Engagement With a Range of Stakeholders Can Lead to Environmental Health Solutions

Communities across the country have addressed local public health challenges by collaborating across systems and sectors. Doing so helps ensure that different groups' needs are addressed and that the potential impacts—sometimes unexpected—are considered. Such efforts also highlight how many of these issues are rooted in complex problems that require multipronged responses.

Katrina Korfmacher, an associate professor of environmental medicine at the University of Rochester Medical Center, researches the role of science in policymaking, particularly how community groups generate, access, and use information. Her 2019 book,  Bridging Silos: Collaborating for Environmental Health and Justice in Urban Communities, examines how local entities addressed different environmental health disparities in Rochester, New York, Duluth, Minnesota, and Southern California.

She recently answered questions about how the process can work. This interview has been edited for clarity and length.

Q. What are some of the first steps for communities facing public health issues?

A. In each of the cases in the book, community members identified an environmental public health problem and sought help from government professionals, academics, and/or nongovernmental organizations to understand what was driving the problem, who it was affecting, and what gaps in policies and programs allowed it to continue. Effectively addressing the gaps required changing policies, systems, or environments. Working together to reframe a longstanding environmental health problem as an equity issue brought new stakeholders to the table who provided the energy needed to develop a new approach. So, there was an iterative process of increasing understanding of the problem and bringing in new stakeholders to come up with solutions.

Q. What are some of the key challenges in advancing cross-sector collaborations and how did the communities highlighted in the book tackle them?

A. Public health professionals generally recognize the importance of collaboration in promoting health equity objectives, but the reality of sustaining impactful collaborations is often challenging. For example, it's hard to find dedicated funding to bring people together and support their work outside of their home institution's scope. In addition, resource-limited institutions may not have time to devote to collaboration. There also may be internal barriers such as staff incentives, training, cultures, and conflicting objectives. Overcoming these challenges takes energy, commitment, and perseverance. In each of the initiatives examined, there was at least one partner who was mission-driven to promote partnerships. That dedicated capacity was modest but essential to finding and leveraging support from diverse sources.

Q. Did health impact assessments (HIA) or a health in all polices framework (HiAP) contribute to these initiatives?

A. The idea that promoting health often requires changing policies that are not typically considered health policies was important in all three cases. In Rochester, the Coalition to Prevent Lead Poisoning recognized early on that lead was a health issue with a housing solution, so it focused on changing local rental inspection policy. Similarly, the partners working around the ports of Los Angeles and Long Beach, California, wanted to increase consideration of health in all decisions related to goods moving through the ports and engaged in a formal HIA of a major highway expansion proposal.

The built environment work in Duluth benefited from three HIAs done in partnership with the Minnesota Department of Health. Thus, although the formal role of HIA varied, all three initiatives were grounded in the concept that changing systems to better account for health in nonhealth decisions is essential to achieving environmental health equity.

Q. What can funders, academics, and agencies do to foster environmental health initiatives?

A. Each of these cases highlights how local initiatives can instigate systemic change with relatively small shifts in how funders, academics, and agencies normally function. For example, many funders focus on outcome-oriented projects, but several foundations provided core support for the convening efforts in Los Angeles. Most academics need to focus on conducting research to thrive in their university careers, but in both Los Angeles and Rochester, universities had core funding from the National Institute of Environmental Health Sciences that supported community engagement. Faculty and staff in these academic centers played key roles in local partnerships.

Because of resource limitations and state mandates, many local health departments focus narrowly on surveillance, education, and vaccination. In Duluth, however, the State Health Improvement Program encouraged local health departments to widen their scope to work in partnership with communities to foster lasting, sustainable changes.

These examples show that even small institutional changes can go a long way toward supporting more effective local environmental health initiatives.

Q. What 'lessons learned' might help other communities address health equity in other kinds of challenges?

A. One of the surprises in researching this book was the diversity of local and national resources each group harnessed. There was no single, common recipe for success. None of these efforts started with a large commitment of funding by a single organization; rather, they made creative use of small amounts of staff time, funding, and technical expertise from a variety of sources. They did a lot with a little, but they all started with something. This suggests that modest sustained investments in communities' ability to convene, plan, and collaborate can go a long way. On the flip side, communities with the fewest resources—those that may face the most severe environmental injustices—may lack the capacity to initiate such collaborations.

So while the book focuses on the potential to better support local initiatives, it also highlights the importance of integrating their innovations through state and national organizations so all communities can benefit. This requires new ways of promoting learning from local initiatives. For example, the Health Impact Project's HIA map allows communities to learn directly from each other, and provides an encyclopedia of approaches that agencies and funders can promote in other places. Without such resources, it is difficult for communities to learn from one another's stories.

At the same time, the cases clearly showed that working together at the local level built networks among stakeholders that were essential to sustaining system changes over time. These networks fostered new collaborations outside of the initial initiatives' goals, highlighting the importance of supporting local groups' continued engagement in adapting, implementing and evaluating solutions.

Q. How can success be tracked and measured?

A. Measuring—or even defining—success in initiatives like these is tricky. For example, evaluation often focuses on whether measurable objectives have been achieved. However, in these initiatives, collaboratively exploring community concerns led to new problem definitions, goals, and strategies over time. In other words, the objectives changed. Similarly, the long-term viability of an organization is also commonly used as an indicator of success. But these initiatives aimed to "put themselves out of business" by changing existing organizations, policies, and practices so they were no longer needed.

Efforts like these take place in complex and evolving policy systems where change cannot be attributed to a singular actor. One challenge in environmental health initiatives is that health outcomes may be affected by many factors over a long period of time. Measuring changes in the physical environment may be more proximal, but documenting changes in policies, processes, and social networks is also critical. For these reasons, in-depth case studies are essential to understanding the full impact of such initiatives. One of the main goals of this book is to provide a useful framework for designing, supporting, and evaluating other efforts by sharing the "nitty gritty" of how long-term local collaborations struggle, change, interact, and progress over time.