Implementing the Boston Healthy Start Initiative: a case study of community empowerment and public health

This article examines the efforts on the part of a city health department, in partnership with a broad-based coalition of community-based, government, and social service agencies, to plan and implement, using principles of empowerment and community participation, a federally funded infant mortality reduction program. It examines the social and institutional dynamics of sharing power in an environment highly charged politically. Infant mortality in Boston is much more than a public health problem. It is the focal point of complex racial, political, and institutional factors. This case study illustrates how empowerment moves from rhetoric to reality and the challenge to both traditional public health practice and traditional community mobilization. The article describes the federal Healthy Start Initiative and its community participation mandate, the background on infant mortality in Boston, a case study of the development of the Healthy Start program from the perspective of community empowerment, and finally, the lessons learned in the first 2 years of the program. It describes the controversies encountered, some of the mistakes made, and the ways found that government must be reinvented if empowerment is to be a real public health tool.