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Those well-established rules, then, are the guides for our behavior. Society has already determined that as a rule we should help others in need. Thus, we instantly know that we should try to rescue someone from drowning and call the police when we see an assault. Society has also determined that not every decision in our lives rises to the level of moral urgency, and some are matters of personal preference. There are no established moral rules that regulate what toothpaste we purchase or the leisure activities that we engage in, such as watching TV.

We would not be promoting general happiness by making hard-and-fast rules about these decisions. Instead, general happiness would be better served if we endorsed a rule that allows each of us a range of free activity. As noted, according to Mill we appeal to the utilitarian principle only to establish moral rules, but not to judge the morality of individual actions. However, on rare occasions we may be caught in a moral dilemma between two conflicting rules.

Suppose I borrow your gun and promise to return it when you ask for it. The next day, you have a dispute with your boss and, in a fit of rage, ask for the gun back. I am now caught in a dilemma between two conflicting moral rules: I should keep my promises, yet I should not contribute to the harm of others. In such rare cases, I can determine the proper course of action by appealing directly to the utilitarian principle to see which rule has priority.

Mill explains this point here:. We must remember that only in these cases of conflict between secondary principles [that is, rules] is it requisite that first principles [of general happiness] should be appealed to. There is no case of moral obligation in which some secondary principle is not involved. In this case, I bring about more happiness by following the rule to avoid harming others, and so I should hold onto your gun.

Thus, the only time we should directly examine the consequences of an individual action is settle a conflict between conflicting rules. Early defenders of utilitarianism offered their theories as radical alternatives to the more conventional approaches to morality that emphasized God, natural law, and instinctive duties.

From the start, utilitarian theories were challenged by more conventional theorists. We will look at four important criticisms of utilitarianism. One of the first criticisms of the utilitarian theory was presented by English clergyman Thomas Gisborne — According to Gisborne, we are incapable of knowing all of the consequences of our actions. As we attempt to hunt down the various consequences, we will never be in a position to discover all of the relevant effects and form a conclusion about the overall happiness or unhappiness that results.

He offers a picturesque analogy for this point:. As well might a fisherman infer, that his line, which has reached the bottom of the creek in which he exercises his trade, is therefore capable of fathoming the depths of the Atlantic. He, who has had sufficient humility to become convinced. Imagine that I use a 15 foot line to fish in a local creek, and with that I can reach its bottom. I then conclude that this same 15 foot line would be sufficient for me to fish in the depths of the Atlantic Ocean, which, obviously, it is not. By analogy, in our ordinary lives we are good at figuring out some of the immediate consequences of our actions.

However, this skill in discovering immediate consequences of ordinary actions does not equip us to discover all the long term effects of many of our other actions. It may well be that the police catch me and send me to jail, which in turn reforms me and makes me a more productive and responsible citizen. I just do not know what all the remote consequences will be. Rule-utilitarians like Mill have the easiest answer. Through trial and error over many generations, our ancestors have experienced and evaluated the long term results of all sorts of actions.

They kept records of these in stories and histories, and constructed laws to minimize the unhappy consequences that some courses of actions bring about. It makes no difference whether we as individuals lack the mental vision to detect all the remote consequences of our actions. Like so many other areas of our lives, we rely on cultural tradition to teach us lessons that we could not individually discover. But even the act-utilitarian has some response to Gisborne.

Nevertheless, nature has provided me with enough foresight to assist me in planning my life and my community. The ability to project the consequences of actions is a critical survival skill. While I cannot literally see into the future to evaluate all the remote consequences of my actions, I can set up scenarios that are more likely than others. And, even if I reform in prison, that experience is not likely to improve my life when I get out, but will instead permanently restrict my career options. I also know my act of theft will place a burden on my family, the insurance industry and the criminal justice system.

In the end, I can make a good best guess that my act of theft will produce more unhappiness than happiness. It is also not that much different than other critical decisions that I make in my life that are not strictly speaking moral ones. When choosing to accept a job offer, I try to make a reasonable cost-benefit analysis based on the limited knowledge that I have. So too with decisions about marrying someone, buying a home, and having children. Whether my actions are morally significant or morally neutral, nature has not left me helpless when it comes to projecting their most likely long term consequences.

A second criticism of utilitarianism, presented by British philosopher F. Bradley — , is that utilitarian moral judgments often conflict with our ordinary conceptions of moral obligation. For example, it is theoretically possible that you cheating on your spouse will maximize general happiness. It may make you and your lover happy, and as long as you keep it a secret, your spouse will not be unhappy.

But even in this situation our ordinary moral judgment is that adultery is wrong:. Let us take the precept, Do not commit adultery. How are we to prove that no possible adultery can increase the overplus of pleasurable feeling? To put the whole matter in to words; the precepts of Hedonism are only rules, and rules may always have exceptions: they are not, and, so far as I see, they can not be made out to be laws.

Thus, utilitarianism fails as a guideline of proper conduct. For example, suppose that I capture and enslave an unimportant person who has no relatives, and force him to perform all the menial tasks that I and my family hate. We have him clean the house, do the laundry, mow the yard, change the cat litter box, fix broken appliances, and so on. However, we commonly feel that it is simply wrong to enslave someone, in spite of the overall happiness that this might produce.

According to rule-utilitarians such as Mill, we do not calculate the consequences of each action, such as whether general happiness is maximized when Jones in particular cheats on his wife. So too with exploitive acts like slavery. So, a rule prohibiting all exploitation will be one that, on balance, serves the general happiness. With slavery there is the long term problem of slave rebellions, and creating an underclass of people that society may never fully recover from even after slavery is outlawed. In fact, the long-term negative consequences of slavery in the United States are still unfolding.

The problem that Bradley exposes is not so much with act-utilitarianism itself, but with human nature and our tendency to prefer short term benefits over long term ones. It was much easier for slave owners to focus on the immediate economic benefits of slavery than the long term social and economic devastation that it would create. Suppose we wanted to determine whether an action like the execution of Karla Faye Tucker is morally permissible.

According to utiltarians, we find this out by looking at how much pleasure and pain result from actually putting people to death. This involves an experiential inspection of the various consequences—an approach that, in essence, grounds morality in our factual observations. In his posthumously published An Examination of the Utilitarian Philosophy , John Grote — criticizes this purely experiential approach to determining our moral obligations. For Grote, appeals to experience will only perpetuate the status quo, and it will not include an ideal moral goal toward which we should aim.

There is no room for anyone with special moral vision to expose the flaws with our current moral standards and put us on the path to moral reform. Morality should include guidelines for moral improvement, but we will never get such guidelines by appealing only to what is the case. Grote makes this point here:. Man has improved as he has, because certain portions of his race have had in them the spirit of self-improvement, or, as I have called it, the ideal element; have been unsatisfied with what to them at the time has been the positive, the matter of fact, the immediately utilitarian; have risen above the cares of the day.

According to Grote, to obtain ideal guidelines, we need an intuitive knowledge of morality, which goes beyond mere experience and a utilitarian analysis. Utilitarians have a response to both of these aspects. Regarding the first, imagine an isolated village where nothing ever changes. The population is stable and they have consistent growing seasons with no unpredictable droughts or insect infestations.

There have been no technological advances in hundreds of years, and work routines are firmly established. Their political structure is stable, with no conflicts between social groups. There is no contact with outsiders who might introduce foreign customs or pose threats of war.

In this situation, there would be no utilitarian grounds to move morality beyond the status quo. For this particular village, Grote is correct: utilitarianism would only perpetuate the status quo. However, very few societies are like this today, and probably have not been since the dawn of human civilization.

Within most societies, there are continual changes as a result of population fluctuations, natural disasters, epidemics, clashes with foreigners, new technologies, social inequalities, political factions, and differing religions. Where there is constant change within societies, there will always be a need to reexamine which actions and policies bring about the greatest happiness for the greatest number of people.

Where there is heated debate, the status quo is not fixed, and there is a need to draw on utilitarianism to make society a happier place. Within the isolated village described above, moral visionaries seeking to reform the status quo would only be troublemakers who would risk disrupting the efficient traditions of that past. In spite of their good intentions, their efforts at reform might produce more unhappiness than happiness.

Again, in this village Grote is correct: utilitarianism has no room for the moral visionary. However, when we turn to societies that are ever-changing with constant social clashes, there is an important role for utilitarian moral visionaries. They are the ones who propose new ideas for mediating social conflict and bringing about the greatest happiness for the greatest number. The moral visionary is the one who brings these new social ideas to the public and attempts to gain consensus with them.

The visionary will not seek guidance from an inner and intuitive sense of morality, as Grote suggests. Instead, the visionary will seek out areas of discontent within society and propose ways of remedying it. Some discontent will be so overwhelming that it may call for radical changes to set society on a long-term path of general happiness. The abolition of slavery and the civil rights movement are cases in point, and the leaders of these movements could fully justify their reforming efforts with utilitarian reasoning.

We saw that the most distinctive feature of his theory is that happiness consists of both higher and lower pleasures, and that higher pleasures are qualitatively superior to lower ones. The problem is that Mill appears to offer two separate standards of general happiness: 1 pleasure and 2 dignity. If we see pleasure as the sole criterion, then we must deemphasize dignity; if we see dignity as the principal criterion, then we must deemphasize pleasure.

American philosopher Ernest Albee — concisely states the central issue here:. The inconsistency, in truth, may be expressed in a word: If all good things are good in proportion as they bring pleasure to oneself or others, one cannot add to this statement that pleasure itself, the assumed criterion, is more or less desirable in terms of something else e. The problem here is a serious one, and it appears that Mill simply cannot hold up both pleasure and dignity as the principal standard of happiness. One option is to set aside the notion of dignity, and simply to see pleasure as the standard of happiness.

This solution brings Mill closer to Bentham, since any difference between pleasures would then have to be quantitative. This even allows for the possibility of a utilitarian calculus of differing quantities of pleasure. However, this resurrects the problem that Mill hoped to avoid—namely, that utilitarianism is a doctrine worthy only of swine since swine also pursue pleasure. Thus, this is not the best option for Mill. A second option is to redefine the notion of human pleasure to make it inseparable from the notion of human dignity.

That is precisely what Mill tried to do when distinguishing between higher and lower pleasures.

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The lower ones are bodily in nature, which even animals can experience. By contrast, the higher ones are uniquely human and involve human dignity. It is here that Mill needs help. Suppose that both I and my pet hamster break a leg as a result of an accident. We both will experience physical pain from our respective injuries. However, I, with my more complex brain, will reflect on my pain in ways that the hamster cannot. What I am experiencing now is not just pain, but suffering.

1. Fighting ignorance

The specific formula is pain plus reflection produces suffering. While suffering of this sort may not be a uniquely human experience, it would at best be restricted to higher animals sophisticated thought processes. Consider now how I and my hamster would react to a pleasurable experience of, say, eating our favorite meal. The hamster eats its food pellets and I eat a pizza. We both experience gastronomic pleasure, but, because of my more sophisticated thought process, I reflect on it in different ways.

While my gastronomic pleasure is similar to that of the hamster, my overall enjoyment of the experience is entirely different since it is filtered through my higher thought processes. At least some of this thought process involves a sense of dignity. The formula here is ordinary pleasure plus reflection produces higher pleasure. But, on the occasions that my eating enjoyment is connected with my higher functions, my experience is more valuable.

With a sense of human adventure, I might expand beyond my usual eating routine and try different foreign foods and enjoy them. Similarly, I might expand beyond the action-adventure movies that I watch and try foreign films and documentaries, and enjoy them as well. But as it becomes elevated to a higher pleasure, it cannot be separated from my human dignity. In this way, contrary to Albee, higher pleasures are not inconsistent with hedonism.

The utilitarian strategy for moral decision making has withstood the test of time and this in and of itself demands that we take it seriously. In this final section we will consider two lingering problems with utilitarianism, one of which questions whether pleasure is the only important moral value, and the other that questions whether any bare-bones utilitarian formula can function as the sole authority in moral judgments.

On the plus side, by focusing exclusively on the pleasure that results from a course of action, morality stands up to experiential and even scientific judgment. Hedonistic utilitarians argue that we can record experiences of pleasure, quantify degrees of pleasure, and use this as the basis of our moral judgments. Scottish economist Francis Edgeworth proposed the idea of a hedonimeter that could scientifically measure the pleasure that a person was experiencing:.

Let there be granted to the science of pleasure what is granted to the science of energy, to imagine an ideally perfect instrument, a psychophysical machine, continually registering the height of pleasure experienced by an individual, exactly according to the verdict of consciousness. Such a machine has not yet been created, but, even today, many philosophers and social scientists defend hedonistic utilitarianism because of its objectivity.

Books in microeconomics routinely include chapters on techniques for numerically measuring utility. For the hedonistic utilitarian, then, moral assessment is not a matter of personal feelings or intuitions. Instead, it attempts to place the issue of morality squarely in the arena of public observation.

The minus side of hedonistic utilitarianism, though, is that, as critics point out, pleasure is not the only thing in life that is morally significant. Religious and political martyrs are vivid illustrations of this. Many people throughout history have felt morally compelled to defend their religious or political ideals knowing full well that they would be tortured and ultimately killed for their actions. Their lives would have been more pleasurable—or at least far less painful—if they had simply conformed to social expectations.

It seems, then, that an important part of our moral assessments goes beyond mere pleasure. Perhaps Mill would say that martyrs experience higher pleasures that counterbalance their pains. To more successfully address this problem, some contemporary defenders of utilitarianism abandon pleasure altogether as the ultimate criterion and propose instead a standard that is broad enough to include cases like religious and political martyrs.

The two most popular alternatives are ideal utilitarianism and preference utilitarianism. Ideal utilitarianism is the view that the morally right course of action is the one that brings about the greatest amount of goodness , regardless of what we specifically identify as good. Many things in life are intrinsically good, such as aesthetic beauty, integrity, friendship, fulfillment of desires, fairness, and freedom.

However, we should not single out any one of these qualities as definitive, which is exactly what Bentham and Mill did by focusing on pleasure. According to British philosopher G. Moore — , it is actually impossible for us to pinpoint all of the qualities that constitute absolute goodness:. It is just possible that the Absolute Good may be entirely composed of qualities which we cannot even imagine.

This is possible, because, though we certainly do know a great many things that are good-in-themselves, and good in a high degree, yet what is best does not necessarily contain all the good things there are. Rather than focusing on a specific quality, such as pleasure, we should instead recognize that any consequence that counts as good needs to be entered into the utilitarian tally. Suppose I live in a repressive country and am considering voicing my unpopular political opinions.

I not only tally the pain I will experience from being tortured, which is clearly bad, but also tally the assertion of my freedom and the integrity of my convictions, which are good things. How do we recognize the various things that count as good? Moore argues that we should start by pointing out the flaws in popular standards of goodness that leave out important goods.

How to Be a Good Leader

Moore concludes that the ideal standard we arrive at will emphasize a mixture of aesthetic enjoyments, such as beauty, and admirable mental qualities, such as sociability. Ultimately, we must rely on intuition to recognize the various goods. Preference utilitarianism is the view that the morally right course of action is the one that maximizes our preferences. Again, if I live in a repressive country and am considering expressing my unpopular political opinions, I would tally my preference for free expression in addition to the pain I would experience from being tortured.

Preference utilitarianism is most associated with contemporary British philosopher R. Hare Moral Thinking , Second, my preferences include a combination of both immediate and long-term preferences. Among other combinations, it includes 1 what I prefer right now to attain right now, 2 what I prefer right now to attain in the future, and 3 what I will prefer in the future to attain in the future.

Third, my preferences are not merely restricted to myself but also include the preferences of other people. For example, I would not prefer that, if I were Tucker, I should be executed. But I would prefer that, if I were a relative of the victim, Tucker should be executed. If my preferences focused only on myself, then I would be an egoist, and not a utilitarian. Both ideal utilitarianism and preference utilitarianism allow us to tally a broad range of possible consequences in our utilitarian calculus. Contrary to hedonism, they recognize that pleasure is not the only thing that counts.

However, ideal and preference utilitarians pay a price for being so inclusive— namely, they lose objectivity. As mentioned earlier, according to hedonistic utilitarians, pleasure can be experientially measured. But, ideal goodness and personal preferences cannot be experientially measured. These are founded in gut feelings and private intuitions, which do not lend themselves to public inspection, and is precisely what Bentham was trying to avoid. Consequently, many utilitarians stick with the old hedonistic version in spite of its narrowness.

Utilitarians from Bentham and Mill onward are united in the view that morality is a matter of weighing the positive versus the negative consequences of a course of action. Utilitarian writers present different claims about the purpose of the bare-bones utilitarian formula. They sometimes see it as 1 a description of how we actually make moral decisions or 2 a description of how we should make moral decisions or 3 a quick and easy test to use in making moral decisions.

But no version of utilitarianism is successful in any of these claims. First, utilitarianism does not accurately describe how we always make moral decisions, as we can see from the Karla Faye Tucker story. Although both sides of the dispute at some point offered utilitarian reasoning for their views, they also appealed to a variety of non-utilitarian reasons. Tucker herself believed that, as a matter of simple mercy, society should forgive criminals who reform.

Appeals to simple mercy or to eye-for-an-eye justice do not involve utilitarian tallies of good or bad consequences. Also, utilitarianism involves a type of arithmetic by which we subtract the weight of the negative consequences from the weight of the positive ones. That is, they did not subtract the positive consequences from the negative ones, as a true utilitarian would. Second, it is not clear that we should adopt the utilitarian formula when making all of our moral decisions. Kant made this point specifically with regard to capital punishment. Although Kant himself defended the death penalty, he argued that, if we execute a criminal because of its positive value for society, such as crime deterrence, then we are using the criminal as a tool for our own purposes.

For Kant, it is always bad to use someone as a tool, even if the person in question is a criminal Metaphysics of Morals, Third, in many if not most cases, the utilitarian formula is neither a quick nor an easy way of making moral decisions. It is difficult to see how many people might be affected by a given course of action.

It is also difficult to know how to assign weight to the various good or bad consequences that emerge. Although hedonistic utilitarians brag that pleasure can be experientially quantified, the fact remains that scientists have not yet invented a pleasure meter. Assigning weight to pleasures and pains will still involve some level of subjective judgment. Perhaps the problem with utilitarianism is its bare-bones claim that morality depends entirely on calculations of consequences. Philosophers today are drawn to simple formulas and to simple explanations for complex philosophical puzzles.

But moral decision making appears to be one area that we cannot account for with a simple, unified formula.

Our actual moral decision-making process depends on a patchwork of various theories and explanations that cannot be reduced to a single theme. At times, we do rely on utilitarian reasoning, and, to that extent it is an important part of moral decision making. Utilitarians merely need to abdicate their claim to sole authority.

Many philosophers as far back as ancient times believed that pleasure is the standard by which we should judge moral conduct. Philosophers during the 18th century refined this notion, and, with Bentham, we find the classic statement of hedonistic utilitarianism. According to Bentham, we determine whether an action is right by calculating all of the pleasure and pain that results from that action. Mill offered a version of utilitarianism that parted company with Bentham in two important ways.

First, he emphasized the difference between higher and lower pleasures, where the higher ones are more important and are incapable of numerical computation. Second, Mill offered a version of rule-utilitarianism holding that we test only the general happiness of moral rules, not that of each action. We next looked at four criticisms of utilitarianism, the first of which by Gisborne is that we will never be able to discover all of the relevant effects of our conduct. Next, Bradley criticized that utilitarianism conflicts with common moral values; for example, with utilitarianism, we could justifiably commit adultery or enslave someone if doing so maximized the general happiness.

Grote criticized that utilitarianism locks us into the morality of the status quo and does not account for moral progress. Albee criticized that Mill inconsistently holds to two standards of moral value: pleasure and dignity. Finally, we looked at two lingering problems with utilitarianism. The first is whether pleasure is the only important moral value.

Ideal utilitarians such as Moore recommend that we tally the total good versus bad that results from a course of action. Preference utilitarians such as Hare recommend that we assess our total preferences regarding a course of action. The second lingering problem concerns whether any bare-bones utilitarian formula can function as the sole authority in moral judgments. He explains his position in the following selections. With Phases I. The Community Tool Box at the University of Kansas includes several assessments related to collective impact.

The Collective Impact Readiness Impact assesses the extent to which preconditions are met or will require further investment. The Magnolia Community Initiative exemplifies a collective impact approach, and a description of its efforts is also included in the Community Tool Box. Communication is facilitated through a shared website that offers access to discussion forums, group blogs, e-mail blasts, a shared calendar, and shared files and documents.

Shared measurement is informed by a shared theory of change. Backbone support is provided by the network partners. In addition to individual strategies and tools, a number of tool kits have been developed.

Koo et al. In addition, they required that the tools targeted more than one sector and were freely available on the Internet. The six tool kits and their contents are summarized in Table Koo et al. Other tool kits also provide guidance on various specific aspects of community-based solutions.

For example, the National Partnership for Action to End Health Disparities Toolkit for Community Action was developed to help individuals, organizations, and policy makers: 1 raise awareness about health disparities by providing descriptions of health disparities and their causes; 2 engage others in conversations about the problem and solutions with tools to guide efforts to promote programs and policies for change; and 3 take action for change by providing information and tools to help individuals and organizations to address health in their communities HHS, n.

There are also specific guides that demonstrate the application of the tools in a specific domain: for example, multi-sector partnerships for preventing violence Tsao and Davis, The resource is designed to help select interventions to improve health and prevent disease at the community level as well as at other levels.

The Community Guide contains reviews designed to answer three questions of key relevance to those wishing to implement community-based solutions: 1 What has worked for others, and how well? In addition, another type of tool kit—collections of community exemplars—are useful to inform community-based solutions by highlighting successful practices at the local level through narrative. For example, the Prevention Institute offers a searchable database of more than community profiles that address a variety of social determinants of health Prevention Institute, b.

The Community Guide also provides stories featuring those who have used the Community Guide to make people safer and healthier. Chapters 4 and 5 described why communities matter and highlighted nine examples of community-based solutions to promote health equity in the United States. This chapter outlines specific tools that communities can use to move toward health equity organized by: 1 those tools that apply across all three elements of health equity as a shared vision, cross-sector collaboration, and community capacity to shape outcomes; 2 those that apply specifically to one of the elements; and 3 prominent tool kits that can inform community-based efforts to promote health equity.

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Medical—legal partnership toolkit.

2. Fighting fear

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The emerging fourth sector: Executive summary. Sadler, B. Wampler, J. Wood, M. Barry, and J. The Denver regional equity atlas: Mapping access to opportunity at a regional scale. Sanchez-Vaznaugh, E. Rosas, J. Baek, and S. American Journal of Preventive Medicine 42 5 — Schoeni, R. Dow, W. Miller, and E. The economic value of improving the health of disadvantaged Americans. School-Based Health Alliance. Sege, R. Preer, S. Morton, H. Cabral, O. Morakinyo, V. Lee, C. Abreu, E. De Vos, and M.

Medical—legal strategies to improve infant health care: A randomized trial. Pediatrics 1 — Springer, A. Hoelscher, B. Castrucci, A. Perez, and S. Prevalence of physical activity and sedentary behaviors by metropolitan status in 4th-, 8th-, and 11th-grade students in Texas, — Preventing Chronic Disease 6 1 :1— Stratton, C. Rose, A. Parcell, and J. Made in Durham: Building an education-to-career system. Taylor, D. Bernstein, E. Carroll, E. Oquendo, L. Peyton, and L. Journal of Health Care for the Poor and Underserved 26 3 — The City Project. Quality education, physical education, and schools of hope.

Transit to trails. The Pew Charitable Trusts. Issue brief: Is health impact assessment effective in bringing community perspectives to public decision-making? Lessons from 4 case studies in California. Thompson, H. Are physical education policies working? Preventing Chronic Disease Tsao, B. Multi-sector partnerships for preventing violence: A guide for using collaboration multiplier to improve safety outcomes for young people, communities, and cities. Oakland, CA: Prevention Institute. The Civil Rights Project.

University of Colorado Law School. USDA U. Department of Agriculture Economic Research Service. The food access research atlas. Virginia Department of Health. Virginia health opportunity index HOI. Waidmann, T. Estimating the cost of racial and ethnic health disparities. Washington, DC: Urban Institute. Work Group for Community Health and Development. The community tool box. The community tool box: Chapter 1, section 3. Our model of practice: Building capacity for community and system change.

The community tool box: Chapter 13, section 1. Developing a plan for building leadership. In the United States, some populations suffer from far greater disparities in health than others. Those disparities are caused not only by fundamental differences in health status across segments of the population, but also because of inequities in factors that impact health status, so-called determinants of health.

When these factors are not optimal in a community, it does not mean they are intractable: such inequities can be mitigated by social policies that can shape health in powerful ways. Communities in Action: Pathways to Health Equity seeks to delineate the causes of and the solutions to health inequities in the United States. This report focuses on what communities can do to promote health equity, what actions are needed by the many and varied stakeholders that are part of communities or support them, as well as the root causes and structural barriers that need to be overcome.

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Making the Case for Health Equity The Cost of Health Inequity The cost of health inequity is usually calculated as a difference in cost, specifically, the excess burden that arises from certain groups. Strategies for Investment Recognizing that health inequities arise from many factors, decision makers face a challenge in weighing different strategies to improve health equity and health outcomes and decrease the cost of inequity.

Mobilizing the Private Sector While there is strong motivation at the individual level to pursue improvement, such as education, because of the prospect of higher incomes in the future, there is also a societal component at play. Framing Outcomes and Success in Community Solutions The major outcome of interest for community solutions is impact on health. Data Sources Increasingly, there are sources of electronic data that are publicly available and can be used to examine issues related to health and health.

Indicators For the purpose of this report, the committee uses the definition of indicator from the IOM report: a statistic or measure that is widely acknowledged to be useful for measuring something of concern to policy makers or the public IOM, Interactive Tools Although lists of indicators are useful in determining what to measure and how it should be measured, Web-based interactive tools make data sets more accessible to communities.

In the short term there is a need to determine which existing indicators are most relevant for measuring and monitoring progress toward making health equity a shared vision and value, developing community capacity to shape outcomes, and encouraging multisector collaboration. Other aspects of community capacity building, including leadership development, community organizing, organizational development, and fostering collaborative relations among organizations are additional areas for potential indicator development.

Conclusion There are many existing data sources, indicators, and interactive tools that are relevant to meeting the information needs that drive community-based solutions; however, Many communities may be unaware that such tools exist or lack some of the prerequisite skills for their effective use. Furthermore, these tools need to be made more user-friendly to facilitate use by community members. Many of the indicators and interactive tools provide data at the national, state, or county level.

More tools are needed that provide interactive access to data at the neighborhood or community level. Using Civil Rights Law to Promote Health Equity Civil rights laws can support community-based solutions to promote health equity and are an integral part of the culture of health in the United States. Related Examples of Policies and Actions to Promote Health Equity Agencies can also promote health equity through broad-based, more equitable community engagement.

Physical Education in Public Schools A successful community-based effort to promote health equity through wellness and prevention is physical education in public schools. The major findings of the study include Fitnessgram passing rates differed significantly based on race and ethnicity. Non-Hispanic white students had the highest average passing rate, at 34 percent, followed by Asian students, at 31 percent. Hispanic students had a Fitnessgram passing rate of 26 percent.

African American students had the lowest passing rate at 22 percent. Additionally, African American students had the highest percentage of poor scores, with nearly districts reporting an overall passing rate of 10 percent or less among this racial group. School districts with more low-income students eligible for free or reduced-price meals tended to have lower Fitnessgram passing rates.

Districts with higher API academic performance index scores tended to have higher Fitnessgram passing rates Green et al. Medical—Legal Partnerships In contrast to civil legal aid organizations that provide assistance to community members on issues that affect health through a justice-driven framework, medical—legal partnerships operate through a public health framework that includes the social determinants of health and values population outcomes as well as individual outcomes.

The HIA process built the capacity and ability of communities facing health inequities to engage in future HIA and in decision making more generally: 1 communities facing inequities lead or are meaningfully involved in each step of the HIA; and 2 as a result of the HIA, communities facing inequities have increased knowledge and awareness of decision-making processes and have attained greater capacity to influence decision-making processes, including the ability to plan, organize, fundraise, and take action within the decision-making context.

The HIA resulted in a shift in power benefiting communities facing inequities: 1 communities that face inequities have increased influence over decisions, policies, partnerships, institutions, and systems that affect their lives; and 2 government and institutions are more transparent, inclusive, responsive, and collaborative. The HIA contributed to changes that reduced health inequities and inequities in the social and environmental determinants of health: 1 the HIA influenced the societal and environmental determinants of health within the community and a decreased differential in these determinants between communities facing inequities and other communities; and 2 the HIA influenced physical, mental, and social health issues within the community and a decreased differential in these outcomes between communities facing inequities and other communities.

Funding Mechanisms for Communities Regardless of the intended impact and the process of development and implementation of any community intervention to promote health equity, a key element is identifying the necessary fiscal resources for the project or program. Clearly stated shared purpose and values. This may include a commitment to collective impact, which is described later in this chapter Public Health Agency of Canada, A champion.

An effective champion is trusted, respected, nonpartisan, and works effectively with political leaders; is strongly committed to the determinants of health philosophy; and welcomes, encourages, and successfully brokers multiple and varying perspectives to shape a health equity agenda Public Health Agency of Canada, Capacity Building for Leadership Development Capacity building in regards to leadership development at the individual level includes building the skill sets that committed participants need to take a key role in representing the interests of their community and enhancing their effectiveness in helping shape intervention elements that respond to the specific community member needs.

Capacity Building for Community Organizing Community organizing through local outreach brings together individuals with shared interests and gives voice and power to individuals who traditionally are excluded and marginalized. Capacity Building for Organizational Development In the United States, fairness is obtained by efforts that begin at the community level.

Build a guiding coalition: A volunteer army needs a coalition of effective people—coming from its own ranks—to guide it, coordinate it, and communicate its activities. Form a strategic vision and initiatives: Strategic initiatives are targeted and coordinated activities that, if designed and executed fast and well enough, will make the vision a reality. Enlist a volunteer army: Large-scale change can only occur when significant numbers of local, regional, or national citizens amass under a common opportunity and drive action in the same direction.

Enable action by removing barriers: By removing barriers such as inefficient processes or hierarchies, leaders provide the freedom necessary for volunteers to work across boundaries and create real impact. Generate short-term wins: Wins are the molecules of results. They must be collected, categorized, and communicated—early and often—to track progress and energize volunteers to drive change. Sustain acceleration: Change leaders must adapt quickly in order to maintain their speed. Whether it is a new way of finding talent or removing misaligned processes, the leaders must determine what can be done—every day—to stay the course toward the vision.

Recruit the right people. Devise a set of preliminary objectives and activities. Convene the coalition. Anticipate the necessary resources. Define elements of a successful coalition structure.

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Maintain coalition vitality. Make improvements through evolution. As part of community-based solutions, multi-sectoral collaborations can benefit from the following general principles that have been delineated by a number of authors: The ability of partners to commit resources: Multi-sectoral collaboration requires a human resource plan that is documented and agreed to by all partners, the identification of skill requirements and opportunities for training and development, the sharing of examples of innovative working methodologies, and consensus on a cost-sharing plan Public Health Agency of Canada, Investment in partnership includes financial obligations such as time, personnel, and money and may also include forgoing other opportunities and taking on risks Public Health Agency of Canada, The health sector as a leader or facilitator: Depending on the focus of the multi-sectoral community-based solution, the health sector may assume a leadership role when the solution is tied.

Political support and a public policy environment that supports collective action: A direct link to the political level facilitates visible political support, sustained partner participation, and access to necessary resources Public Health Agency of Canada, Successful working relationships: Relationships are characterized by trust and mutual respect; being inclusive of all participants; reflecting clear and unambiguous communication; being transparent, clear, timely, and fair in the handling of issues; being supported by a clearly articulated vision; being enabled by effective leadership that ensures the various partners participate on an equitable footing; and having clarity around roles and responsibilities Danaher,