Working in collaboration with grassroots organizers, advocacy organizations, and other government partners, the Alameda County Public Health Department, California, helped change local policies and practices related to housing habitability, affordability, and access to eliminate housing and health inequities in low-income communities.
Who Took This On
Alameda County Public Health Department, CA
Ways You Can Get Started
- Approach community organizations in your jurisdiction working on housing or other social determinants of health to learn about their work, frameworks, the issues they are most concerned about, and potential opportunities to collaborate
- Develop a report that profiles inequitable political, social, economic, and built environments and their impacts on health. Use the report as an opportunity to build partnerships and develop policy to address social determinants of health.
See Advice for Local Health Departments below for more ways to take action.
What Sparked This?
Health inequities data sparks creation of Community, Assessment, Planning and Education unit
In the 1990s, the Alameda County Public Health Department (ACPHD) identified significant health disparities between African Americans and other racial/ethnic groups in Alameda County. As the health department had limited capacity to address the root causes of these health disparities, Department leaders created and funded a new Community, Assessment, Planning and Education (CAPE) unit. The unit evolved to include staff focused on community capacity building, internal capacity building, and policy change. Today, ACPHD’s vision is, “Everyone in Alameda County, no matter who you are, where you live, how much money you make, or the color of your skin, has a healthy, fulfilling and productive life.”
Collaborative strategic planning and training builds internal capacity
In 2006, ACPHD started a participatory strategic planning process that included internal discussions on racism, gender discrimination, and class exploitation; 7 community forums; dialogues with the Public Health Commission and ACPHD staff on a vision for a healthy Alameda County; interviews with county supervisors and other key stakeholders; and 2 planning retreats. This process strengthened their vision to integrate a health equity practice within the organization, and guided subsequent activities that garnered staff and partner commitments.
ACPHD’s 2008–2013 Strategic Plan identified 6 strategic directions to guide their cross-departmental workgroup and divisional implementation:
- Transform the organizational culture and align staff’s daily work to achieve health equity.
- Enhance public health communications internally and externally.
- Ensure organizational accountability through measurable outcomes and community involvement.
- Support the development of a productive, creative, and accountable workforce.
- Advocate for policies that address social conditions impacting health.
- Cultivate and expand partnerships that are community driven and innovative.
Leadership knew that staff had diverse health equity experiences and could use those experiences to activate more health equity work within the Department. For example, many ACPHD staff experienced racism, classism, and other forms of oppression and were leaders addressing these issues in their churches, families, neighborhoods, and community groups. At the same time, line staff, who had been vocal about inequities and wanted to do more on root causes, were unsure how to navigate restrictive grants, budgets, and internal infrastructure. Other staff had less exposure to considering the role of oppression for health and their role in addressing these issues to achieve health equity.
ACPHD developed a 5-module Public Health 101 training series for all staff, to create space for dialogue, cross-learning, and developing a shared language to normalize institutional change and shifting power. In addition, ACPHD developed a training on policy development and advocacy that was offered to staff engaged in policy work. Department leadership highly encouraged staff to attend the PH 101 series, although it was not mandatory. Staff attendance was around 70-90% for each module.
What topics were included in the Public Health 101 training series?
The training series covered the history of public health, cultural competency and cultural humility, undoing racism, social and health equity, and community capacity building.
Place Matters launch and Unnatural Causes report focus on upstream policy change
In 2006, what is now the National Collaborative for Health Equity (NCHE) launched a national initiative called Place Matters. The goal was to improve the health of participating communities by identifying the root causes of health disparities and policy strategies to address them. As part of this launch, the NCHE invited the County Supervisor to create an Alameda County Place Matters team. The Supervisor’s office worked with ACPHD to develop and implement the initiative, which focused on building multisector partnerships and health department and community capacity building, as well as advancing health equity through policy and systems change.
In 2008, ACPHD released the report Life and Death from Unnatural Causes alongside the national film launch of Unnatural Causes: Is Inequality Making Us Sick? Using the documentary and local data, ACPHD staff organized numerous presentations to Health Department staff, partners, the Public Health Commission, other government agencies, community organizations and residents, and decision makers to build momentum to address health inequities in Alameda County. Through this work, ACPHD developed and strengthened relationships with various community and government stakeholders working on the social determinants of health. They also strengthened their understanding of and ability to describe their health equity framework. Finally, because of the report’s focus on social, political, economic, and built environment conditions, there was a focus on policy solutions that laid a foundation for future Place Matters work.
Place Matters Workgroups identify ACPHD policy agenda
In 2010, ACPHD organized 4 Place Matters community engagement gatherings to determine priorities for their local policy agenda in the areas of criminal justice, economics, education, housing, land use, and transportation. Over 200 local residents and representatives of community-based organizations participated in at least 1 gathering. As Alameda County has many longstanding community groups advancing racial and social equity, Place Matters’ staff built the initiative to: support the work community partners were leading, frame key policy issues with a health equity lens, and avoid duplication of effort through robust and proactive community collaboration. Learn more about Place Matters Workgroups accomplishments.
Department leaders publicly support staff and community innovation
As described above and in a NACCHO Exchange article, various factors enabled ACPHD’s equity work over the past 2 decades. One important factor was the role of ACPHD’s leadership in taking initiative on health inequities, speaking publicly about the injustice of inequities, and supporting staff to work with communities to improve conditions that fell outside traditional public health parameters.
Specifically, current and previous ACPHD directors, health officers, and other senior leadership created a supportive staff environment to advance social change work, a key part of which was explicitly focusing on structural racism as a driver of health inequities and normalizing discussions about racism. Leadership testified and supported staff to testify at public hearings on the health impacts of policies, projects, or plans, and spoke at community meetings and rallies, press conferences, government gatherings, and other public venues about the importance of tackling the root causes of health inequities. They wrote articles and op-eds in peer-reviewed journals, health agency–specific circulars, newspapers, and other media. ACPHD leadership were also deeply engaged in the Bay Area Regional Health Inequities Initiative (BARHII), contributing to and informed by BARHII’s work to build organizational health equity capacity, as well as other national health equity initiatives.
Since their initial meetings in 2010, the Alameda County Place Matters Housing Workgroup has involved residents, community advocates and organizers, housing-related service providers, government agencies, and decision makers to develop, advocate for, adopt, and support implementation of policies to address housing habitability, affordability, and access in Alameda County. The Workgroup’s efforts have primarily been focused in Alameda County’s lowest-income neighborhoods that are most impacted by racial health inequities.
The Housing Workgroup has utilized 4 strategies to address housing inequities:
- Build internal capacity to address health inequities across programs, including service delivery
- Collaborate with community organizers, advocacy groups, and governmental partners
- Communicate with decision makers to address the root causes of health inequities
- Implement a multifaceted approach to leadership development
Build internal capacity to address health inequities across programs
ACPHD is building staff understanding of the link between policy and direct service outcomes, to institutionalize cross-programmatic work to address health inequities. The Housing Workgroup includes staff who provide direct services and have a special vantage point that alerts them to potential policy issues. For example, home-visiting staff were the first to bring up concerns about habitability issues like mold and the challenges tenants faced in holding landlords accountable. Staff also organize trainings, lunchtime learning opportunities, and dialogues between direct service and policy staff to develop a shared analysis and understanding of housing issues that are particularly grounded in program work and client experiences. Specifically, staff working with clients in the Asthma Start, Family Health Services, and Healthcare for the Homeless programs shaped the Housing Workgroup’s policy agenda through their knowledge of issues and client perspectives. The service providers also contributed to policy analysis and implementation through participation in workgroups with community partners.
Collaborate with community organizers, advocacy groups, and governmental partners
In 2008, ACPHD partnered with Causa Justa::Just Cause (CJJC) to document the health and social impacts of the foreclosure crisis. CJJC is a multi-racial, grassroots organization building community leadership to achieve justice for low-income San Francisco and Oakland residents. CJJC conducted an in-depth survey of close to 400 community residents. The resulting 2010 report, Rebuilding Neighborhoods, Restoring Health, was one of the first reports in the country to describe the health impacts of foreclosure and received extensive media coverage.
In 2015, CJJC and ACPHD partnered on another housing-focused project. Written by CJJC with ACPHD’s Place Matters team providing data and policy analysis, Development without Displacement: Resisting Gentrification in the Bay Area reframed issues of development, gentrification, and displacement as public health issues and highlighted the role that local governments can play in ensuring that development benefits all residents. The report combined quantitative data with stories from community members to expose the health impacts of gentrification and amplified the voices of residents in affected neighborhoods. The report’s findings garnered extensive media coverage, and its policy recommendations have been instrumental in coordinating strategies among partners working to prevent displacement.
With CJJC and other community members, policy advocates, and city agencies, ACPHD continues to work on rental housing quality, affordability, and stability. For example, ACPHD currently works with its sister agency, the Alameda County Healthy Homes Department, to advocate for code enforcement policy and practice changes to protect health (e.g., moving from a complaint-based to proactive inspection approach, developing new protocols to address mold).
Communicate with decision makers to address the root causes of health inequities
Place Matters staff recognized that in addition to being reactive to housing issues, they needed to develop a proactive platform and agenda and address the root causes of the issues. ACPHD developed the platform through a community-engagement process that identified and analyzed the root causes. The platform prioritized improving the code enforcement system and ensuring that housing funds focus on those with the greatest housing need.
The housing affordability crisis in the Bay Area presented another opportunity to communicate with decision makers. ACPHD staff increasingly heard anecdotes about the impact of skyrocketing housing costs on clients and ACPHD’s own staff. In response, Place Matters worked with department leaders and CAPE to develop a survey of ACPHD and Alameda County Behavioral Health Care Services staff. The survey’s focus was on the impact of the housing crisis on clients, services provided, and staff. Using the results, staff produced short briefs for a press conference and other City Council meetings, garnering media coverage (e.g., in the East Bay Express) that framed the housing crisis as a serious public health issue.
Implement a multifaceted approach to leadership development
ACPHD is also implementing a multifaceted approach to leadership development focused on building the leadership of others, particularly partners with less formal authority; playing a supporting role in larger campaigns; sharing leadership through convening and catalyzing collaborations with consensus-based processes; and, when appropriate, exercising independent leadership as the local public health authority. ACPHD’s role in supporting leadership development was determined through collaborative identification of solutions and strategies to achieve them, as well as an understanding of the Department’s authority, capabilities, and limitations as a government agency.
Using this approach, ACPHD:
- Led the development of joint goals and strategies with Housing Workgroup partners
- Tapped the experience and knowledge of their own staff working in communities through direct services programs such as Asthma Start and Healthcare for the Homeless, which emphasized habitability issues as a primary concern for asthma patients and the importance of code enforcement policies and practices
- Participated in tenant protection and rent stabilization campaigns under the leadership of community-based organizations. In these cases, ACPHD provided objective health analysis in public testimony and comment letters while community partners drove coalition advocacy.
- When appropriate, led in more explicit ways by exercising the County Health Officer’s public health authority to highlight health-harming conditions in housing and to support tenant protections
- Acted as a convener and catalyst to bring together partners from multiple issue areas and sectors interested in preventing displacement. These dialogues created opportunities to advance recommendations from the Development without Displacement report and build ways for the Health Department to strategically partner in efforts to prevent displacement.
Outcomes and Impacts
Oakland’s Vacant Property Registration Ordinance
Working with advocates, ACPHD helped pass a model policy for cities across the state that requires banks to abate blight in foreclosed properties or pay a fine—leading to more than $1.6 million in funds for the city.
Rent Ordinance Reform
Passed unanimously by the Oakland City Council in 2014, the ordinance caps rent increases and reduces the cost that landlords can pass through to renters when making capital improvements on properties. Drawing extensively on their Development without Displacement report and leveraging key spokespeople, CJJC and ACPHD raised the visibility of gentrification as a public health priority and framed the proposed ordinance as a way to prevent displacement in Oakland’s rapidly gentrifying neighborhoods.
Protect Oakland Renters Initiative and County Affordable Housing Bond
While ACPHD could not endorse ballot initiatives, they contributed research and health impact recommendations on renters’ rights and affordable housing development that supported advocates in pushing for the passage of expanded just-cause eviction protections and other renter rights in Oakland, as well as a $580 million bond for affordable housing in Alameda County.
Pilot health inspections in Oakland’s Code Enforcement Department
The Code Enforcement Department has had dedicated staff to respond to health-related housing complaints since 2011, and is piloting joint, proactive inspections with community partners. ACPHD’s Asthma Start program worked closely with Code Enforcement staff to identify the causes or triggers of children’s asthma attacks (e.g., mold, pests, dust, etc.) and document code violations.
Supporting sister agency capacity building
Recognizing that the Code Enforcement Department has been relatively isolated and embattled by budget cuts, ACPHD worked to support relationship building and collaboration with the Code Enforcement Department by: 1) conducting cross-agency health equity trainings to build staff awareness, 2) joining the Department’s fight to restore funding for needed personnel, 3) leveraging their relationships with community groups to help bring attention and action to “problem properties” in neighborhoods, and 4) engaging in joint outreach and inspections.
Community partners increase use of health framing in their work
Through the past decade of collaboration, CJJC organizers and other community partners have increasingly adopted a healthy housing and health equity framework into their work on tenant and housing rights organizing, tenant legal aid, and affordable housing advocacy. For example, in 2014, CJJC launched a “Healthy Housing for All” campaign for a new city ordinance to enforce protections for renters against landlord harassment, including habitability violations as a form of harassment.
Strong relationships and understanding of strengths with community organizations
Through their work together, both CJJC and ACPHD came to better understand how to leverage the unique strengths of the collaboration and their distinct roles. CJJC brings people power, campaign knowledge, and a deep understanding of housing issues in low-income communities. Engaging local residents to take collective action was essential for moving policy solutions forward, and community partners, free from the restrictions placed on government, could bring direct organizing capacity. ACPHD staff brought data and policy analysis skills and a health lens to offer objectivity, credibility, and urgency to issues.
ACPHD is working with Oakland residents, community-based organizations, and city staff to develop Healthy Development Guidelines, the goal of which is to achieve health equity through the development process and projects in Oakland. The Guidelines are shaped by a resident engagement process and technical advisory group and intend to direct the Oakland Planning Department to prioritize the health needs of residents in historically underserved communities in their decision making. ACPHD also plans to advance the community engagement and policy agendas for their Place Matters workgroups.
ACPHD will continue to conduct staff trainings and workshops on specific policy areas (e.g., housing and immigration) to provide information and to hear about what front line staff see in their work that may inform the policy work. This capacity building will build greater infrastructure to connect the Department’s service delivery work to their structural change work that aims to prevent health crises in the first place.
ACPHD continues to seek out and hire staff who bring a strong commitment to social justice, and build staff skills to engage diverse audiences, present data in innovative ways, facilitate discussions around racism and other forms of oppression, and move people toward action, all the while working respectfully with community residents and building staff skills and awareness.
Advice for Local Health Departments
Building trust is needed, but it takes time
Building relationships between local health departments and community-based partners takes time — trust is not built overnight, and many groups may have had negative experiences with government agencies, including public health departments. Take the time to listen, and work to understand each other’s worldviews, frameworks, theories of change, and values.
Develop internal structures and processes with community partners
ACPHD and community partners invested in and built internal processes to concretize their points of contact, support clear communication, and affirm both organizations’ commitments to devote resources to develop a shared analysis of issues and policy solutions. This helped build trusting relationships and influence the collaboration’s success and impacts.
Develop process and outcome goals
Using both process and outcome goals ensures that partnerships and practices contribute to strong and trusting relationships, shift institutional power toward affected communities, advance a health equity narrative around policy issues, and create space for residents and community-based organizations to identify and drive needed changes.
Leverage power as health experts
Advancing a local housing policy agenda requires ACPHD to work across multiple sectors and with non-traditional partners in ways that are considered outside the scope of public health. To be effective and credible, this approach must be grounded in the tangible contributions that public health departments can make to policy change. They can leverage their unique position and power as health experts using their data, rigorous methods, and other tools that demonstrate the connection to health.
Find and foster strong leadership
Cultivating champions among policymakers and county leadership is an essential part of building support, raising resources, and providing vision for the practice of health equity.
Contribute to building grassroots power
Many of ACPHD’s partners are base-building organizations that mobilize residents around policy issues. Their leadership is essential to build the grassroots power necessary to address the root causes of health inequities. Being responsive to community organizations and leaders ensures that the work is grounded in the experiences and perspectives of local residents and organizations. Health departments should continually reflect on what they can contribute to ongoing policy work led by local community members and how they can leverage their institutional power. A key goal should always be supporting and building community power. Recognize that partnering with community groups builds capacity within the health department, and that this may mean expanding frameworks, shifting the way work gets done, and not always being comfortable.
Dedicate staff resources to work reactively and proactively
Consistent, dedicated staffing is important to institutionalize the work, but a small staff can be adequate to get started, especially if other staff throughout the department can contribute when their expertise is needed. It is important to be able to respond to emerging issues that are partner priorities even while pursuing a proactive health equity policy agenda.
Understand the institutional power of your agency and be willing to use it to benefit communities
This could include providing backing for and affirmation of community-identified concerns via official partnerships or public statements, providing analytical support, serving as a messenger of community concerns in spaces that community partners cannot access, or being a bridge or convener of diverse partners that otherwise would not meet.
Start with community epidemiology and policy change skills
If your staffing is limited, 2 key roles/skill sets that are important — along with a strong grounding in racial and social justice — are community epidemiology and policy change. Someone who is adept at social epidemiology can work closely with community partners to determine data collection and analysis strategy, and can translate data to action in innovative ways. Policy-focused staff can facilitate through conflict, engage in policy analysis and tracking, develop campaign strategy, and work in deep partnership with community groups, partners, and other government agencies.
Build comfort and capacity to take risks
Policy work on the social determinants of health will include taking risks, so build leadership and staff who are comfortable with that approach. Create strong communication channels and develop internal processes and procedures to understand, assess, and determine what level of risk to take.