Public Health

By Sophia Simon-Ortiz, Sari Bilick, Maddy Frey, Solange Gould, Clara Long, Emma Waugh, and
doi: 10.1377/ Lili Farhang
hlthaff.2024.00035
HEALTH AFFAIRS 43,
NO. 6 (2024): 798–804
This open access article is
distributed in accordance with the
Community Power–Building Groups
And Public Health NGOs:
terms of the Creative Commons
Attribution (CC BY-NC-ND 4.0)
license.

Reimagining Public Health

Advocacy
Sophia Simon-Ortiz, Human
Impact Partners, Oakland, ABSTRACT Public health frameworks have grappled with the inequitable
California.
distribution of power as a driver of the social conditions that determine
Sari Bilick, Human Impact health. However, these frameworks have not adequately considered
Partners.
building community power as a strategy to shift the distribution of
Maddy Frey, Frey Evaluation, power. Community power–building organizations build and organize a
LLC, Atlanta, Georgia.
base of affected people to take collective action to transform their
Solange Gould, Human Impact material conditions, using advocacy and other tactics. We conducted
Partners.
qualitative interviews with representatives of twenty-two national
Clara Long (claralong@ nongovernmental public health organizations (public health NGOs) and
humanimpact.org), Human
Impact Partners.
thirteen community power–building organizations to explore the nature
and potential of partnerships between public health and community
Emma Waugh, Hoehn Public
Health Consulting, LLC,
power–building organizations. Our findings suggest ways to close
Atlanta, Georgia. advocacy gaps within the public health ecosystem and ways in which
Lili Farhang, Human Impact
public health can strategically leverage its power, resources, and expertise
Partners. to support social justice campaigns and movements.

P
ublic health frameworks have long engagement, in which community members par-
grappled with the inequitable dis- ticipate in, contribute to, and inform better de-
tribution of power as a driver of the cisions, without necessarily affecting who has
social conditions that determine power over decisions and agendas.
health, but they generally have not As stated by the Lead Local project, “commu-
considered building community power as a strat- nity power building is particularly critical for
egy to shift the distribution of power.1,2 And yet underserved, underrepresented, and historically
community power—the ability of communities marginalized communities who have been ex-
most affected by structural inequities to act to- cluded from decision-making on the policies
gether to influence decisions affecting their and practices that impact their health and the
lives—has been linked to health for decades, in health of their communities.”4(p6) Community
settings all over the world.3 Why is this link so power–building organizations are the entities
strong? The answer is not surprising: Human most active in this work: They build and organize
health thrives when people experience a sense a base of affected people to take collective action
of agency and autonomy over their lives, along- to transform their material conditions, using
side opportunities for social participation and advocacy as one of many tactics in pursuit of this
belonging. As a uniquely democratic manifesta- goal.
tion of strength, connection, and mutual ac- As a field, public health also cares about chang-
countability, community power is also an instru- ing material conditions to achieve health equity
ment necessary to transform the conditions that and racial justice. However, when the public
produce health. It is distinct from community health sector engages in advocacy, efforts rarely

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focus on the same policy issues that community tions5 and nongovernmental public health or-
power–building organizations are fighting for, ganizations (public health NGOs) from across
even when the issues, such as tenants’ rights, the US.
community safety, fair wages and benefits, and Interview Methods Interviews were con-
climate resilience, are key determinants of ducted with one to three people from each orga-
health. If public health joined community nization, usually senior-level leadership, during
power–building organizations and the wider so- summer and fall 2023.
cial movements they are a part of, the aligned ▸ COMMUNITY POWER – BUILDING INTER-
voices and greater collective power could make VIEWS : We first conducted thirteen interviews
campaigns and movements more likely to win. with community power–building organizations
This, in turn, could lead to better material con- or national networks comprising these organi-
ditions, better health for marginalized commu- zations, whose members bear the brunt of in-
nities, and more lasting societal transformation. equitable social, economic, and environmental
Human Impact Partners is a national nonprof- conditions and who are leading campaigns for
it focused on transforming the field of public social justice. Their work primarily focuses on
health to center equity, building collective power determinants of health including housing, eco-
with social justice movements, and bridging nomic and worker justice, climate and environ-
public health with social justice movements. mental justice, and community safety. Organiza-
From this vantage point, we witness public tions were invited to participate on the basis of
health’s separation from community power– prior partnerships with Human Impact Partners
building organizations, even though these or- or because they were identified as leading
ganizations share the public health sector’s goals community power–building organizations or
of achieving health equity and racial justice. We networks across one or more of these social de-
also see how collaboration with public health is terminants. Community power–building inter-
elusive to community power–building organiza- viewees received a $250 monetary contribution
tions, in part because they have few strong rela- for their time.
tionships within the field and a limited under- Human Impact Partners staff developed and
standing of what public health could offer. These reviewed an interview guide, conducted inter-
missed connections are frequently felt in the ad- views, and took detailed notes of the responses.
vocacy context, where community power–build- The interviews were not recorded. Through the
ing organizations lead policy campaigns to interviews, we assessed where public health voic-
transform social, economic, and environmental es, analysis, advocacy tactics, and partnerships
conditions, whereas public health is largely ab- could support community power–building or-
sent. ganizations’ campaigns and movements and
To explore this gap and how to bridge it, Hu- would be welcomed. Interviews explored the or-
man Impact Partners conducted a national land- ganizations’ understanding of their work’s con-
scape scan to understand what it would take for nections to public health, the degree to which
nongovernmental public health to build rela- they were already connected to public health or-
tionships with, and provide advocacy support ganizations, their readiness to partner in the
to, community power–building organizations future, what they might need in terms of part-
and the wider social justice movements they nership and relationship building, and their will-
lead. The aim was to identify opportunities to ingness to advocate for public health in the face
reimagine and strengthen the relationships be- of the current backlash against the field.
tween these two realms to achieve the shared ▸ PUBLIC HEALTH INTERVIEWS : We then con-
goals of health equity and racial justice. ducted twenty-two interviews with public health
NGOs,6 which included large, mostly national
organizations representing different aspects of
Study Data And Methods public health and its workforce, academic public
We conducted a qualitative landscape scan to health groups focused on training students and
explore the hypothesis that meaningful public practitioners in advocacy, and a variety of coali-
health partnerships with and advocacy alongside tions and capacity-building groups. Organiza-
community power–building organizations are tions were invited on the basis of our perception
possible and necessary. We also evaluated the of their power and influence in the field, a dem-
opportunities and barriers to alignment and col- onstrated interest in or capacity to support com-
laboration across the sectors. To that end, Hu- munity power building, or a known academic
man Impact Partners, with help from Frey Eval- focus on building advocacy capacity. Public
uation, LLC, designed and conducted interviews health NGO interviewees did not receive mone-
and online research with representatives of thir- tary compensation for participating.
ty-five community power–building organiza- Frey Evaluation and Human Impact Partners

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Public Health

staff developed an interview guide for public Given this, we did not expect our results to be
health NGOs and pilot-tested it with two partic- applicable to governmental public health. In-
ipants. Interviews were recorded, included one stead, we focused on the wider public health
to two interviewers and a notetaker, and were ecosystem that influences and supports the goals
not transcribed. Interview questions were of governmental public health and can play a
shaped, in part, by the interests and needs ex- significant policy role through nonprofit organ-
pressed by community power–building organi- izations, academic public health, philanthropy,
zations in the first set of interviews. Overall, and professional associations.
interviews explored public health NGOs’ capaci-
ty and willingness to partner with community
power–building organizations and to use a range Study Results
of advocacy tactics identified by those organiza- Results from the analysis of both sets of inter-
tions, and the extent to which public health views reflect the “ships crossing in the night”
NGOs are already working to advocate for the nature of public health and community power–
most upstream causes of health inequities. Inter- building relationships: shared aspirations and
views also explored the need for coordinating concerns, but a lack of understanding, misun-
these efforts with those of other public health derstandings, or reservations about each other’s
organizations and potential actions moving approaches. Here we explore the six thematic
forward. findings from our research.
Online Information Review In addition, we Public Health Doesn’t ‘Get’ Power Build-
conducted online research to enable us to under- ing Most public health interviewees were not
stand each public health organization’s work in deeply familiar with community power–building
social determinants of health (SDOH) policy, efforts to improve SDOH, how community en-
their use of advocacy tactics, and partnerships gagement is different from community power
with community power–building organizations. building, or how community power–building or-
This included a thorough review of each organ- ganizations are distinct from community-based
ization’s website before interviews, reviews of organizations more broadly. And although many
programs and activities using key terms related of the interviewees understood that unjust pow-
to SDOH, and keyword searches of posted er imbalances are a root cause of health in-
resources. This information was used during in- equities, they were relatively new to the idea of
terviews to affirm or clarify the advocacy tactics community power building as a concept or strat-
used, as well as organizational commitments to egy to achieve social change. As one respondent
SDOH. stated: “Within the public health field…there re-
Analyses Interviewers conducted a debrief ally isn’t a real robust understanding of power
with one another after each interview and iden- and need for power building, and power as a
tified key takeaways. The interviewers extracted determinant of health.” Finally, many were un-
key takeaways from each interview into a spread- aware of, or had few relationships with, the com-
sheet, using categories based on topics in the munity power–building organizations leading
interview guide (for example, interest, readi- movements to transform social, economic, and
ness, needs, barriers, capacity, and roles), and environmental conditions.
they added emergent categories that arose from Community Power–Building Organiza-
the data (for example, advice for Human Impact tions Don’t ‘Get’ Public Health We found that
Partners, other organizations working in this many community power–building organizations
space, or salient points not expressed by other lacked an understanding of what public health
interviewees). Data in each category were ana- does. “I don’t have a sense of what public health
lyzed to develop themes, which were then shared workers do every day,” one community power–
and explored with the wider research team to building organization respondent said. Some
discuss and identify key findings, which are pre- saw public health organizations narrowly as ser-
sented in this article. Anonymous quotes from vice providers, not as organizations committed
interviews are included to illustrate key findings. to primary prevention and structural change that
Limitations We acknowledge several limita- work upstream to improve SDOH. For some, this
tions. Not all who met the inclusion criteria led to conflating public health and health care,
agreed to be interviewed. Also, governmental and the harms perpetuated by both fields. For
public health agencies were excluded because example, some community power–building in-
of their perceived and actual constraints (includ- terviewees noted that many historically margin-
ing financial, regulatory, and cultural con- alized groups are keenly aware of extractive and
straints) on policy advocacy and documented abusive public health and health care research
unease around advocacy and lobbying in partic- practices that have caused trauma and lasting
ular.7 harm, many of which remain unaddressed and

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 example, nearly all of the NGOs we spoke with
There is a tension in generated research and reports, although some
stated that they had difficulty getting their prod-
overemphasizing ucts to reach community power–building organ-
“expert” professional izations. Letter-writing campaigns or signing on
to others’ letters was another common advocacy
voices over those of tactic that public health NGOs engaged in, al-
though not necessarily for community power–
community members building organizations’ campaigns. Public
health advocacy efforts are often focused on
with lived experience. shoring up the public health system, workforce,
and funding, or on specific health issues such as
smoking and sugar-sweetened beverages—not
necessarily for the more upstream conditions
that community power–building organizations
are organizing around.
unreconciled. This undermines trust and rela- Few public health NGOs reported having de-
tionship building, even decades later. Health in- fined procedures or criteria to determine when
stitutions’ perpetuation of narratives that blame to engage in and advocate on issues, or which
individuals for unhealthy behaviors does not tactics are appropriate. Some worried that they
help, interviewees noted. would be duplicating other advocacy efforts in-
The concept of SDOH resonates with some stead of filling a gap; others said that they would
community power–building organizations be- only join coordinated advocacy work that is “be-
cause it aligns with how they frame their own ing led and deeply informed by the aspirations of
campaigns (such as around racial justice or en- [Black, Indigenous, and people of color] com-
vironmental justice), but community power– munities.” Most of the reluctance was related to
building organizations’ external, public use of advocacy and lobbying for what some perceived
health framing in campaigns and movements to be nonhealth social determinants, such as
was inconsistent. Some perceived public health criminal justice reform and worker power build-
as backing away from the bold, structurally fo- ing, which were not in NGOs’ comfort zones.
cused policy stances that it adopted early in the Public health’s unease with advocacy and lob-
COVID-19 pandemic, such as halting evictions bying for social determinants8 reflects a cultural
and enacting worker protections. Community difference between the two groups that creates
power–building organizations had learned that barriers to partnerships. “There’s a tension with
these policy stances were possible and ques- power-building organizations sometimes be-
tioned why they are deemed less necessary for cause of their level of advocacy involvement,”
their continually affected members now than at one public health respondent stated. “Organiza-
the height of the COVID-19 pandemic. tions like [ours] are trying to teeter the line, and
Public Health NGOs Use Many Advocacy sometimes choose not to go there. That’s a big
Tactics In the first phase of the interviews, com- barrier that keeps us from working together a
munity power–building organizations named lot.” Some public health NGO interviewees re-
several advocacy tactics on which they would ported being actively engaged in countering this
be interested in having public health support. risk aversion by clarifying the distinction be-
Tactics named for public health entities to em- tween advocacy and lobbying and the limits of
ploy were providing research and data reports, allowable lobbying. They also are encouraging
writing letters, providing testimony, speaking more latitude in doing advocacy.9
with the media, lobbying, mobilizing people Although they are currently few in number,
(for example, professional associations), facili- several academic public health programs that
tating relationships across the health sector, were among the interviewees also focus on teach-
crafting a narrative strategy, making public ing advocacy and lobbying to public health stu-
health and social determinants linkages, and dents and practitioners, with some embracing
providing or partnering on applications for the title of “activist labs.” In conjunction with
funding. Using this list, we then asked public other coalitions and broader schools of public
health NGOs about their use of these tactics health, these programs aim to increase the mo-
and their ability and interest in providing sup- tivation and skill set for advocacy within public
port to community power–building organiza- health’s ranks, while also connecting students
tions and their campaigns. and practitioners to their counterparts in social
We found that the public health NGOs gener- justice movements through internships, events,
ally did use these tactics in their own work. For and joint projects.

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Public Health

Community power–
Community Power–Building Organiza-
tions Value Experiences With Public Health
Partnerships Community power–building or-
ganizations that have collaborated with public building organizations
health entities described their experiences as
largely positive and strategic, and a value-add
often describe their
to their campaigns. Regarding the ways in which
public health could add value, community
work in terms of
power–building organizations prioritized the “justice,” whereas
provision of research and data and related advo-
cacy to support their policy campaigns. They de- public health tends to
scribed and valued public health voices as helpful
“validators” and “allies,” particularly when data use “equity”
and research affirm the lived experiences of com-
munity members. However, they also noted a terminology.
lack of relationships with public health to seek
and secure these contributions, just as public
health lacks the relationships with community
power–building organizations.
Although community power–building organi-
Public Health And Community Power–
zations recognize and want to use the power of
Building Organizations Face The Same
public health, there is a tension in overemphasiz-
Threats Public health is understandably con-
ing “expert” professional voices over those of
sumed by rising attacks on its work and authori-
community members with lived experience.
ty. But it lacks an expansive analysis of these
“Validators are useful,” one community power–
attacks as part of larger attacks on the public
building organization respondent noted. “[I]
sector, government, and democracy, and the
wish it wasn’t that way. Directly impacted people
value of partnering with social justice move-
should be heard in the same way, but some of
ments to fight back. Community power–building
these folks have more power. There’s ways to do
organizations said that they could and would
that accountably. Sometimes, our folks are
join advocacy efforts to defend public health,
brought in for just the story, not the solution.”
but they need help connecting their own goals
Similarly, many public health NGOs that ex-
and causes with those of public health.
pressed interest in supporting community
power–building organizations stressed the im- When asked about their work with national
portance of providing support in a way that is organizing groups and community power–
accountable to, and does not harm, the aims or building organizations, several public health
strategies of these groups. NGO interviewees talked about the field being
Community power–building organizations stretched thin and under attack, and about work-
said that they would like more and deeper col- force fatigue contributing to an inability to en-
laborations with public health, and a bolder pub- gage in work as nuanced and politically risky as
lic health sectoral presence at the national level. supporting community power building, espe-
They felt that public health was missing oppor- cially via advocacy. Community power–building
tunities in national legislative and policy fights— organizations took a wider view, connecting the
for example, the Fight for $15 movement (to political attacks on public health with a broader
raise the minimum wage to $15 per hour) and authoritarian and antidemocratic project that
the People’s Response Act (to support non- seeks to reduce the public sector’s funding,
carceral approaches to community safety). One scope, and power at the local, state, and national
community power–building organization repre- levels. They recognize that these attacks make it
sentative said, “I see environmental justice [and] even less likely that public health organizations
unions [there], less public health. Not that they will engage in controversial acts or statements.
don’t care or aren’t interested, but we just Community power–building organizations
haven’t built those bridges.” Indeed, in our scan, said that they were open to joining and support-
we observed several of the larger public health ing public health against these attacks, but they
NGOs—which we perceived to have the most would like to see public health make more of an
power and influence within public health— explicit connection between attacks on the field
describing themselves as the least willing and and the wider attacks on government and the
interested in participating in coordinated advo- public sector, including specifics of how public
cacy efforts to support community power– health supports the material conditions that the
building movements and campaigns. community power–building organizations are

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fighting for. “I would love to do more FOR public pertise to support community power–building
health,” one community power–building organi- campaigns and movements.
zation respondent said, referring to underfund- Public health NGOs need to be better orga-
ing of public health. “I’d like to be invited to nized, as a sector, to take collective action in
understand the risks and challenges better and support of community power–building policy
to advocate for more funding for it. …It would be priorities. Despite questions about focus,
nice to be more reciprocal.” breadth, and roles, there was widespread inter-
Public Health NGOs Seek Coordination To est among public health NGO interviewees in
Support Community Power–Building Organ- establishing a coordinated infrastructure to pro-
izations Most public health NGO interviewees vide advocacy support for campaigns and move-
felt that to best partner with community power– ments. Creating a formal structure would help
building organizations, greater coordination is overcome many of the challenges identified by
needed, as they saw no or very little coordination national organizing groups and community
happening. Among those who would welcome power–building organizations, including the
more coordination, anticipated benefits includ- lack of an understanding of what public health
ed “more consistency in how…public health does, deep relationships, adequate power as in-
[NGO] partners show up. That consistency could dividual organizations, and a bold and visible
go a long way toward building that trust, which presence at the national level. Community pow-
would allow for deeper relationship building er–building organizations have a strong desire
with [community power–building organiza- for public health to strategically leverage its “ex-
tions], which would in turn help them advance pert” role in support of communities’ leadership
their social aims.” and priorities; this is one strategy to achieve that
Even though most public health NGO inter- goal. As one community power–building organi-
viewees were interested in a coordinated eco- zation representative put it: “At a minimum, [we
system to support community power–building would benefit from] building relationships at a
organizations, they wanted to understand what horizontal level [across public health]. …We
was being requested of them and to clarify their would benefit tremendously as an organization
roles. Some also noted a potential tension be- to have access to a [space] like that, because of
tween focusing narrowly on a single issue and how fragmented public health is.”
trying to form a broader coalition. Some public This new structure should begin with and then
health NGOs saw climate or housing justice is- sustain the relationship-building work that is
sues as places to start for several reasons: They needed to bridge national public health and com-
offer both broad and specific opportunities for munity power–building organizations with the
public health; public health understands the many organizations that are ready to participate.
health implications and sees a role for itself; The group should focus on clarifying roles; iden-
and public health might be more ready to engage tifying assets and resources; determining focus
fully with community power–building organiza- areas and shared policy priorities; coordinating
tions on these issues compared with other issues narratives and messaging; and helping public
such as worker power, civic engagement, and health and community power–building organi-
noncarceral approaches to community safety. zations learn more about each other in produc-
tive and strategic ways that lead to joint work to
transform the social, economic, and environ-
Reimagining Public Health Advocacy mental conditions that affect health.
To Support Community Power– Once formed, the group could provide colearn-
Building And Social Movements ing spaces for public health and community
Despite the disconnects and different cultures power–building organizations to learn about
and structures revealed and affirmed by the in- one another’s frameworks, analyses, and ap-
terviews, public health NGOs and community proaches and to explore more meaningful and
power–building organizations have great poten- deeper collaborations. One area to focus on is the
tial to work together on policy advocacy strate- contrasting ways in which the sectors approach
gies to achieve health equity and racial justice. To their work. For example, community power–
that end, we propose creating a coordinated pub- building organizations often describe their work
lic health movement infrastructure (for in- in terms of “justice,” whereas public health tends
stance, a coalition, alliance, or network) for pub- to use “equity” terminology. In substance, hous-
lic health NGOs to provide ongoing advocacy ing initiatives in public health focus on health
for community power–building campaigns and outcomes linked to specific housing conditions
movements. This has the potential to close the (for example, smoke-free housing and removal
advocacy gap in the public health ecosystem and of lead or mold), whereas community power–
for public health to strategically leverage its ex- building organizations often focus on structures

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Public Health

that shape these conditions, such as tenants’ public health NGOs, noting the significant ab-
rights and the decommodification of housing. sence of support for community power–building
In the economic and work realm, public health in most public health analyses, approaches, and
might focus on workplace safety and providing advocacy efforts. With public health under at-
social services to low-income people, whereas tack, asking public health organizations to be
community power–building organizations bolder may seem counterintuitive and even dan-
might focus on wages, corporate accountability, gerous. But in many ways, urging the public
and building worker power. These differing health sector to understand and support commu-
frameworks and approaches must be reconciled nity power–building and wider social justice
and bridged for the sectors to explore more movements is a call for public health to return
meaningful and deeper collaborations. to its social justice roots10 and reimagine what it
Finally, the group also could support narrative means to engage in advocacy. Moreover, this
change by developing and disseminating an ex- landscape scan has demonstrated that if public
pansive narrative about public health’s structur- health engaged in this way, strong social justice
al and social determinants focus throughout movement allies might be ready and willing to
community power–building organization cam- link arms, accelerating the collective vision to-
paigns and tying attacks on public health to at- ward health equity and racial justice. A coordi-
tacks on democracy more broadly. nated public health ecosystem that has the ca-
pacity and passion to support broader social
justice movements is a prescription for better
Conclusion health and better politics, and it is increasingly
Community, power, and health are inextricably evident that community power and health are so
linked. The findings and recommendations gen- inextricably linked that it is not possible to have
erated by this scan put more onus for change on one without the other. ▪

This work was funded by a Robert Wood drafting support. This is an open access properly cited, not altered, and not used
Johnson Foundation grant to Human article distributed in accordance with for commercial purposes. See https://
Impact Partners to help build a wider the terms of the Creative Commons creativecommons.org/licenses/by-nc-nd/
ecosystem of public health actors to Attribution (CC BY-NC-ND 4.0) license, 4.0/. To access the authors’ disclosures,
support community power building. The which permits others to distribute this click on the Details tab of the article
authors thank Nicole Lezin for her work provided the original work is online.

NOTES
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