Power-building Partnerships for Health: Lessons From Santa Barbara About Building Power to Protect Farmworker Health and Advance Health Equity

Abstract

The distribution of power in society is “upstream of the upstream” social determinants of health, and community organizers redistribute power to change social and political systems that shape health. Power-building Partnerships for Health (PPH) was launched in 2018 and pairs local public health departments and community organizing groups to support transformational health equity work, prioritizing trust and relationship building as precursors for action. Through PPH, the Santa Barbara County Public Health Department partnered with 2 grassroots organizations, CAUSE and MICOP. This partnership led to their launching a Latinx Indigenous Migrant Health COVID-19 Task Force and to the passing of a first-of-its-kind Health Officer Order on safety in farmworker housing. This practice brief discusses the importance of relationship building and key activities within PPH, and the roles of both the health department and community organizers in taking action to advance health equity in Santa Barbara County during the pandemic.

Partnerships between health departments and community organizers are an innovative “leading practice”^* to address health inequities. Health departments often work in communities harmed by structural inequities and racism but may face understandable mistrust. This mistrust can stem from past harms caused by medical professionals or government agencies, including neglect, compulsory sterilization, threatening immigrant deportation, or being unaccountable to community needs.^1,2 Effective partnerships require reckoning with these legacies and investing time in building or rebuilding trust.

In 2018, Human Impact Partners (HIP), with support from The California Endowment, and in partnership with the Bay Area Regional Health Inequities Initiative (BARHII) and the Public Health Alliance of Southern California (the Alliance), launched Power-building Partnerships for Health (PPH), a pilot project to build trusting relationships between community organizers and local health departments with a goal of building community power to improve community health.^†

This practice brief describes PPH as an innovative public health model, highlighting the PPH-nurtured collaboration between Santa Barbara County Public Health Department (SBCPHD) in California and 2 community organizing groups—the Central Coast Alliance for a Sustainable Economy (CAUSE) and the Mixteco Indígena Community Organizing Project (MICOP)—to address farmworker health during the COVID-19 pandemic and recovery.

Power and Community Organizing

The distribution of power in society can be seen as “upstream of the upstream” social determinants of health (SDOH). The WHO Commission on SDOH noted that power is “arguably the single most important organizing concept in social and political theory.” Effectively addressing health inequities therefore “requires understanding [of] how power operates in multiple dimensions of economic, social and political relationships.”³

Many health departments work on SDOH, yet few actively analyze or address power imbalances. In contrast, most community organizers are fluent in the analysis of power and seek to redistribute power to change social and political systems that shape health, making them valuable potential partners for health departments.⁴ The USC Equity Research Institute defines community power building (which we refer to here as community organizing) as:

The set of strategies used by communities most impacted by structural inequity to develop, sustain and grow an organized base of people who act ... through democratic structures to set agendas, shift public discourse, influence who makes decisions and cultivate ongoing relationships of mutual accountability with decision-makers that change systems and advance health equity.⁵

Importantly, community organizing's focus on power building differs from general policy, advocacy, mobilization, or service provision work common in many nonprofit organizations.⁶

Throughout history, communities of color and Indigenous, LGBTQ+, disabled, low-income, and other communities have organized to build power within their communities, as illustrated by past and present movements to abolish slavery and prisons, return and protect Indigenous lands, and defend human rights.

Farmworkers are one group that has experienced systematic exclusion and organized extensively to defend their rights.^‡ Today, farmworkers have won some basic rights, but exclusions and vulnerabilities persist.⁷ For example, Indigenous migrant farm workers often experience social and linguistic isolation, making them vulnerable to dangerous and exploitative working conditions and creating barriers to health care.⁸

About Power-building Partnerships for Health

PPH is grounded in an understanding that to address health inequities, health departments must pursue transformational change with community and government partners. Key to this transformation is developing an analysis of power and working with grassroots community organizers, in places where people closest to harm are identifying solutions and building their collective power to transform society.⁹

HIP initiated PPH to support health departments, deepening their health equity work by investing in community power building. With support from BARHII and the Alliance, HIP launched the first cohort of 5 health department-community organizer partnerships in 2018 and launched a second cohort in August 2021 with the Alliance and the Right to the City Alliance (RTTC).^§

The first round included monthly meetings between local partners, 2 in-person convenings for all participants, 6 statewide webinars, presentations on public health and organizing from field leaders, and 3 peer-to-peer learning sessions. The Table shows examples of the strategies used in PPH activities and their focus on relationship and trust building.

TABLE - Sample Strategies for Creating Trusting Relationships Between Community Organizers and Health Departments in Power-building Partnerships for Health^a

Professional/organizational relationship building Sharing organizational charts Explaining how decisions are made within the organization Understanding the powers (eg, relational, political, administrative, narrative) that each organization has and can leverage Peer learning with other health department leaders or other organizers Crafting the Public Narrative: Story of Self, Us, and Now10

Personal relationship building Facilitating exercises that encourage personal reflection and sharing—eg, racial and gender identities, family histories, relationship to place, and experiences with organizing Eating meals together

Developing a shared analysis Establishing a shared vocabulary and understanding of the root causes of health inequities Discussing structural racism and how it plays out in institutions that affect health

Creating a container for conversations + building trust Acknowledging that to grow into relationships, participants may leave their comfort zones and experience strong and challenging emotional reactions Creating group agreements for how to address and process conflict when it arises Having a facilitator support the group to build and use a container for personal, challenging, and vulnerable conversations Facilitating process evaluation to reflect on the partnership generally, if/how trust is being built over time between the partners, and what is contributing to trust building

Identifying strategic actions Identifying 3-5 actions each organization would take to support the others' work to advance equity For health departments, this included: Testifying on the health impacts of proposed legislation that organizers were campaigning around Developing fact sheets that connect organizer priorities to health Convening joint meetings to connect organizers to other government agencies Helping organizers navigate government structure and procedures For community organizers, this included: Using a public health lens and framing in their advocacy with elected officials Collecting data about health conditions faced by their members Training health department staff on power and community organizing

Abbreviation: PPH, Power-building Partnerships for Health.

^aSee additional details about past, current, and upcoming PPH partnerships and the project evaluation at https://humanimpact.org/capacity-building/power-building-partnerships-for-health.

Through PPH, SBCPHD partnered with CAUSE, a grassroots organization dedicated to social, economic, and environmental justice in working-class and immigrant communities. Their partnership focused on building farmworker power to improve working conditions and access to drinking water, toilet facilities, and handwashing stations.

Through the intentional relationship building in PPH, SBCPHD and CAUSE built mutual trust that meant when COVID-19 arrived, they were ready to take action together. As noted by SBCPHD's Director, “This relationship informed my response efforts for the Latinx population and helped me allocate resources to address vulnerable populations based on data that I may not have had [otherwise].”

Santa Barbara Partner Organizations Respond to COVID-19

From the beginning of COVID-19, SBCPHD and CAUSE recognized farmworkers as a particularly vulnerable population who experienced limited access to health care, language barriers, social isolation, overcrowding, and fears of retaliation and deportation. With technical assistance from HIP and the Alliance, the department deepened its partnership with CAUSE and brought in MICOP, which supports and organizes Indigenous migrants and farmworkers on issues including workers' rights, access to health care, and youth empowerment.^11,12

Throughout the pandemic, the 3 organizations met monthly to address COVID-19's effects on farmworker, Latinx, and Indigena communities in Santa Barbara County. SBCPHD drew on these partnerships and their relationship with UC Santa Barbara to establish the Latinx Indigenous Migrant Health COVID-19 Task Force in March 2020. The task force grew to include more than 150 participants representing 60 organizations and, by August 2020, had expanded its mission to understand and address the many barriers experienced by historically marginalized communities in the county.¹³

An early focus of the task force was sharing accessible, accurate, and up-to-date information about COVID-19 with agricultural workers who spoke a variety of languages and with varying levels of literacy. Ultimately, their strategies included a radio campaign, YouTube videos, Facebook livestreams, and posters designed specifically for low-literacy populations.

Over the following year, with support and guidance from CAUSE and MICOP, SBCPHD established a farmworker hotline and resource guide, hired a bilingual environmental health technician, and developed language capacity and protocols for requests in other languages.

Collaboration Leads to First-of-Its-Kind Health Officer Order on H-2A Housing

In May 2020, SBCPHD staff observed a concentration of COVID-19 cases among Latinx residents around the city of Santa Maria. Many of these residents were employed as temporary agricultural workers with H2-A visas living in employer-provided H2-A housing.¹⁴ After the death of one H2-A visa worker, SBCPHD realized it needed to take stronger action to protect people in group housing. After legal research, discussion with task force members, and negotiation with employers, they issued a Health Officer Order mandating screening and reporting requirements for H2-A housing and homeless shelters.¹⁵

While the department had already issued other emergency health orders,¹⁶ it needed political support from the broader community and county board of supervisors to pass the H2-A order. Here CAUSE's organizing skills and community relationships were pivotal. CAUSE helped convene diverse community members to learn about the order's connection to health and mobilized significant support for the order at the board meeting. It also identified a city council champion and helped broker a relationship between the council member and SBCPHD's director.

The H-2A Health Order went into effect in September 2020 and was renewed monthly until June 2021 when California officially reopened. While the order did not eliminate Latinx inequities during the pandemic, the county's number and proportional rates of COVID-19 decreased after its passage.

This success paved the way for SBCPHD's continued close work with CAUSE and MICOP to implement equitable vaccine clinics during limited vaccine allocations, address vaccine hesitancy, support labor protections, and expand services in Indigenous languages.

Discussion

The foundation of a strong relationship between SBCPHD and community organizers allowed them to respond quickly to COVID-19 and work together to prioritize Latinx and farmworker communities. On their own, neither the department nor CAUSE and MICOP would have garnered the political support needed to pass the H2-A Health Order, but by leveraging their respective roles and power, they enacted programs and policy changes that protected the health of farmworkers.

Their 3-year collaboration has not always been conflict-free, but taking time to build relationships and trust early on through PPH meant health department staff and organizers have been able to lean into and work through conflict. Identifying shared goals of improving farmworker health and shared analysis about the root causes of health inequities was important. It was also important for the partners to acknowledge their different roles in this work, balancing cooperation with continued accountability.

Increased federal COVID-19 response funding for health departments creates ample opportunities to fund relationship building and collaboration with community organizers. These partnerships can support a more equitable recovery from the pandemic and lay the groundwork for future collaborations to address structural racism, power imbalances, and inequities in the SDOH.

Implications for Policy & Practice

• Partnerships between public health departments and community organizers create opportunities to pass innovative policies and programs to protect the health of communities facing inequities.
• Community organizers are important partners for health departments to advance equity and support community powerbuilding, with each playing different but complementary roles to change policy and address structural racism.
• Investing time in relationship building and acknowledging past harms lays the groundwork for trusting long-term partnerships and can make it possible for health departments and organizers to collaborate quickly and effectively in the face of emergencies such as the COVID-19 pandemic.
• Having external facilitators and a program such as Powerbuilding Partnerships for Health can be helpful to provide the structure and skills to facilitate relationship building.