Assignment: Community-Based Health Program

that it is imperative that we share our health personnel and expert- ise, along with essential pharma- ceuticals and material goods, with resource-poor countries— I have become involved with HAS to develop a program to prevent mother-to-infant trans- mission of HIV infection and to treat infected individuals. There is good reason to believe that the same strong health care infra- structure that has improved the survival and well-being of chil- dren and that allowed Fitzgerald and colleagues to reduce cases of congenital syphilis will also pro- vide the framework for effective family AIDS prevention and treatment programs.

The lack of exposure to inter- national health issues within my own medical training created ob- stacles to my providing quality health care for newly arrived im- migrant children and their fami- lies when I first arrived in New York City decades ago. A rotation in international pediatrics during

pediatric residency training would be an important step to- ward improving the quality of community pediatrics in the United States.

The central philosophy of Al- bert Schweitzer, as envisioned and implemented by Larimer and Gwen Mellon, is alive and well in Haiti. But it would be an important, long overdue, and beneficial evolutionary step in our own health care system if we were able to incorporate a world view into our everyday practices.

Stephen W. Nicholas, MD

About the Author Stephen W. Nicholas is with the Depart- ment of Pediatrics, College of Physicians and Surgeons, Columbia University, New York, NY, and with Harlem Hospital Cen- ter, New York, NY.

Requests for reprints should be sent to Stephen W. Nicholas, MD, Harlem Hospi- tal Center, 506 Lenox Ave, Room 17-105, New York, NY 10037 (e-mail: swn2@

This editorial was accepted December 18, 2002.

References 1. Paris B. Song of Haiti: The Lives of Dr. Larimer and Gwen Mellon at the Al- bert Schweitzer Hospital of Deschapelles. New York, NY: Public Affairs; 2000.

2. Mellon GG. My Road to De- schapelles. New York, NY: Continuum; 1998.

3. Albert Schweitzer. The Philosophy of Civilization. CT Campion, trans. New York, New York: The MacMillan Com- pany; 1949.

4. Berggren WL, Ewbank DC, Berggren GG. Reduction of mortality in rural Haiti through a primary health- care program. N Engl J Med. 1981;304: 1324–330.

5. Poised for the Future: Annual Report 2001 Hospital Albert Schweitzer. Sara- sota, Fla: Grant Foundation; 2001.

6. Perry H, Volk D, Philippe F, Dor- tonne JR, Berggren G, Berggren W. The long-term impact of a community- based health care program on infant and child mortality: the experience of the Hospital Albert Schweitzer in Haiti. Paper presented at: Annual Meeting of the American Public Health Association; October 24, 2001; Atlanta, Ga.

7. Perry H. Description of Haiti, its health, health services, and health-related

behaviors. Background document to the assessment of HAS programs. Sarasota, Fla: Grant Foundation; 2000.

8. Fitzgerald DW, Behets F, Preval J, Schulwolf L, Bommi V, Chaillet P. Decreased congenital syphilis inci- dence in Haiti’s rural Artibonite re- gion following decentralized prenatal screening. Am J Public Health. 2003; 93:444–446.

9. Patel A, Moodley D, Moodley J. An evaluation of on-site testing for syphilis. Trop Doct. 2001;31:79-82.

10. Warner L, Rochat RW, Fichtner RR, Stoll BJ, Nathan L, Toomey KE. Missed opportunities for congenital syphilis prevention in an urban south- eastern hospital. Sex Transm Dis. 2001; 28:92–98.

11. Downing RG, Otten RA, Marum E, et al. Optimizing the delivery of HIV counseling and testing services: the Uganda experience using rapid HIV an- tibody test algorithms. J Acquir Immune Defic Syndr Hum Retrovirol. 1998;18: 384–388.

12. Kassler WJ, Alwano-Edyegu MG, Marum E, Biryahwaho B, Kataaha P, Dillon B. Rapid HIV testing with same-day results: a field trial in Uganda. Int J STD AIDS. 1998;9: 134–138.

13. Nicholas SW, Abrams EJ. Boarder babies with AIDS in Harlem: lessons in applied public health. Am J Public Health. 2002;92:163–165.

Community- Based Interventions

The article Reconsidering Com- munity-Based Health Promotion: Promise, Performance, and Poten- tial by Merzel and D’Afflitti1 in this issue of the Journal makes a valuable contribution to the literature on community ap- proaches to health promotion. The breadth of studies covered in this review article, combined with the prominence the Journal is giving to the subject in this issue, suggests how far the field has come in its understanding of the links between public health and communities. The authors summarize many of the community-based studies since 1980 and draw useful conclu- sions for strengthening commu- nity-based efforts at improving the health of the US population.

Moreover, by drawing from the lessons learned from human immunodeficiency virus (HIV)- prevention programs, they pro- vide significant recommenda- tions for improving the potential of community-based strategies. However, we would like to draw the readers’ attention to some of the substantive issues involved in reviewing such a diverse liter- ature, including a number raised by Merzel and D’Afflitti.

The term community-based has a wide range of meanings. In this editorial we focus on 4 cate- gories of community-based proj- ects based on implicit construc- tions of community employed by investigators: community as set- ting, community as target, com- munity as agent, and community

as resource. This typology (many typologies of community ap- proaches have been proposed in the literature, the most fre- quently used of which is Roth- man’s Strategies of Community In- tervention2; we chose not to use Rothman’s categories explicitly, although some of his ideas are included in the discussion) is used to illustrate the difficulties in summarizing results across the array of community-based proj- ects (of course we recognize that projects rarely fit our categories neatly and that any one project may have characteristics bor- rowed from each of the cate- gories). This brief discussion of “types” of projects is followed by a discussion of the importance of community capacity; the use of


American Journal of Public Health | April 2003, Vol 93, No. 4530 | Editorials

social ecology as a framework for community interventions; the use of a theory of community change; and the role of public health values.


As indicated by some of the studies reviewed by Merzel and D’Afflitti, the term community- based often refers to community as the setting for interventions. As setting, the community is pri- marily defined geographically and is the location in which in- terventions are implemented. Such interventions may be city- wide, using mass media or other approaches, or may take place within community institutions, such as neighborhoods, schools, churches, work sites, voluntary agencies, or other organizations. Various levels of intervention may be employed, including edu- cational or other strategies that involve individuals, families, so- cial networks, organizations, and public policy. These community- based interventions may also en- gage community input through advisory committees or commu- nity coalitions that assist in tailor- ing interventions to specific tar- get groups or to adapt programs to community characteristics. However, the focus of these com- munity-based projects is prima- rily on changing individuals’ be- haviors as a method for reducing the population’s risk of disease. As a result, the target of change may be populations, but popula- tion change is defined as the ag- gregate of individual changes.