AMA Journal of Ethics^®

Abstract

In the past few decades, scholars have begun to establish ethical principles for public health engagement. A key tension has been how to reconcile public health improvement with local autonomy in decision making so as to express respect for community members’ on-the-ground experience. This article describes the experience of one children’s hospital in learning to ethically engage a surrounding community in conversations about housing development in partnership with a local faith-based development organization.

Making Neighborhoods Better

In 2008, amidst the throes of economic recession, a major crossroads confronted the Nationwide Children’s Hospital (NCH) in Columbus, Ohio’s South Side. The hospital had decided to remain in its location of 126 years and invest more deeply in the community. The collapse of the nation’s housing markets had left hundreds of vacant properties in the area just beyond the hospital’s campus, and it was clear that addressing housing was key to improving pediatric health outcomes for 3 reasons: (1) housing plays a documented role in the health of children,¹ and this neighborhood had severe housing shortage; (2) outreach efforts made clear that housing was a neighborhood priority; and (3) because of instability in housing, children were moving too frequently to make school-based or neighborhood-based programs effective. Accordingly, the new hospital administration was committed to effecting change in the neighborhood.

Because hospital collaboration with communities remains relatively uncharted territory, trial and error, financial risk, and humility would be integral components of the hospital’s efforts. But the hospital needed to learn how to undertake this work ethically. Ethical problems can easily arise when large institutions work in local communities, especially communities with high levels of poverty and other socioeconomic challenges. Community members might feel ignored, or even bullied, if hospitals do not attempt to see proposed strategies for community improvement from residents’ perspectives. Beginning this initiative required not only planning the practical aspects of improving housing stock and safety but also learning how to listen to diverse local residents and to collaborate with community leaders.

Healthy Neighborhoods, Healthy Families

The result of a long planning process yielded a new initiative: Healthy Neighborhoods, Healthy Families (HNHF). HNHF is a 5-pronged program focusing on affordable housing, health and wellness, education, safe and accessible neighborhoods, and workforce and economic development.^2,3 One of these prongs, the HNHF Realty Collaborative, aims to (1) redevelop existing vacant properties to provide safe, affordable homes for low-income and moderate-income families, (2) reduce blight, (3) increase homeownership (which was a special focus during 2008-2016 after the national housing collapse and Great Recession), (4) assist existing homeowners in improving their houses through grants, and (5) cultivate a mixed-income community by developing and operating properties that rent below market rates (ie, 80% of area median income).^2,4 All of this was a challenge in Columbus, where wealth inequality is growing and the percentage of home ownership continues to decline.³

To achieve these goals, NCH partnered with Community Development for All People (CD4AP), a community housing development organization. CD4AP itself is an offshoot of the Church for All People, a brick-and-mortar church and faith-based organization that encompasses several programs and initiatives in its ministry. This organization provides a wide range of social services, including a free clothing store, a fresh produce market, workforce development, and after-school programming.⁵ CD4AP also has been instrumental in the development of a social enterprise bike shop. With over 20 000 persons taking part in its services on the South Side, CD4AP aims to be a true neighborhood connector. To this project of neighborhood revitalization the hospital contributes funding, personnel, logistical support, and other resources.

Over a period of 10 years, NCH and CD4AP established deep levels of trust with community members who have generated effective and creative housing strategies. The foundation of these community relationships are one-on-one and small group discussions that occur in normal, day-to-day interactions and focus on collaborative neighborhood revitalization efforts, strategies for improving access to medical care, the creation of a drive-through produce stand, and inserting hospital mentors into local schools. Ongoing meetings with local civic associations also allow for focused, structured conversations about preferences related to housing development. Resident surveys supplement this work. CD4AP and NCH have the goal of ensuring nondisplacement of lower-income residents as the neighborhood becomes more opportunity rich. A decade after their partnership began, over 40 stakeholder groups and neighborhood leaders are participating in the HNHF Realty Collaborative as conditions improve and construction shifts to the development of long-term affordable rental housing.⁴ NCH’s experience with HNHF shows that effective and sustainable programs require good partners.

Ethical Challenges

Perhaps the biggest ethical challenge the collaborative encountered concerned tensions between the public health model underlying the hospital’s aims and the community’s immediate and long-term concerns.⁶ These tensions arose from NCH’s and CD4AP’s approach to neighborhood health on a system level, on the one hand, and the tendency for residents to focus on more specific, often singular needs and wants, on the other.

Two examples illustrate this tension. First, HNHF made efforts to close a local liquor store where violence regularly occurred. Shootings decreased as a result, but there was a negative response from some community members due to the loss of several jobs. In this case, the short-term loss of jobs may have long-term benefits, but only if the lost jobs are replaced with new employment opportunities. For developments such as these to succeed, an agreement must be reached about whether a proposed change is in the best interest of all involved. Second, local residents communicated a strong preference for retaining the neighborhood’s historical composition of primarily single-family homes. Although multifamily housing might have had a positive impact on local homeless individuals by providing comparatively less expensive options with greater density within the HNHF zone, HNHF honored community members’ wishes and limited new housing primarily to single-family homes.⁴ The compromise was not only strategically beneficial but also part of HNHF’s ethical learning. Sometimes, for purposes of cultivating the relationship, doing right by the community’s perspective is an end in itself.

It can be hard to resolve such ethical tensions without significant learning on the part of hospital leaders and authentic collaboration with communities. Sometimes programmers will have to accept suboptimal (from a public health perspective) approaches to retain community participation. To facilitate long-term partnerships, anchor institutions must discuss openly with community members the advantages and disadvantages of proposed changes, which requires that all parties focus less on convincing one another of the rightness of their position at each stage than on learning from each other and compromising to work toward a future together. This learning can and should take many forms. In an effort to become better integrated with the community, NCH helped fund a neighborhood leadership academy for community resident leaders, facilitated by CD4AP. This initiative created an opportunity for the neighborhood to learn about the health and development goals set by city and hospital leaders and to build capacity for resident-led change. NCH, in turn, stepped outside its comfort zone and learned from its neighbors, which informed its guiding principles going forward.

While new situations arise continually in collaborations of this nature, the key to is to learn from mistakes and be open to adjusting strategies moving forward. Over time, hospital personnel involved in HNHF, as well as those not directly involved but aware of its aims, have become increasingly comfortable with the idea that hospitals can and should be involved in this kind of community programming.

Ethics and Community Health Partnerships

In the case of HNHF, collaboration between a children’s hospital, a local development group, and residents provided a forum for improving community well-being. Yet, it would be irresponsible to suggest that a system of ethical community engagement can be extrapolated from this case study and applied to other emerging hospital-community partnerships. A more accurate takeaway would be an acknowledgement of the tension at the core of HNHF, namely that public health—the NCH’s key focus—and community values such as autonomy and choice cannot always be reconciled. In this case, however, views held by hospital personnel as well as by community members were far from homogenous. Priorities within the hospital spanned financial profitability, the traditional mission of healing sick children, improving the community to create a safer and more appealing perimeter for the hospital, and addressing social determinants of health to benefit low-income and marginalized families. The hospital continues to lack a single, unified perspective on these issues. Similarly, the community must also reconcile competing values such as promoting neighborhood safety, increasing neighborhood cohesion and opportunity, and ensuring that displacement is not a main outcome of collaborative efforts to improve the neighborhood’s housing stock. Over time, NCH and community residents have developed a way to integrate diverse voices and address multiple priorities in the housing program.

Public health ethicists have acknowledged the importance of this type of collaboration in community-based projects. As public health practice has shifted to the “new public health,” which focuses on populations and preventive models,⁷ the need for sustained community engagement has required specific attention to how health care institutions, researchers, and public health agencies should engage local residents in planning, implementing, and assessing interventions.^8,9 These partnerships are challenging to build but hold significant potential for disrupting existing power dynamics between large institutions and residents and for developing models for shared decision making.

The experience of learning to engage Columbus’s South Side has led us to embrace a notion of authentic collaboration, wherein hospitals do less leading and more listening. Hospital programmers should assume that no matter how many “open” forums they hold, they are only hearing a fraction of community voices. Helping residents—and also the mayor, the city council, the school district, and others—learn to engage with the hospital has also proven important for resident-led change. Partnering with a trusted organization like CD4AP is vital to success and establishing credibility with the community. This partnership allows for asset-based community development, which prevents hospital overreach. For example, HNHF initially focused on improving existing community assets, such as old housing stock and an abandoned school building, and sought the commitment of well-endowed local families. Over time, however, the program has transitioned to the development of new assets through job training, a “hire local” program, and a leadership academy. This type of engagement requires dedication, time, and patience.

With the HNHF program now past its first decade of operation, we are in a position to reflect on what has and has not worked, although these lessons remain very much in progress. An ethical approach to hospital-community development requires attention to the local context and is resistant to the very idea of best practices. Based on our experience, however, we share the following lessons in the spirit of facilitating continual improvement.

1. Know your context. All neighborhoods contain important and unique histories. In this case, the long-standing presence of NCH, dating from 1892, was a key part of that history.
2. Take an asset-based approach. Developing strong relationships with community organizations can help to unify hospital and community interests. It is critical to identify real assets within the community and to connect with diverse neighborhood factions.
3. Find new and regular ways of communicating. Developing opportunities for local residents and hospital leaders to communicate regularly requires sustained relationships, time in place, and recurrent assessments.
4. Make ethical critique a centerpiece and focus of collaboration. Successful partnerships ensure that initiatives meet the aims of both the hospital and the community; initiatives should be regularly revisited to assess progress in meeting goals.
5. Be aware that interests may not always align. As with any relationship, both sides will not always agree, even after extended dialogue. Early engagement with the community can help cultivate relationships.
6. Work within the hospital to clarify core values and then forthrightly articulate these in ways that build authentic solidarity and partnerships with community members. To do so requires an openness to having these core values challenged, shaped, and enhanced by the perspectives of local residents.

Ethical approaches to hospital-community development require staying close to changes in the community. No preformulated approach allows hospitals to serve as passive funders—or residents to insist on complete governance—if programming is to have real success. To do this work ethically, hospitals must be willing to devote full-time employees to it (funded and unfunded) who can build trusting relationships with community residents. The end result will be as much about new partnerships as any new program.