Democratizing Health: The Power of Community

By George Flores
September 16, 2016 | Commentary

“Plugging the voice of community into the right kind of political power grid will do more to create health and wellness than any other single intervention.” – (The California Endowment)


The phrase “democratizing health care” is gaining popularity in discussions about how technology is enabling consumers to better manage their health-related behaviors and to participate more fully in decisions about treatment (Topol, 2015). The effect is reshaping the power balance in doctor-patient relationships; and applications such as e-visits and telehealth are becoming transformative factors for how the health care delivery system operates (Topol, 2015).

Although technology-enhanced health care and self-reliance are important advancements toward improving personal health, additional gains in health status are possible with technology-enhanced civic action directed toward improving population health.

It is widely accepted that a population’s socio-ecological conditions shape its health status (McGinnis et al., 2002; IOM, 2010). An example of this is evident in the disparities in life expectancy between residents in low-income places compared to residents of higher-income neighborhoods (NRC and IOM, 2013). Changes in policies and institutional practices can lead to more health-supportive socio-ecological conditions. But achieving policy and institutional change to improve health is difficult, even when it stands to benefit thousands of people for generations, because it challenges the power that supports a status quo. Consequently, it may take a popular movement to confront power and the status quo with facts and reason to change.

The people who give experience and voice to that popular movement for health-supportive policies and practices are themselves change agents. They represent democracy in action.

The California Endowment supports the development of hundreds of change agents to improve health across the state, particularly in 14 low-income communities. We call it people power. We equip community residents with the skills to look for and understand the health impacts of the social and environmental conditions that surround them. They collaborate, neighbor with neighbor, to form robust groups for advocacy and stewardship with health improvement goals in common. Support comes from organizations with technical expertise in public health, education, land use, justice, policy, and more. The catalyzing ingredient is added by the residents themselves—social networking—often in the form of social media messages, self-made videos, house meetings, and even barrier-busting retreats involving former gang rivals. The result is energy and commitment to a common cause of improving conditions to benefit everyone’s health.

Technology in the form of mobile phones, and technology-mediated resources such as social networking on the Internet, access to larger amounts of data about health and social conditions and strategies, and more, all serve to enhance the capacity of change agents to improve population health, and help build individual and collective resiliency.

Below are a few examples of progress that we are seeing from the democratization of health in California communities:

  • Historically neglected communities gain parks, sidewalks, public transportation, and safety improvements in response to broad public involvement in regional priority setting.
  • Immigrant advocates succeed in pressing elected officials to expand Medicaid (MediCal) to cover 200,000 otherwise uninsured undocumented immigrant children.
  • Youth in Fresno, Los Angeles, Santa Ana, and elsewhere lead efforts to end school zero-tolerance policies that contribute to the “school to prison pipeline.” As a result, state regulations are changed. Expulsions and truancy are down and graduation rates are climbing. 


Positive outcomes from democratizing health through people power are not limited to changed policies or better services. The change agents themselves, many of them young people in school, often become stewards for neighborhood unity and civic participation, and role models for healthy behavior. Their individual and collective commitment to improving health and community conditions has the potential to affect entire generations.

Community participation in research, planning, and evaluation is not new. But engaging in such activities democratically is, and it is particularly important in low-income places where there is a legacy of studying the plight of residents and then leaving them no better off. Sharing information, power, and technology leads to greater capacity that can be left behind in the community after the process is over. Lasting self-sufficiency and resilience become tangible outcomes, along with increased skills that can lead to economic gains.

Democratization of health can be transformative. In places where the foundation works, we are seeing greater civic participation lead to greater institutional accountability. The local population invested in making better health happen is shifting social norms for behavior and spending (The California Endowment, 2016). Communities with agency and purpose to improve the population’s health are positioning to become engines for greater collective impact on the quadruple aim (better care, lower cost, better health, greater equity) by combining community wisdom with the resources and technical expertise of health care and public health. (See for example the California Accountable Communities for Health Initiative,

Efforts aimed at modernizing systems to improve population health, including Public Health 3.0, and Precision Public Health, should institutionalize the role of community residents as change agents (DeSalvo et al., 2016; Khoury et al., 2016). Technology’s importance as a tool is growing. But the most critical first step is to strengthen the capacity of community residents along with staff of public health departments and other community serving institutions to work together on common goals.



  1. The California Endowment. 2016. A New Power Grid, Building Healthy Communities at Year 5, The California Endowment. July 1, 2016).
  2. DeSalvo, K. B., P. W. O’Carroll, D. Koo, J. M. Auerbach, and J. A. Monroe. 2016. Public Health 3.0: Time for an Upgrade. American Journal of Public Health 106(4): 621-622.
  3. IOM (Institute of Medicine). 2010. For the Public’s Health: The Role of Measurement in Action and Accountability. Washington, D.C.: National Academies Press.
  4. Khoury M. J., M. F. Iademarco, and W. T. Riley. 2016. Precision Public Health for the Era of Precision Medicine. American Journal of Preventive Medicine 50(3): 398-401.
  5. McGinnis, J.M., P. Williams-Russo, and J. R. Knickman. 2002. The Case for More Active Policy Attention to Health Promotion. Health Affairs 21(2): 78-93.
  6. National Research Council and Institute of Medicine. 2013. U.S. Health in International Perspective: Shorter Lives, Poorer Health. Washington, D. C.: National Academies Press.
  7. Topol, E. 2015. The Patient Will See You Now: The Future of Medicine is in Your Hands. New York, NY: Basic Books.



Suggested Citation

Flores, G. 2016. Democratizing Health: The Power of Community. NAM Perspectives. Commentary, National Academy of Medicine, Washington, DC. doi: 10.31478/201609e

Author Information

George Flores, MD, MPH, is program manager at The California Endowment and a participant in the activities of the Roundtable on Population Health Improvement.


The views expressed in this Perspective are those of the author and not necessarily of the author’s organization, the National Academy of Medicine (NAM), or the National Academies of Sciences, Engineering, and Medicine (the National Academies). The Perspective is intended to help inform and stimulate discussion. It has not been subjected to the review procedures of, nor is it a report of, the NAM or the National Academies. Copyright by the National Academy of Sciences. All rights reserved.

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