelter.

As director of food sustainability, Hagney has responsibility for the Food Bank’s agricultural and gardening efforts, including 75 acres of farmland. All of this land is within the central loop of San Antonio. The crops raised on it, from onions and sweet potatoes to cantaloupes and strawberries, are distributed to community members. A portion also goes to local farmers markets.

The Food Bank has office space for Metro Health employees at its main campus. While utilities can track the distribution of services such as electricity or water, the city doesn’t have a way of knowing where food is coming from, where it’s going or who is buying what, says Hagney. The Food Bank does have data about this, however, data of great value to Metro Health.

Different Insights

These examples don’t include everything CBOs in San Antonio are doing that supports Metro Health’s vision of “healthy people thriving in a healthy community,” but they are powerful examples of capabilities that exist in CBOs that are outside the realm of local governments.

San Antonio has no “department of agriculture,” Hagney observes. The health department does focus on nutrition, but that doesn’t encompass the kinds of gardening or farming capabilities and education offerings that CBOs in the city bring to the table.

CBOs also have different insights than public servants as a result of their engagement with citizens, insights that can help government be more responsive to community needs, says Hagney.

“We can look at areas that are not covered by the municipal government and make recommendations that aren’t predicated on what existing departments are.”