In October of 1998, over 350 partnership representatives from 14 states and 41 communities convened in Phoenix, Arizona to continue the dialogue that began  at the 1998 San Francisco Forum. Framed in a "partners helping partners" theme, the goals of the Phoenix Forum were to: a) expand networks among national, state and community partners; b) share ideas, progress, salient lessons, ideas, and challenges; c) help partnerships assess areas of strength and those needing improvement via exposure to new methods/models of collaboration; and d) chart the next steps for the initiative.

Of the myriad of important ideas that emerged during the Forum, below are a few salient themes that came to the fore.

More Strategies Needed for Social Determinants of Health

Critical to Turning Point's philosophy is a strong focus on the social determinants of health. Broadly defined as influential forces, social determinants of health reflect social and cultural influences that affect positively or negatively individual risk factors and thus "determine" human health outcomes in incredibly complex ways. In most instances, these social influences are more reflective of one's societal position than of individual human biology. Examples of such determinants are socioeconomic status, culture, education, and occupation. The interconnectedness of even the smallest list of determinants is quite apparent. Less apparent, unfortunately, are solutions to mitigate the ill effects of determinants of health vis-.-vis categorically-based approaches. Nonetheless, focusing on social conditions expedites effective public health intervention by targeting "upstream" influences that are obstacles to well being. In fact, in the U.S. as well as abroad, the origination of public health as a viable prevention methodology stems from a focus on poorly designed and serviced living environments in impoverished areas and inequitable exposures to environmental hazards in the workplace. Such exposures often affected children disproportionately. While daunting, many Turning Point partnerships are actively incorporating a health determinant perspective as they develop their public health system improvement plans. For instance, several partnerships are examining issues such as socially-responsible economic development, youth and adult education, and crime prevention.

Building Plans for an Integrated Public Health System

Forum speakers and participants debated broad categories of health care system components, such as public health law, media advocacy, measurement of public health infrastructure (e.g., capacity, including community health "system" assessment), communications technology, and self-evaluation strategies. As a national initiative, Turning Point's success relies on each partnership's ability to make significant changes in the public health system by strengthening the interconnections with other disciplines to improve health and overall quality of life. Such transformation will focus on issues related to the reintegration of increasingly disparate disciplines such as public health, environment, medicine, agriculture, housing, education, crime prevention/law enforcement, and others.

At the Forum, the discussions clearly illuminated the need to advance this national dialogue focused on how these disciplines - at a systems level - should be interconnected to ensure improvements in services, and subsequently, health status, are achieved. At the core of these interconnections are onerous questions such as: how are collaborative priorities for intervention best established; what data are used and to what extent are they reflective of overall quality of life and general well-being across disparate populations/cultures; what mechanisms are in place to engage a broad range of community voices and equitable participation and decision making, including leadership from public and private sectors, tribal governments, and others; how is health system performance best measured; how can law reform strengthen the public health and health care systems; what are the respective roles of states versus communities in system transformation; what policies support the advancement of public health and what policies inhibit progress; and what are the most effective strategies to impact positively the social determinants of health?

Frameworks Needed for Communicating Public Health's Import

Mantras such as assessment, policy development, and assurance may strike a chord for those immersed in governmental and academic public health organizations, but in the absence of concrete connections with day-to-day crises and victories experienced by communities, such jargon yields little excitement or support from a broader audience. Additionally, the use of such jargon frequently serves as an obstacle to collaboration and effective communication, and often results in battles over resource allocation for what may be considered "traditional" public health activities. Turning Point partners continue to find that public health activities already are supported by a myriad of different entities even though frequently the effort is not defined by traditional public health language. For example, many hospitals now provide population-based services under the rubric of "community medicine." Findings reported in the 1996 Harris Poll clearly demonstrate that effectively communicating public health's critical functions to a larger public will require new frameworks which incorporate more concrete language and concepts. Increasing media advocacy for public health was a significant highlight in Phoenix, and while some partnerships are engaging successfully local media to trumpet their accomplishments, much work still lies ahead.

After the Forum: Heading in New Directions

The bona fide success of any national Forum lies in its ability to affect positively the "action-based practice" undertaken once partners return home. While these effects remain to be seen, participants hailed the Phoenix experience as a progressively invigorating and thought-provoking experience. And while a clearly demarcated—or cookbook—approach to system transformation simply does not exist, a common theme of agreement once again emerged from the Forum. More specifically, sustainable advancements in public health protection transcend managerial and organization-focused reform. This is not to say that adopting new models of service regionalization, conducting capacity assessments, and implementing other types of managerial reform have little import.

However, the work of Turning Point partnerships demonstrates again and again that effective public health system reform requires an expansion of public health practice that engenders, at all levels of policy and practice, greater public awareness, support, and participation. Moreover, the lack of public support for, general awareness of, and participation in public health as a movement grounded in both art and science must be addressed if the concept of "health" in the U.S. is to be expanded to adopt truly preventive approaches that promote a more equitable use of resources geared toward the betterment of social, cultural, spiritual and physical well-being.

Striving to engage greater public support and participation to improve health is challenging at best and may often prove discouraging. In an excerpt from The First Step, a poem by C. P. Cavafy, Theocritis consoles a disconcerted Eumenes who, after toiling for two years on a daunting task, is dissatisfied with his progress:

For even this first is far distant from
the common herd
To set your foot upon this step
You must rightfully be a citizen
of the city of ideas.
And in that city it is hard
and rare to be naturalized.
In her market you find Lawmakers
whom no adventurer can dupe.
Coming as far as this is not little;
what you have achieved is great glory.