Beyond Hospital Walls: Creating Healthy Communities

Last fall, AIHA began shaping a program that takes partners outside their health care institutions to schools, churches, work places, neighborhood centers and throughout their communities to create healthier living for everyone. Healthy communities are much more than ones that have a low incidence of disease--they provide clean air and water; have access to healthy food; are secure from crime and violence; and minimize drug and alcohol abuse.

With the transformation to democracy, an emphasis has been placed on health care reform, governments are empowering municipalities and individuals to assume greater responsibility for their health and the health of the community. A healthy community project emphasizes this. The task of maintaining good health cannot rely solely on a few decision makers. Health and healthier communities are a collective responsibility of key stakeholders in all segments of the community (see box 1).

The AIHA healthy community project represents a unique opportunity for partners to learn and expand their role in community health assessment, planning and improvement. AIHA provides a valuable linkage for partners to work in a peer-to-peer relationship with experienced community-based health care systems and organizations in the United States. The planning process gives partners technical assistance and consultation in epidemiology, community organization, research and health education. Community leaders are empowered with lasting skills to improve the overall health of their community.

Healthy Communities Projects in Slovakia

AIHA has established two partnerships in Slovakia to work toward improving the overall health of communities. At first glance, the two communities appear very different from each other. One is a congested district of Bratislava, Slovakia's largest city, with a population of 441,000. The other is a rural town nestled in the foothills of the Tatra Mountains of central Slovakia. Despite their differences, they have the same goal of mobilizing residents to take charge of their own health and neighborhoods.

Turcianske Teplice-Cleveland

The town of Turcianske Teplice is best known for its thermal spa, which has been used to help with orthopedic, rheumatoid and urological problems for more than 700 years. The partnership pairs the town of Turcianske Teplice, represented by the mayor's office, with Cleveland, Ohio's MetroHealth System, a large public hospital system, and the Cleveland-Bratislava Sister Cities project. As the partnership evolves, the progress made in Turcianske Teplice, population 7,000, will be shared with 26 other villages in the Turiec region of central Slovakia.

Alena Chlapkov, Turcianske Teplice's mayor, is a medical doctor. The town's manager, the chairman of the town's health committee and the director for the environment are also participating in the partnership. Turcianske Teplice has already been designated a Healthy City by the World Health Organization, and town leaders plan to emphasize lifestyle changes, such as better nutrition and increased exercise, for residents.

Petrzalka-Kansas City

The Petrzalka district of Bratislava lies across the Danube River from the older, more picturesque section of the city with its turreted castles and spired churches. Petrzalka, by contrast, consists largely of recently built high-rise public housing buildings. The district's population mushroomed from 14,000 in 1970 to 128,000 in 1991.

With severe overcrowding, pollution and a high unemployment rate, Petrzalka's children have had an especially difficult time during the rocky transformation to a market economy. The Aid to Children at Risk Foundation is the first organization in Petrzalka to confront issues such as drug abuse and mental health of children and adolescents. The Foundation, along with the Institute of Preventive and Clinical Medicine, is paired with the Truman Medical Center, a 125-year-old public hospital system in Kansas City, Missouri. The Missouri Department of Health, which has developed its own healthy communities strategy for the state, also participates in the partnership.

Life expectancy in Slovakia still lags behind western Europe, and the Institute of Preventive and Clinical Medicine plans to study the reasons for this gap. In 1992, life expectancy for men was 66.6 years, six years less than in neighboring Austria and one year shorter than in the Czech Republic. Life expectancy also varies by as much as six years across regions of Slovakia, depending on education, ethnic background and other factors, according to research by Emil Ginter, PhD, and Tom Trnovec, MD, PhD, of the Institute, which is the largest medical research facility in Slovakia. Through the partnership, they will continue to study such questions as why the more heavily polluted areas paradoxically have a higher life expectancy. They will also investigate cardiovascular disease. Slovaks have similar rates for such risk factors as smoking, high blood pressure and high cholesterol as their western Europe neighbors. Yet, they experience a high rate of cardiovascular disease. The Institute plans to study the role that environment, nutrition and stress play in the disease.

The Worldwide Healthy Communities Movement

The projects in Slovakia are part of a worldwide effort to both create healthy communities and to redefine what health means. A 1994 survey by the Healthcare Forum, an education and research organization, shows that the public has a new concept of what creates health and healthier communities--one that focuses on quality of life issues, rather than merely medical ones. Those surveyed cited several critical determinants of a healthy community, including a low crime rate and low infant mortality.

These qualities are the same ones Canada had in mind when it adopted the Ottawa Charter for Health Promotion in 1986. This initiative provided the framework to define health promotion--the process for enabling people to take control of and to improve their own health. The definition infers action, self determination, advocacy and change, and the healthy communities concept builds on this framework.

The World Health Organization (WHO) Healthy Cities project is one example of a long-term international development project that put health on the agenda of decision makers in European cities. Begun in 1988, the project has created a strong public health movement at the local level involving more than 600 cities participating through 30 national networks. Because of the importance of community health and the success of the healthy cities programs, WHO is devoting its annual World Health Day in April to healthy cities. In 1993, WHO began a new planning initiative that includes a strong emphasis on public policy and comprehensive city health planning. Cities participating in this initiative must be committed to taking action on several major issues that make up WHO's Health for All agenda, including reduction of inequalities in health status, improvements in access to health, lifestyle change, creation of better environments and health care reform.

According to the American Association for World Health, healthy cities can work because they take an optimistic, holistic approach that strives to engage all facets of the community in a collaborative effort to define their needs and use their own resources. This process is dynamic, energizing and empowering, one that AIHA believes can strengthen not just the impact of the partnerships in Slovakia, but can widen the horizons of partners' work throughout the NIS and CEE.

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