By Peter Manetta
​Community participation and leadership is critical for advancing equity, addressing upstream determinants, and practicing public health generally. Assuring and supporting such participation is now and will continue to be a core capacity for LPH. But for many agencies, it is one of the most challenging elements of public health practice. As we are immersed in system transformation, these challenges raise a key question: is there a part of local government infrastructure that can promote sustained, equitable, and effective community participation and leadership?
 
This challenge is not only one of sound public health practice and equitable governance, it also relates to larger public health threats posed by a lack of community connectedness, social capital, and the decline of American civic life. This is a massively complex upstream determinant with impacts on other determinants as well as individual health behaviors. A sobering report from the National Conference on Citizenship shines a light on what they call “civic deserts,” framing it as a health problem. The report details how the decline of many socially-active institutions, such as places of worship and unions, are contributing to the erosion of shared values and accepted facts, trust of neighbors, and belief in the possibility of positive collective change.
 
While we are engaged in structural transitions, it is timely to think about how local government structure can promote or inhibit community participation. On its own, public health is clearly transitioning to models that have the potential to ameliorate the situation, though not always explicitly. To answer the question posed above, it may help to start recognizing that public health community and partnership engagement is in itself an intervention to improve equity and health, not just a way to support other interventions. If we apply the same upstream-ecological program design methods we increasingly use for other health interventions to community engagement, we may start seeing ways of making community participation more sustained and meaningful through systemic changes in government.
 
A recently adopted Health Equity in All Policies (HEiAP) resolution in Genesee County, Michigan (home of Flint) offers one example: an “interdepartmental body with representation from all sectors of community life” who receive training and technical assistance in considering equity and upstream determinants. This body serves their board of commissioners by
“1) considering any new governmental policy for which the likely health impacts are not clear; 2) considering current governmental policy whose negative health impacts have been called into question by the public; 3) analyzing the health impacts of any such policy; 4) providing recommendations to the governing body on any changes in these policies that would reduce negative health impacts.”
 
This appears to be an adaptation of a HiAP model resolution from Changelab Solutions, that included a similar body made of only government staff. There are not yet many details available on how this type of structure is initiated, its feasibility, or its impacts. And one wonders if just an advisory role is enough, or would such a body need specific authority to be effective.
 
There are also clear chicken and egg challenges with this approach. If a community lacks the social capital to engage in collective improvement efforts, how is it supposed to get enough citizens to serve on such a body? It would also need a structure that permitted members of all education levels and languages to participate and be able to accommodate those with limited time and transportation options. Some communities  may have to consider preliminary social capital interventions before attempting to form a permanent and quasi-professional community advisory body.
 
Other models aim to use the existing interactions between government and community members to engage on issues that are related to the interaction topic but are broader and systemic in scope. An example might be asking survey questions about a community’s overall food systems while on a restaurant inspection. This may be a more practical stepping-stone to a formal advisory body, but such activities would require significant training and probably additional staff. It would also require a redesign of how certain services are provided, including new process workflows, updated forms, and investing in relational databases and assessment capacities that can tie all the information together.
 
 I’ll be following this topic over the next year and hope to explore some more specific examples of how LPHAs and their governments can foster civic engagement. In the meantime, check out a recent research report from New America that tested some of the assumptions we make about the potential benefits of increased civic engagement and the tactics used to get there.

​We often point to reduced smoking rates as an historic public health win, but new products and promotion strategies seem to be outpacing current youth tobacco control methods. Tobacco companies are pushing new ways to addict youth and young adults, including e-cigarettes like Juul that are engineered to deliver significantly higher levels of nicotine. Products that deliver more nicotine, are easy to use, are more socially acceptable, and that challenge existing regulatory rules or practices are a disturbing for many reasons.

• A consensus report from the National Academies of Sciences, Engineering, and Medicine (NASEM) concluded that “There is substantial evidence that e-cigarette use increases risk of ever using combustible tobacco cigarettes among youth and young adults.” This conclusion was reached through studies of vaping product that deliver lower nicotine levels than Juul and Juul-like products.
• While speed of addiction is highly context-dependent, higher nicotine levels have been an established tobacco industry method to addict more people, faster.  We can assume that higher nicotine levels in e-cigarettes is very likely resulting in substantially higher addiction rates in our youth.
• More Colorado youth are vaping compared to the national average (Aspen Times story).

 
There are many more dimensions to this increase in youth nicotine use, so this is not an exhaustive list of concerns. We need to be asking ourselves whether our current control strategies are nimble enough to respond to an industry that is constantly innovating ways to addict kids to nicotine. 
 
There is already a lot of work being done in response to these developments. In 2016, the FDA began implementing broader enforcement under its “new” regulatory authorities granted under the 2009 Family Smoking Prevention and Tobacco Control Act. Their enforcement activities, notably including e-cigarettes, are primarily retail inspection and compliance checks (including stings using undercover minors). The FDA also has the authority to mandate the reduction of nicotine levels in all tobacco products to near zero, and advocates are waiting eagerly for news on whether they will move forward with that.
 
At the state level, CDPHE just opened access to a GIS (geographic information system)-enabled database of tobacco retailers, inspections, and violations, overlayed with myriad community attribute data (like school location). With this tool, called Tobacco Retailer Access Colorado (TRAC), LPHAs and communities can clearly see which of their local retailers have been caught selling to minors or violating other regulations. This will permit a new level of scrutiny on establishments that, in the words of one state tobacco policy expert, “are recruitment centers for new smokers.”
 
At our local level, more and more Colorado counties and municipalities are starting to regulate tobacco on their own. Eleven areas now have some level of regulation and enforcement, from T21 to taxes on all tobacco products.
 
This is not an exhaustive list of emerging tobacco control efforts. There are myriad lawsuits and campaigns on both sides of the fight that continue largely outside the public eye. To stay on top of these critical public health efforts, bookmark Tobacco-Free Colorado and visit often!
 

By Peter Manetta
​
Economic prosperity is an established upstream health determinant, but planning for and encouraging economic opportunity is well outside governmental public health’s core services. It is usually the responsibility of economic and community development organizations. These organizations are multi-sectoral and bring together partners with a variety of motivations and interests – a partnership process that is certainly familiar to local public health agencies. Economic and community development usually rely on structured strategic assessment and planning for long-term outcomes. With health and economic opportunity being so intertwined, and with the growing similarity between their partnering and planning processes, some alignment of strategic priorities between governmental public health and economic development could benefit both sectors.
 
Economic and community development overlap but typically play different roles. Economic development attempts to increase economic activity by attracting new business and cultivating existing business in its region, with job growth being the primary goal. Community development often has a narrower focus on creating affordable housing and encouraging economic opportunities in low-income communities, though it can also refer to the municipal or county planning agency. These organizations can be a governmental, mixed, or self-organized private sector interests. This is by no means an exhaustive description of these two activities, and they will look very different in each locality. For an agency seeking to identify these activities in their district, any entity working to promote economic opportunity should fit the bill.
 
There are many resources for broadly understanding the ins and outs of economic and development, but the best help you connect the concepts to your local circumstances. This webinar, from Pueblo County’s Department of Economic Development, provides excellent grounding in how regional economic development tactics are adapting to new circumstances and adopting a more systems-thinking approach. One of the more comprehensive resources is found at WealthWorks, which also provides a method for identifying equitable market opportunities. Their framework is also a good place to start if you want to map your own community’s economic assets, including types of capital.
 
If your agency doesn’t already have a relationship with economic or community development, starting one may require a partnering topic that non-public health folks clearly perceive as a public health issue. Below are some areas that are justifiably in the LPHA bailiwick:
 

• Environmental health: Many LPH environmental health services are imbedded in their region’s land use decision making entities along with economic development partners, and others are involved through certifying onsite wastewater treatment systems (OWTS) or strategizing for better waste diversion. Environmental health staff also regularly interact with business owners through retail food inspection. To make themselves more of a partner (as opposed to being seen just as a regulator), they have begun systematically weighing the employment or economic consequences of their inspection decisions and promoting the business case for food safety. These activities could be “feet in the door” for expanded LPH involvement in economic development.
• Food access: Several Colorado LPHAs are actively promoting the expansion of healthy food options in certain communities or engaging in comprehensive food system assessments. Since they involve local systems of production, distribution, and consumption, these activities should benefit (or may require) the participation of chambers of commerce or regional economic development corporations. Learn more about promoting food access with economic development partners from this report by ChangeLab Solutions.
• Advocating for adequate care services:  The adequacy and availability of non-medical care, from childcare to assisted living, is an urgent challenge for most communities. Care professionals are underpaid and often need better support and training, and many other forms of care are entirely uncompensated and unsupported. Along with its health care and community partners, LPH can advocate for transforming and growing the local “care economy” so that it both adequately matches demand and becomes more equitable for care professionals. Expanding a community’s care capacity is an economic development opportunity to both grow a source of employment and provide an increasingly demanded service. Care cooperatives that are worker owned offer a promising route. Learn more through the University of Wisconsin’s Center for Cooperatives, which contains excellent informational resources on child care cooperatives and home care cooperatives.

 
Not all economic development is supportive of community health, and much of it has been exploitative of certain populations and damaging to the environment. LPH and its close partners can advocate for healthier alternatives that aim to build local wealth in addition to attracting new jobs. Supporting the development of cooperative businesses that are worker-owned and democratically controlled aligns well with these goals and with advancing health equity. Co-ops are less likely to uproot, tend to benefit lower-income communities, encourage social connectedness, and can increase self-reliance and entrepreneurialism – all of which can have mental and physical health benefits.
 

By Shannon Kolman

CALPHO members and staff can now breathe a sigh of relief as the 2018 Colorado legislative session ended on May 10th with mostly good news for local public health. The session was full of intrigue, with more than 700 bills being introduced, many late in the session. Close majorities, an election year, term limits for key leaders, Colorado’s booming economy and a large budget surplus also added to the hectic session. Overall for Colorado, much needed transportation investments were secured, PERA was safeguarded, and school funding received a boost. CALPHO staff and Frontline Public Affairs kept busy juggling 48 positions on bills and budget items (see the full list here). CALPHO took 33 positions to support various bills and budget items and of those 21 (64%) were passed. Of the seven items CALPHO opposed, four failed, one never became an issue (Air Quality Division budget), and two passed.
 
Following are some highlights of CALPHO’s achievements this session and the continued fight on two bills we hope to see vetoed.

• CALPHO saw its four biggest wins early in the session as the two bills with Actively Oppose positions were defeated, another was stopped from being introduced, and one of the marijuana club bills was killed:
  
  • SB18-045 would have repealed the successful and environmental friendly Paint Stewardship Act
  • SB18-139, from the tobacco industry, would have required some licensure requirements for retailers selling tobacco products but would have taken significant funds from tobacco prevention efforts and preempted local efforts at comprehensive licensing
  • A proposed cottage foods bill was stopped from being introduced through a stakeholder process
  • SB18-211, Marijuana Consumption Club License, was a good defeat for public health as it would have allowed exemption from the Colorado Clean Indoor Air Act for “fully ventilated” facilities”

 

• Health equity advocates in the state, including CALPHO, had a major win in the defeat of SB18-214, which would have implemented self-sufficiency provisions to Colorado’s Medicaid program.

 

• CALPHO supported seven bills which passed that expanded safeguards and prevention efforts related to opioid misuse, substance abuse, and behavioral health care: HB18-1003, SB18-022, SB18-024, HB18-1136, SB18-071, HB18-1007, HB18-1357.

 

• CALPHO along with the organizations in the Colorado Tobacco Free Alliance worked diligently to defeat SB18-179, Extend Credit for Out-of-State Tobacco Sales, and HB18-1258, Marijuana Accessory Consumption Establishments, however the two bills passed and are now sitting on the Governor’s desk. CALPHO and the Alliance have sent letters to the Governor asking that the bills be vetoed, and Amy Winterfeld, with Tri-County Health Department, joined CALPHO staff and other Alliance members on May 14th to request veto on HB18-1258 in a face-to-face meeting with the Governor’s office.  Stay tuned in June for the Governor’s decision on those two bills.

By Tracy Anselmo
On April 4th CALPHO and about half a dozen public health professionals participated in the Call to Action to Promote Healthy Communities Symposium along with representatives from approximately 16 cross-sector organizations. The Symposium, sponsored by The Colorado Health Foundation and the American Planning Association Colorado Chapter, gathered to begin developing a network of professionals in Colorado to operationalize the Promote Healthy Communities Joint Call to Action.  
 
In preparing my remarks for the event, I reflected on several issues and came to some conclusions that I wanted to share with you all.
 
CALPHO has been engaged for over 12 months in efforts to understand and promote Health in All Policies (HiaP), a specific way of approaching health equity using a wide range of community policies and applying a health impact lens in traditionally “non-health” sectors.
 
Health equity and social determinants of health (SDoH) are an increasingly important aspect of governmental public health work, and CALPHO supports local public health agencies (LPHAs) in defining their role in health equity work and identifying the best strategies to move toward health equity in their communities.
 
Since social and environmental determinants of health, such as education, transportation, finance, and justice “live” in sectors other than public health and health care, and inequity exists across the systems we all work in, public health policy development needs to occur in all sectors and across many systems.
 
All LPHAs have power to influence health at various policy levels. For example, a 2016 survey of Colorado LPHAs (n=47) revealed that approximately 30% reported working on land use planning policy. CALPHO believes that a HiaP approach can help broaden policy target areas and bring in a wider variety of sectors – such as those present at the Symposium, elected officials, and others – to the table, and bring forth a common understanding of all sectors’ roles in community health.
 
LPHA’s are required by law to conduct a community health assessment (CHA) and develop a Public Health Improvement Plan (PHIP) every 5 years. This entails using data on key health indicators (such as suicide rates, tobacco use, and diabetes prevalence), and engaging the community in setting top priorities to work on over the next 5 years. In this current fiscal year, almost 70% of LPHAs are working on their CHAs and 21% are working on their PHIPs. There is tremendous opportunity for multi-sector networks all to engage in the dialogue in a meaningful and productive way.
 
Let me share with you a quote that I found particularly interesting while researching these comments.
 
“Planning is not an academic exercise, it affects things and real people. You affect matter of health through your choice of streets, parks and infrastructure project.”
--John Morck AICP past president of the American Planners Association, North Carolina Chapter.
 
HiAP aspires to promote health equity through the consideration of the health impacts in every type of policy decision, in every type of organization, so that any public or private entity can take health into account.
 
Through engagement, building the relationships, sharing expertise, establishing health goals, and developing comprehensive strategies to improve health, we create windows of opportunity, promote intersectoral collaboration, and develop innovative, community derived strategies that will make Colorado a healthier place to live.
 
To learn more about HiAP work at CALPHO, please visit www.calpho.org. Look for curated resources on our website, as well as the original postings on the national sponsoring organizations and others such as NACCHO, American Planning Association, Public Health Institute, American Public Health Association, The American Institute of Architects. 

By Peter Manetta

​Health care reform debates will continue to swirl around cost. The most vocal participants across the political spectrum rail about the chunk of our GDP dominated by health care, the bills that bankrupt families, and the lack of affordable coverage options. Whether they believe in private or public-sector solutions, they all recognize that changes must be made. But such debates rarely include discussions about the demand-side, namely the role of preventable chronic diseases as both adriver and amplifier of costs. If fewer people develop these conditions, demand will go down.  Public healthneeds to be making this point loudly. Every time there is a politically divisive argument over single-payer vs. private insurance, or market self-correction vs. regulation, public health advocates need to be there saying “there is a better way to make this system manageable.”
 
While economists will tell us that it is difficult to predict exactly what effect demand reduction would have on our incomprehensible health care “marketplaces,” economic theory indicates that this would reduce costs. What’s more evident is that demand reduction would be immediately beneficial for public and private payers. Most importantly, preventing chronic disease will dramatically reduce the economic burden for consumers themselves, freeing up their resources for other life essentials. The prevention argument is simple to make: “let’s focus on not needing so much health care in the first place.” It is an obvious point that appeals directly to core American values of thrift and common sense.  So why isn’t it a part of the debate?
 
Pundits don’t talk about demand because the experts they listen to also don’t talk about it. A February 2018 report from the Network for Regional Healthcare Improvement (NRHI) comparing cost drivers across five states is a great example. Entitled Healthcare Affordability: Untangling Cost Drivers, the authors do not even mention chronic diseases as a cost driver. The report is entirely focused on factors they see as within the health care system, despite the absurdity of considering anything external to an industry that dominates nearly 20% of our economy. The closest they come to mentioning demand is discussing disparities in use patterns, for which there is not yet a clear explanation:
 
“Outpatient resource use in Colorado was 25 percent above the benchmark, the highest percentage above the average in any category in any participating state. Coloradans also had the highest utilization of prescriptions, at 23 percent above the benchmark.”
 
It might be important to find which structural inefficiency is causing this disparity, but the burden of preventable disease that is likely behind most of this pattern is undeniably the more critical factor. The authors seem to be ignoring this. Also, what guarantee do we have that the cost reductions resulting from increasing efficiency in health care delivery will be passed on to consumers or even payers?
 
Pundits aren’t the only people paying attention to such reports. Policymakers rely on them when planning reform efforts. An alliance of seven governors, including Colorado’s, just released their new plan called the Blueprint for Improving Our Nation’s Health System Performance.  Most solutions they propose are also limited to similar within system factors found in reports like NRHI’s that realign incentives and increase efficiency. The plan contains only the vaguest nod to the demand-side, suggesting that reforms should “encourage responsible              choices by empowering      consumers with useful information and incenting healthy lifestyles.” This statement at least hints at more demand-side considerations, but it certainly does not reflect current thinking in primary prevention. It echoes sentiment from public health 1.0, which prioritized individual behavior change over addressing systemic factors.
 
As a hopeful if not substantive gesture, both approaches do claim to be considering many factors at once. The NRHI references the “health care cost balloon” metaphor, which describes how squeezing one side just moves air to another. As one of its core beliefs, the Blueprint states that “the best strategies to improve our health care system address multiple objectives simultaneously.” This indicates that both pundits and politicians perhaps are open to a more systems-thinking approach that at the very least doesn’t ignore the obvious.
 
How do we meaningfully enter the conversation? To start, we can openly criticize reports like NRHI’s. Public health can directly answer their myopic conclusions with op-eds and articles in academic journals. Public health can also join politically charged debates in the mainstream press on health care reform. Our message is simpler and saner, and for most people it will be a breath of fresh air. Concurrently, public health can continue to demonstrate its value at the local level by involving more community members in its programs and planning, so they can recognize and celebrate its successes. If they are involved in community health prevention efforts, then such efforts will no longer be invisible to them. 

By Peter Manetta

​Multi-sector community health partnerships are critical for building local capacity to address upstream determinants of health. This is a key takeaway from CALPHO’s exploration of local-level Health in All Policies. Moving upstream requires long-term planning, systems thinking, sustained funding, and political support – areas that challenge many partnerships and may limit their scope to addressing specific outcomes. I am not suggesting that more narrowly-focused partnerships are a waste of resources. There are certainly benefits to focusing on proximal health causes that participants feel empowered to address, and a history of successful collaboration and the resulting collective efficacy are powerful glues. But collective efficacy is just one of the necessary ingredients for moving a partnership upstream toward effecting local, systems-changing policies. What are the others?
 
A recent study published in Health Affairs helps to answer this question. Noting a lack of objective data on multi-sector partnerships, the authors designed a thorough study to identify facilitating characteristics for a partnership to engage in “regional health system transformation.” They developed a four-part conceptual framework to evaluate a partnership’s readiness for this kind of engagement: stewardship, strategy, financing, and environment (meaning health system market and policy environment). Within this framework, they set a list of readiness expectations adapted from a body of collaboration literature and past partnership assessments by ReThink Health. Finally, they compared these expectations to analyses from an extensive interview and site visit process. This resulted in a list of the most mature partnerships (which included the North Colorado Health Alliance), and a snapshot of how most partnerships compare to their expectations. Perhaps not surprisingly, most did not meet those expectations. (if you are interested in learning more about the expectations and maturity lists, email me)
 
This framework and its embedded expectations are valuable assessment tools, and when combined with operational knowledge of local context, can help guide partnerships' strategic direction. But the authors' vision for systems change, while extensive, is not comprehensive. From the outset, it limits the concept of "multi-sector" to sectors with power – power often originating from and sustained by inequitable systems. Under this framework, a mature partnership includes governmental public health, health care entities, business interests, elected leaders, and economic development entities. It does not account for groups whose power must grow – and whose voice must be heard – in order for the entire system to change equitably. In other words, this framework may help community partnerships develop relationships with the powerful, which is necessary, but it misses the critical importance of engaging affected populations and sharing leadership with community members. This absence limits the contribution that more grass-roots organizations like Lake County Build A Generation can add to our understanding of community health partnerships, and especially how they can help foster understanding and unity between groups at different ends of the power spectrum.
 
ReThink Health’s most recent Pulse Check on Multi-Sector Partnerships does a better job of including this factor in its analysis, noting that “less than half report that their authority comes from broad-based grassroots support.” ReThink also noted the lack of engagement of sectors like media, faith, and health insurers. Some of Colorado’s partnerships offer rich examples of why these sectors are important. For example, Healthy Mesa’s overarching focus on community connectedness places family, faith, the arts, and local recreation at the center of Mesa’s health ecosystem (as opposed putting efficient health care provision in the center). This aligns the partnership with the values of its community and may increase its clout with local leaders.
 
CALPHO will continue to support LPHA’s partnership efforts, especially opportunities to learn from each other. Along with CDPHE’s Office of Planning, Partnerships and Improvement, Trailhead Institute, the Rocky Mountain Public Health Training Center, and County Health Rankings & Roadmaps, CALPHO is developing a workshop on partnerships for the community health assessment/improvement plan process, and we hope to extend learning opportunities on that topic. If you have suggestions for this workshop or other ways we can help, please email us.  

by Shannon Kolman

In his book Collaborating with the Enemy: How to Work with People You Don’t Agree With, Like or Trust, Adam Kahane presents an unconventional type of collaboration and offers ways to think about collaboration when the situation is increasingly desperate and contentious. Most people’s conventional understanding of collaboration is that it requires everyone in the group to be on the same team and headed in the same direction. The Stretch Collaboration that Kahane presents abandons the assumption of control, gives up unrealistic fantasies of harmony and compliance, and instead embraces messy realities of discord, trial and error, and cocreation. “Stretch Collaboration looks like martial arts practice”.  Because this type of collaboration, which is needed for complex and contentious situations, requires flexibility, patience, and discomfort, we must realize that collaboration is only one of four options available.
 
Before looking at those options though, we must first face the fact that we all “enemify”; we label those who are different than ourselves as others, rivals, adversaries - enemies. We try to simplify complex realities into black and white, us and them.  The conundrum is that we need to work with “others” to move forward yet we also feel we must not work with them to avoid treachery. Because of this challenge, Kahane suggests that we first understand when to collaborate before deciding how to collaborate. 
 
There are four basic paths we can take when trying to change a situation or make a transformation: 1) forcing our will; 2) adapting or getting along; 3) exiting the situation; or 4) collaborating. We use each of these options all the time and it can be helpful to be clear about what choice we are making.  For example, we force through laws, regulations, money, and weapons. We also often adapt because we can’t change the situation yet we must find a way to go on with our lives.  And we exit, such as in divorce or quitting a job. When making the choice to collaborate, it’s important to understand that there are risks with collaborating, especially in complex and untrusting situations, such as the risk of producing too little too slowly, or compromising too much, or betraying what matters to us most. If we decide to enter into collaboration with those we don’t trust, agree with or like we must not take the decision lightly.
 
Stretch Collaboration requires us to stretch in at least three ways: 1) stretch away from a focus of coming to agreement on collective goals and to move toward embracing both conflict and connection, which seem dichotomous but are necessary for complex, contentious situations; 2) stretch away from insisting on clear agreements about the problem, the solution and the plan and move toward experimenting systematically with different perspectives and possibilities; and 3) stretch away from trying to change what other people are doing and move toward action. The first of these three requirements, embracing both conflict and connection, seems to me to be the most difficult. People generally do not like conflict. Yet to collaborate with those you don’t agree with you have to allow for conflict. It’s also difficult to connect or engage with people you don’t trust or like, yet in Stretch Collaboration we need to connect with those others to expand our awareness, allow for new possibilities, and keep conflict from becoming degenerative.
 
I can see that for public health professionals, accepting the idea that social problems do not have definitive or objective answers like math or science problems may be challenging. Many in public health have been trained to use conventional problem-solving models which start with the assumption that there is one right answer. Stretch Collaboration requires that each person reveal their perspective so that the group can have a fuller picture.  It doesn’t mean that they agree though. The author suggests that some of the most robust actions are those that different players support for different reasons. He notes that President Lyndon Johnson succeeded in landmark civil rights legislation because he attended to the interests of individual legislators while harnessing the individual “wholes” into a collective whole.  We cannot just revert to the “good of the whole” because there are multiple wholes.
 
Conventional collaboration assumes we can control the focus, the goal, or plan to reach the goal.  Stretch collaboration offers a way to move forward without being in control – think more of multiple people rafting a river together.  Kahane suggests that we need to get good at alternately connecting with others, or engaging, and conflicting with others, or asserting.  We will each have a tendency to move toward engaging or asserting and we must learn to do both, and know when to move from one to the other.  It’s similar to the job of a good manager reconciling the drive toward self-realization of his individual team members and the need to unite the team to achieve collective realization.  It’s not one or the other, it’s both. 
 
Secondly, in order to Stretch Collaborate, we must also be willing to experiment – take a step and then see what happens. If people don’t like, trust, or agree with one another then they may only be able to try short-term, modest, low risk actions. It is more important to act than to agree. Success means we can get unstuck and take a step. I can think of instances of this in our public health work: most recently, the action to support legislation that would pilot a supervised opioid injection facility in Denver as a pilot project. This goes against ideals around the “war on drugs,” however it is an action that may produce results of saving lives and gain lessons to inform the next step. We can’t hold on to cherished ideas at the expense of the emergence of something new. Kahane points out that artists do not manifest already-finished mental pictures. Picasso destroyed images on his canvas covering them up with new images over and over again.
 
Lastly, to use Stretch Collaboration, we must step from the sidelines into the game of engaging with our “enemies” and then alternately conflicting with one another. This means we must see ourselves at part of the situation. Are we late getting home because of “that darn traffic” or because we are part of the traffic? If you’re not part of the problem, then you can’t be part of the solution.
 
I have no illusion that this will be easy. I know for the collaborations I currently participate in, Stretch Collaboration would mean inviting people that have contradictory ideas to those we currently have in the group. It would mean throwing away the group norms, values, and agreements we came up with. It would be a painful process of listening to those I don’t agree with, truly listening, and arguing my point when necessary while allowing them to argue their point. It would mean taking an action without a complete plan. And mostly it will require me to be uncomfortable as I become part of the traffic and stop blaming the traffic jam.

By Peter Manetta
The idea of “advancing health equity” is a powerful mission or vision, but makes a lousy action-oriented goal. That’s why I was excited to spend an afternoon during our recent Health Equity Advocacy Cohort convening discussing the lack of affordable housing, a major health determinant and pressing equity issue for every Colorado community.
 
We participated in round-robin discussions with mostly Denver-based housing advocates, and one advocate from Grand Junction who provided a more rural perspective. One of the groups, Denver Homeless Out Loud, described how the metro’s recently enacted camping ban, which they refer to as a “survival ban,” has affected their lives. They feel that this ordinance puts them in the position of choosing safety and shelter over obeying the law. And as Homeless Out Loud frequently points out, there is nowhere for most folks to go once the police kick them out of a camping spot. Affordable housing is unavailable, and these advocates described shelters as being no safer than prisons, with thin mattresses on the floor spaced inches apart, violence, drug use, and the resulting increased rates of infectious disease transmission.
 
But there’s a small bright spot for a handful of Denver’s homeless in a pilot-project of tiny-home communities. These small “villages” of a few homes each can be erected quickly on undeveloped lots and have a low environmental footprint. City leaders nominally support these villages, and the mayor leveraged their promising start as a public relations success story (you can follow the tiny-home village project here). But the city had nothing to do with funding, organizing, or building the homes. That was accomplished by a coalition of advocates and private funders. Also, the village zoning permit is temporary, and the villagers will be forced to move every 6 months unless there are permanent zoning changes. Village and other homeless advocates are pushing for more permanent zoning exemptions, but it is unclear why city leadership would so openly support something while allowing policy barriers to impede it.
 
It’s perhaps too easy to blame property developers’ political influence over city government, though this may well be the main barrier. Another major factor might be old policies challenged by new, unanticipated situations. If this is the case, then a thorough examination of our communities’ land use and zoning rules could reveal opportunities to incent affordable housing development and advance housing-first policies with a win-win approach. Some smaller changes demonstrate this possibility. Homeless advocates have been asking for more trash cans, public restrooms, and storage lockers. These won’t solve the affordable housing problem, but such changes would benefit the homeless population while creating cleaner, healthier public spaces. These are bite-size policy changes that, if successful, could build trust and good will between opposing groups, perhaps paving the way for closer collaboration on more comprehensive efforts.

By Shannon Kolman

Although I missed the Colorado Health Symposium last month, I did catch some of the recorded presentations. One that caught my attention was a keynote talk by the columnist and political commentator Sally Kohn. She put forth a call to action to stop hate. Her fundamental belief is that there is too much hate in the world today, that it is spreading like a virus, and that it will keep spreading if we each don’t do something about it. 

Sally touched on the fact that there is a human tendency to define “us and them.” The human brain is wired to make distinctions and to note differences. It is part of our survival mechanism. I recently attend the Center for Health Progress luncheon which featured Rinku Sen, an activist and former president and of Race Forward and publisher of Colorlines.com. She spoke about the fact that although the idea of being “racially color blind” (e.g. disregarding racial characteristic, or saying race doesn’t matter as a way to address discrimination) sounds like a good thing, it isn’t possible. Our brains are not wired that way. In researching this idea of being color blind, I ran into an old (2011) Psychology Today article that suggested rather than being color blind, what if we became more multicultural by recognizing and valuing difference, by learning about differences, and by fostering alliances. Sounds good, but how do we do that?

This suggestion is similar to the three tools that Sally Kohn noted for becoming aware of and putting a halt to our own hate. The word hate seems harsh, and an easily Googled definition states that hate is an intense or passionate dislike for something or someone. So, I would have to agree with Sally that we all hate in varying degrees; we all have implicit and explicit biases, especially given the current political climate, that cause us to feel intense dislike toward certain groups of people or ideas. Sally suggests we use 1) counter networks, 2) counter speech, and 3) counter spaces to bridge the divides hate creates and to breakdown the “virus of hate”. So how do we do that?

Sally gave concrete examples of how we can break down our hate barriers. She is calling for each of us to become extremely self-aware of how we perpetuate our own thinking and ideas, and to step out of our comfort zones to at least consider the ideas of other groups we hate. She gave some compelling statistics such as the fact that three-fourths of white Americans have no black friends, and that most Americans do not have friends on the opposite end of the political spectrum. She also noted that we use “narrow-casting” with our own news stations to reinforce our own beliefs. What we need, Sally says, are real life social networks that counter our in-group out-group divides – and that doesn’t happen by accident, we have to make it happen. Just by getting to know the people you hate, stereotypes start to be challenged and the divisions we’ve created start to break down.

Counter speech requires us to respond to ideas and people we hate by being nice – listening, connecting, and humanizing. When we hate we dehumanize people and counter speech can help to humanize those with disagree with. The idea of counter spaces challenges us to not only build networks of people unlike ourselves, but to step into spaces with people who have ideas and beliefs unlike our own. This is supported by research that shows that children who go to racially integrated schools do not exhibit unconscious racial bias, much less conscious bias. These kids are not color blind they just don’t dislike or hate the other kids who look different than themselves because that has become an accepted difference in their minds.
​
Sally’s suggestions are no easy task. Stepping outside of our comfort zones is uncomfortable and our survival parts of the brain do not like being uncomfortable. She is not the only one offering this challenge though. The August 28th edition of Time magazine featured a collection of articles by leading thinkers called Hate in America. In one portion of the article, Ilhan Omar, a Minnesota state representative and first Somali-American Muslim lawmaker, says “when we interact with those we fear and hate, we will find commonality.” He suggests that to bridge the divide that hate creates we must: 1) realize that most of our differences are exaggerated nuances exacerbated by uncompromising ignorance; 2) see others’ struggles as our own, and their success as our success so we can speak to our common humanity; 3) build a more connected society, using our resources to uplift one another so we collectively benefit. There’s certainly a challenging theme here. The question is, are we up to the challenge?