"Getting the Word Out"

"Getting the Word Out"
A Foundation Memoir and Personal Journey By Frank Karel¹

This chapter is a personal reflection by Frank Karel on his years as vice president for communications of The Robert Wood Johnson Foundation. He looks back on the early days, when the Foundation was groping to find an appropriate role for communications, and traces its evolution to the present. Karel is uniquely qualified to provide this retrospective. He has had the singular experience of heading communications at The Robert Wood Johnson Foundation twice. During his first tenure, between 1974 and 1987, he originated many of the communications strategies that the Foundation follows today. After leaving to head communications at the Rockefeller Foundation, he returned to The Robert Wood Johnson Foundation in 1993 to serve again as the vice president for communications, the position he occupies today. Long active in philanthropy-he is currently a board member of the Council on Foundations-Karel has helped many foundations consider how best to use the tools of communications.

From the beginning, The Robert Wood Johnson Foundation recognized the importance of communications. Starting with a public relations perspective in the 1970s, it evolved to its current state, where communications is an integral component of regular programmatic activities, where communications officers are members of the teams planning and overseeing Foundation-funded initiatives, and where communications has become a major intervention in its own right, accounting for nearly 20 percent of the funds awarded by the Foundation over the past five years. Moreover, the Foundation has been a leader in the nonprofit world in utilizing the channels and techniques of communications-whether through the media, the Internet, social marketing, or its own publications-to advance its mission.

Any nonprofit organization interested in advancing innovation in the field needs to understand and make the most of communications. Getting the word out is essential to bringing about social change. Not only does this chapter provide an informative history of what The Robert Wood Johnson Foundation has done, but it also distills more than 20 years of experience from a person widely recognized as one of the preeminent thinkers and actors in the field.

The Robert Wood Johnson Foundation has had a long learning curve on the value of information and communications. The first lesson on the power of this combination was in December 1971, the night after it was announced that we were in business as a national philanthropy. The information that a foundation with $1.2 billion was operating out of a small Victorian house in New Brunswick, New Jersey-communicated in a New York Times front-page article-was enough to motivate someone to break in and ransack the place before abandoning dreams of misbegotten riches and skulking off with a few office odds and ends.

In truth, the Foundation's first applications of communications were driven by the determination to distribute our funds effectively, but as grants rather than loot. We wanted all the people directing institutions and organizations that could become applicants and grantees to know the Foundation existed, what we were willing to fund and what we weren't, and the terms and processes by which an exchange could take place-our funds for their commitment, capacity, and ideas for moving toward a shared objective "to improve the health and health care of all Americans." Carefully shaping these funding guidelines became a priority of the Foundation's initial staff, and our president made this his centerpiece in the Foundation's first annual report as a national philanthropy, which was widely distributed throughout the health sector and the philanthropic community.

Even so, we were an unknown and untested institution in those early days. When we sent out our first announcements of a competitive grant program for the country's community hospitals, we had to include a copy of our Annual Report to let the hospital officials know-to communicate-who we were and that we had sufficient funds to be offering sixty $500,000 grants for the establishment of group practices in underserved areas. This past year, we issued 26 such announcements, or Calls for Proposals, but we've become well enough known to skip including an Annual Report.

Foundations have been slower to integrate communications into their institutional planning and work than any other class of organizations in our society. This is not surprising, given a cultural bias with three deep roots: the Judeo-Christian ethic that charity ought to be practiced quietly, avoiding public notice; a widely held conviction that foundation funds are private assets; and another belief that foundation trustees' stewardship is primarily defined by donor intent in establishing the foundation.

Just three years before The Robert Wood Johnson Foundation emerged as a national institution, the Tax Reform Act of 1969 became a federal statute. It still stands as the most sweeping single piece of legislation affecting the operation of private foundations. Because foundations had had a very bad time of it in the congressional hearings leading up to its passage, the prevailing mood and mindset in the foundation world was to keep as quiet and as low a public profile as possible. Even today, that experience continues to affect the view of many foundation officials.

There was an immediate tension between shying away from publicity and the Foundation's commitment to using its funds to further specific goals, initially encapsulated as "the encouragement of institutions or individuals who are attempting to restructure the American health delivery system to make effective care more available for non-hospitalized patients."² The first staff members knew that to accomplish this goal they would have to reach widely and deeply into the nation's health sector to find and encourage pioneers, to build alliances, and to design and fund programs-all requiring communications well beyond the norm for foundations.

I believe the convergence of this goal orientation with three other factors caused the Foundation to break from the existing pattern and make communications an integral part of both management and program. First, academic medical centers had been the prior workplace or focus of work for most of Robert Wood Johnson's initial professional staff. These institutions had grown remarkably by communicating the value of biomedical research and the application of its results to the public, especially federal and state policy makers. Carrying this thinking over into the Foundation was a natural step. "We must serve as more accessible sources of information and assistance to those we serve, and find better ways of reporting on the outcome of the endeavors we aid so that more can learn from our experiences," the late David Rogers, the Foundation's first president, wrote in his Annual Report message the year I joined the staff to develop a communications program.³ The chairman of the board of trustees, a formidable, crusty retired Johnson & Johnson executive with a heart of gold who had been hand-picked by Robert Wood Johnson for the job, was more succinct. "Getting the word out" was how the late Gustav O. (Gus) Lienhard used to describe the communications function.

The second factor that caused us to break with the foundation world's pattern of downplaying communications is idiosyncratic and personal, but that's the nature of private foundations. They are largely what one, or two, or a few individuals make them. Rogers and his four principal shapers of the Foundation's initial program-Robert Blendon, the late Walsh McDermott, Margaret Mahoney, and Terrance Keenan-understood the potential value of effective communications through their previous work in the health sectors. Our careers had all crossed and twined in interesting ways. David Rogers had been chairman of the National Advisory Committee for the National Jewish Medical and Research Center, where I was director of planning, when he became the president of the Foundation. He and I had discussed the role that communications might play in a foundation seeking "to help a field move from A to B." Before my arrival I had given Rogers a paper-which he shared with the senior staff-setting out my views on how communications might be harnessed to further the Foundation's objectives. The staff concurred with the approach I outlined, so that even before I arrived, the key players had agreed on the importance of communications to the new Foundation. Moreover, the Foundation's style of group exploration, debate, and resolution ensured me a place at the table where programs were shaped and decisions were made. That my professional background included work as a foundation program officer and institutional planner as well as an institutional communicator-all in the health sector-added to their comfort level with my participation.

The third and final factor influencing us to integrate communications with program and management was a little booklet that has already been mentioned-our Call for Proposals. Known internally as the CFP, it is used to announce the Foundation's multisite national programs (those in which grants are made to a number of institutions-from four to as many as 1,100-for research, policy analyses, or training in a particular field, or to support advocacy efforts toward some particular end such as the reduction of youth smoking, or to field test a new way of organizing, delivering, or financing health care services). In the beginning, and even now, the CFP brings the program concepts to life by combining a succinct description of the problems addressed by the program, the elements of the projects that we will fund to overcome them, what is expected of the grantees, and eligibility and selection criteria.

Over the years, creating a CFP has become second nature to communications and program staff alike, but it was not always so. Early on, in addition to developing the format, the communications contribution was to distill notes from scores of meetings and discussions, staff papers, and professional literature into 2,000 or so words that, in terms familiar to the intended audiences of grant applicants, would strike the necessary balances between Foundation and grantee interests and still be clear and compelling.

Even the idea of grant making for communications purposes came early. In 1975, we co-funded a film on hospital-sponsored group practices for use in explaining that concept to the boards and medical staffs of hospitals eligible to apply for grants under one of our multisite national programs. The film producer was a relatively unknown independent named Henry Hampton, who, before he died in 1998, went on to fame as producer of Eyes on the Prize, the acclaimed PBS series on the civil rights movement.

A key point, however, is that while this process brought communications staff members into the center of program design and development in the early years, it is only in the last five years that the integration has had large-scale programmatic consequences. In this later period, 19 percent of our grant dollars have supported communications activities.

I vividly remember one of my first conversations with board chairman Gus Lienhard in which he and I found we were in agreement that the Foundation ought to maintain a relatively low public profile, becoming known through the work of its grantees. This concept has been our communications compass for more than a quarter of a century and has emerged as one of the core values of the Foundation. In the words of Steven A. Schroeder, our current president, "We speak through our grantees and do not seek a high institutional profile. We have chosen to work primarily through our grantees, rather than establish ourselves as a primary source of information."⁴ This, and the value placed on information by the Foundation, was underscored by including a bibliography of selected books, articles, and other information by our grantees in the 1976 Annual Report-a practice that has been broadened to include their work on the Web, video, data tapes, and audio visuals, and continued to this day.

The primacy of program and the principle of speaking through our grantees also shaped a key dimension in the role of the directors of our national programs. Typically, the directors of these programs are highly respected professionals in their fields who remain as employees of their home institutions, directing their programs on a part-time basis with a small staff whose salaries and operations are funded by the Foundation. They, not a Foundation officer, serve as spokespersons for the programs and, when appropriate, on the issues addressed by the programs. Most of the time, this plays out in relatively friendly or benign circumstances-presentations to audiences of other professionals, press interviews, and the like-but not always. The first such departure from the norm came in 1981, when the program director of our School Health Services Program, a Johns Hopkins University faculty member, went to rural Utah for a series of tense meetings with community residents and leaders after a conservative advocacy group began a series of verbal attacks on the local site. Having an outside expert with hands-on experience like, in this instance, Catherine DeAngelis, a pediatrician who put herself through medical school by working as a nurse, goes a long way toward defusing such situations and confirms the wisdom of speaking through our programs and grantees. Today, Dr. DeAngelis is the editor of the Journal of the American Medical Association.

That early principle of being known through our grantees has determined the focus and the content of virtually all the Foundation's publications and communications products, other than the Annual Report, beginning with a Special Report in 1977 on three grant-supported initiatives-a California program training nurse practitioners in rural family practices; new community-based approaches to the prevention and treatment of child abuse and neglect; and a program underwriting staff for the health committees in the legislatures of Connecticut, Louisiana, Michigan, Minnesota, New Jersey, Texas, Washington, and Wyoming. The most unfortunate departures from this principle have been two videos that attempted to explain the Foundation through the work and the processes of our staff. They turned out to be so self-serving that one is used only as an object lesson to avoid this pitfall. The other was banished from sight so successfully that no copy can be found today.

Today, communications has become an integral part of everything we do, and in turn we help our grantees integrate communications into their programs. The aim is to share our vision of using communications strategically-that is, to create and use information in ways that can help achieve key organizational and program objectives.

Although every unit of the Foundation is involved to some degree, primary responsibility rests with the Communications Department with its staff of 34 augmented by scores of others engaged for varying periods of time each year as consultants. In addition to founding the unit in 1974, I had the privilege of serving as its head until leaving the Foundation in 1986, resuming that post when I returned to the Foundation in 1993.

The Department's seven strategies for pursuing its mission (see Table 2.1) are a useful guide as we plan our work, but virtually nothing we do fits neatly into any single strategy.

Everything we do is designed to advance multiple strategies, although one is often dominant. A news release announcing a competitive grants program, for example, is primarily a way to let potential applicants know about our new funding interests (strategy #5), but it also serves to make the Foundation more accountable (strategy #7). And our website (www.rwjf.org) has become a key means for pursuing all of our strategies.

The website is also illustrative of our efforts to stay abreast of technological advances in communications and to incorporate them into the Foundation's armamentarium when they are sufficiently developed and effective. For example, in 1981 we first used teleconferencing, employing the facilities of public television stations to link grantees and local officials in 19 cities in launching our Program to Consolidate Health Services for High-Risk Young People. About that time, an initiative presenting the work of our grantees on commercial television was made possible through contractual arrangements with a health magazine show reaching 70 percent of the nation's homes. The Foundation's all-text "gopher" on the Internet was replaced in 1996 with a website, and a few years later we used similar technology to create an intranet site for Foundation staff and an extranet site linking the Foundation and its national program offices.

What gives life and substance to all of these words is people. Staff members in the Communications Department have varied experience and education. They come with skills including journalism, public relations, advertising, social marketing, public health and public administration, film and television production, policy analysis, publications design and production, institutional planning, and information science. They also bring knowledge of the health sector from their previous positions with university medical centers and hospitals, as journalists reporting health and health care, and with voluntary health associations, advocacy groups, government, and other foundations.

While examining the various activities and products of the Foundation's Communications Department, one should keep in mind the two contexts within which we work. The first is the seven strategies found in Table 2.1 in the previous section. These are the touchstones that give coherence to our work. The second is the uneven communications capacities of our grantees or their willingness to provide communications backup to the projects we support. For some grantees, such as an academic medical center, a Foundation-funded program may be only a small aspect of their overall work. We also cannot assume that grantees are as prepared to undertake the communications

aspect of their projects as they are to run a clinic, conduct postdoctoral training, or carry out the other, substantive activities for which the grant was made. Moreover, the motivations of the Foundation and its grantees may differ. For example, the physicians directing HMO pediatric services using grant funds to apply innovative approaches for identifying children with asthma may view their challenge as one of integrating this innovation into their services and making it work; for the Foundation, though, this is a field test of the innovation, and sharing the experiences of this project with other HMOs throughout the country is crucial to its success.

To address issues such as these, the Foundation's communications effort begins in the earliest stage of grant making, during program design and proposal review within the Program Management Teams, or PMTs, the Foundation's basic organizational units. Six officers and an equal number of senior consultants in the Communications Department spearhead these efforts to identify ways in which communications might advance the objectives of the program under consideration. How, for example, can community coalitions maintain cohesion among their constituents and effectively influence public attitudes and opinions? Or how can grantees of research or demonstration programs reach decision makers? The PMTs then incorporate provisions for carrying out the relevant communications activities into the grant. Grant budget lines for communications have become the norm rather than the exception. They provide funds for communications staff and for activities ranging from websites to the publication and distribution of policy briefs, and from news conferences to time for project directors to write journal articles.

Once programs are funded and under way, the Department's officers and consultants in the PMTs use technical assistance and training to enhance the effectiveness of the grantees' communications activities. We provide a steady stream of technical assistance and advice to our grantees-including supplementing grantee mailing lists; finding and selecting local communications consultants; and assisting with message development, priority setting, and the multitude of other elements that comprise effective communication. We do this work by phone, fax, and e-mail; through site visits; and by dispatching consultants with specialized skills.

We also contract with organizations conducting media training and sponsor a workshop series teaching representatives of approximately 135 grantees a year the basics of strategic communications and guiding them through the development of communications plans for their projects. In addition, Foundation communications staff members organize and participate in an annual two-and-a-half-day workshop with the extended family of major grantees' communications directors and key consultants. Some 90 professionals attended the 1999 session.

With between 2,000 and 2,500 programs open for business and receiving Foundation funds on any given day, budgetary tradeoffs dictate difficult choices in targeting technical assistance. We try to assist programs that can benefit most from this help, whose staffs are open to this work, and whose success would have the greatest impact in terms of health and health care. However, our decisions are the products of judgment, not science, and we make our share of mistakes.

Much of the assistance to grantees is facilitated by the national program mechanism pioneered by the Foundation in its earliest years to support multisite initiatives. Currently, 87 national program offices oversee 1,218 project sites and related activities. Twenty-one of these 87 have full-time communications staff members, and most of the others have consultants to assist them with their communications. By concentrating our technical assistance on these intermediary professionals-who then provide technical assistance to their far more numerous project sites-the Foundation's communications assistance is more of a wholesale, rather than a retail, operation. The diversity of the programs managed in this way testifies to the flexibility of the national program mechanism, including its embedded communications component-from Covering Kids, assisting efforts of all 50 states and the District of Columbia to enroll all eligible children in Medicaid and state child-health insurance programs, to Faith in Action, with more than 1,000 interfaith organizations of volunteers helping people with long-term health problems to remain in their homes; and from the Minority Medical Faculty Development Program, providing fellowships for minority physicians interested in academic medical careers and in fostering development of succeeding classes of minority physicians, to SmokeLess States, coalitions in 28 states and the District of Columbia working to reduce tobacco use through education, treatment, and policy initiatives.

It bears repeating, however, that technical assistance and training are costly and that a careful weighing of need, readiness, and anticipated outcome determines the degree of communications support for each program. Not surprisingly, most of our technical assistance involves helping grantees make their findings and lessons learned available to others. We do this to drive innovation and improvement by moving new knowledge and new ways of doing things into the mainstreams of practice and policy, and by opening new avenues of thinking and action.

While grantees have the primary responsibility for sharing their findings and experiences, in many circumstances this can be done more effectively and efficiently by combining the Foundation's resources with those of the grantee. For example, the Foundation collaborates with Henry Wechsler, of Harvard University, in planning, preparing for, and orchestrating national news conferences and scores of follow-up media appearances on his series of college binge drinking studies. Combining resources also makes particular sense when the task involves disseminating the experiences of multiple grantees, such as collaborating with staff members of community-based grantees around the country to provide advice and opportunities for the outreach components of the various PBS television series supported by the Foundation.

Over the years, too, we have come to see communications as an intervention that can be used to bring about change, particularly in encouraging attitudes, behaviors, and policies promoting good health-a concept that lies at the heart of our work combating substance abuse in the forms of tobacco, alcohol, and illicit drugs.

Today, Communications Department officers are responsible for overseeing and assisting grantees conducting major communications campaigns aimed at changing harmful behavior patterns. Two examples are the Partnership for a Drug-Free America and the National Center for Tobacco-Free Kids. The Partnership uses its talented staff, organizational experience, and high-level contacts in the advertising, marketing, and public relations communities to be a partner in the federal campaign to reduce the demand for illegal drugs among the nation's young people. This five-year, $1 billion federal initiative is the largest and most comprehensive public health campaign ever undertaken by the federal government.

The National Center for Tobacco-Free Kids has earned a reputation as a key national resource for media, policymakers, and public health organizations on issues regarding tobacco use by young people. Its staff, comprising top-notch communications, marketing, and policy professionals, has augmented and strengthened the skills of individuals and organizations working in state and local tobacco prevention. Center staff members also provide assistance to ensure that youth tobacco issues are front and center on the policy agenda.

Two other initiatives illustrate how communications as a primary intervention can address issues of health care, as distinct from behavioral health issues. The first is Last Acts, a nationwide campaign launched by the Communications Department in 1996. It is the Foundation's first initiative in what has subsequently become an extensive portfolio of grants to improve end-of-life care. More than 400 organizations have signed on as Partners, signifying their participation in raising awareness and taking steps in and through their own organizations to improve end-of-life care. They include most of the major associations of health professionals and institutions, important faith groups, the federal Department of Veteran Affairs, and the American Association of Retired Persons. This campaign-through the products of its task forces, its various meetings and conferences, the media coverage it generates, and its Partners' actions-is successfully building a base of public and professional support for improving end-of-life care. Three examples: (1) just before the trial of Dr. Jack Kevorkian in 1999, Last Acts' consultants provided journalists covering the trial with information about positive alternatives to suicide, which many of them incorporated into their coverage; (2) a workplace task force has developed a model employee benefits package for high-quality, comprehensive end-of-life care; and (3) Last Acts' definition of palliative care-known as "The Precepts"-offers guidance for patients, policy makers, and health providers for end-of-life care, and is now quoted in medical literature as the most up-to-date and accepted summarization. At this writing, in keeping with our tradition of doing our work through grantees, plans are being drawn to transfer management responsibility for Last Acts to an external organization, which would receive grant support for this work.

The other initiative was launched by the Communications Department in 1999 to build greater public awareness of the increasing number of people without health insurance, the accompanying tangle of problems they face, the tragic health consequences, and the proposed solutions to this vexing issue. Key elements of this effort include: (1) educating journalists about the issue of health coverage; (2) visiting key newspaper and magazine editorial boards to persuade them to write about the uninsured and on the specifics of proposed solutions; (3) encouraging and assisting people in communities across the country to write and place columns on the nation's op-ed pages; and (4) analyzing the quality of news coverage of this issue. The campaign was kicked off by HealthCoverage 2000, a one-day conference held in January in Washington, D.C., attended by 425 journalists, policy makers and analysts, and national representatives of health-sector associations. Representatives of the eight cosponsoring organizations, led by Families USA and the Health Insurance Association of America, each presented a specific proposal for significantly decreasing the number of people without health care coverage in this country ⁵ Humorously referred to as the "strange bedfellows conference" by some Washington insiders owing to the diversity of interests and points of view represented, this event sparked major attention in the media and among health care leaders, prompting the Foundation and the cosponsors to begin scheduling a series of similar, regional meetings for immediately after the November 2000 elections.

Another priority of the Communications Department is improving media reporting on health and health care. The Foundation has supported such coverage on National Public Radio's "Morning Edition" and "All Things Considered" since 1986. More recently, we have begun funding the health desk on Public Radio International's "Market Place." In addition, we underwrite a competitive grants initiative through the Benton Foundation that supports health and health-care programming by local public radio stations.⁶ WSKG Public Broadcasting, in Binghamton, New York, for example, used its grant to support a 19-county program of town meetings and conferences, special radio and television programming, a project website, and educational materials housed in the permanent reserve collections of 50 different libraries-all aimed at helping people understand their options for end-of-life care.

We have also long been supporters of relevant specials and series on national public television. The audience demographics of public radio and television make these media particularly attractive locations for calling attention to, and informing people about, important issues as well as innovations in health and health care. In the fall of 2000, for example, PBS is scheduled to broadcast ten hours of television programming with major funding from the Foundation for both production and extensive outreach to engage people across the country in relevant civic action. End-of-life issues are the focus of Bill Moyers's four-part series, On Our Own Terms, and Hedrick Smith's three-hour special, How Good Is Our Health Care, is to be preceded by a related, hour-long "Frontline" documentary he produced, Dr. Solomon's Dilemma, documenting the changes that market forces are making on a Harvard-affiliated Boston teaching hospital.

This aspect of our work has been reported in a chapter of the 1998-99 Anthology, but it's worth repeating that what drives our funding is broadcasting's role, which is "central to certain aspects of modern life:

Mass and professional print media and the newer web-based news sites share these roles with broadcasting, which accounts for our interest in media generally. We round out our efforts to improve the quality entertainment media's depictions of the health and health care matters relevant to our program interests-showing the consequences, for example, of a character's substance abuse-by supporting organizations working with writers and producers seeking insight and information into that aspect of their craft. To improve health and health care reporting, our grant making has targeted organizations and institutions similarly helping journalists to improve the quality of print and broadcast news. Currently, for example, we fund a series of bimonthly briefings on relevant topics and issues for news professionals in New York with the Columbia University Graduate School of Journalism, in Washington with the Alliance for Health Reform, and in Chicago with the Northwestern University Medill School of Journalism.

All of the foregoing media efforts are separate and distinct from our work, and that of our grantees, to pitch specific stories to journalists, as well as to serve as information sources on topics central to our programs. Using time-honored public relations techniques to gain and improve coverage is a staple in our efforts to reach various publics with information important to improving health and health care.

No organization of any size and reach that is active in a field like health care is immune from scrutiny and criticism, but, even so, The Robert Wood Johnson Foundation has had relatively few painful encounters with the media. The first such encounter, in the early 1970s, grew out of a New Brunswick political action group's attacks on Foundation grants to a local hospital. The grants were made for land acquisitions, and these acquisitions were displacing people who lived in rental properties that were to be razed to make way for expanded hospital and medical facilities. There were skirmishes in the local media-and the first-ever picketing of the Foundation-but perseverance eventually made it possible for the hospital to improve and expand its service to the community and the region by becoming a university teaching hospital with adjoining clinical facilities of the Robert Wood Johnson Medical School of the University of Medicine and Dentistry of New Jersey.

Across the country, the Foundation has occasionally come under fire from groups opposed to the development of school-based health care centers. It was tough going in Utah, and in Miami opponents attempted to rally support by a variety of means, including a plane flying over local beaches with a banner demanding that the Foundation "go home." Media coverage, as might be expected, was heavy as both sides sought to present their case to the public. The school centers were approved, and continue to this day with local funding and strong parental support.

Public debate involving the Foundation reached its most vigorous point in the last decade as a result of federal and state attempts to reform health care and expand health insurance coverage. We organized a series of community meetings so that people around the country could tell their stories and express their views, pro and con, to Hillary Clinton, who was then heading the Administration's efforts at reform. Because of this, and because so many of our grantees were involved in that Presidential initiative, hostile critics of the Foundation accused us of partisanship, and were widely quoted. We also made it possible for NBC News to produce and broadcast an ad-free prime-time special on reform issues by buying the commercial time. The critics added this to their charges of partisanship even though viewers, in two national surveys, found the show balanced and fair.

The headline of a national business magazine's opinion piece on our state-based grant making went over the top: "In Bed With the Devil." A couple of years later, the same magazine toned down its headline to "Trojan Horse Money," but the text was equally hostile among other things likening Foundation grants to bribes. Most of the truly one-sided accusatory articles, however, have appeared in relatively obscure newsletters published by partisan think tanks.

A Pennsylvania legislative hearing a few years ago, investigating foundation support of school health projects, included a day of testimony by a Kentucky lawyer who recycled accusations from the past and lambasted us mostly for allegations that had nothing to do with the supposed focus of the hearing. To see if there was any fire in these clouds of smoke, we commissioned a prominent Pennsylvania law firm to examine all allegations made involving our foundation. The investigating attorneys concluded that "the Subcommittee's conclusions about the Foundation and its grants to Pennsylvania agencies are unfounded," and backed up this finding with 36 pages of point-by-point refutation of the Subcommittee's own report.⁸ An editorial in The Philadelphia Inquirer, commenting on the hearings, put it more colorfully by calling on the Subcommittee chairman to "focus his taxpayer-funded investigative efforts on something a bit more sensible. UFOs in the school cafeteria?"⁹

A good communications staff can help ensure that an organization's points of view aren't overlooked in media accounts of conflict-and that an organization doesn't shoot itself in the foot by being lured into unnecessary and futile public debate. But the most important point is that in our free and open society, foundations, like everyone else, have to be willing to take public criticism, and even public attack, if they want to use their funds effectively to help solve important social problems. Steven Schroeder, our president, told a Wall Street Journal reporter, "To avoid controversy means doing things that are so bland that they aren't important. We're going to get our share of potshots. It's a risk that we have to take."¹⁰

Helping to connect grantees with the media and prepare them for interviews is, as noted earlier, a time-honored approach to getting the word out in keeping with our technical assistance and dissemination strategies. A new initiative known as Connect extends this approach from media to include the grantees' local congressional delegations and their staffs. It offers broad benefits all around.

Grantees gain the attention of people who can open doors for them in their communities, states, and even nationally. The members of Congress get to meet interesting constituents with on-the-ground, back-home expertise and experience dealing with a variety of health and health care issues and challenges. In Maryland, a Congressman met with representatives of an interfaith caregivers project in his district and pitched in to help them identify potential clients who might use the shopping, housekeeping, transportation, and other services offered by the project's volunteers. Members of his staff have since worked with the project to provide letters of support for new funding requests, organize in-kind donations from local businesses, and identify new opportunities for media coverage. A California Congressman visiting a clinic in his district funded by the Foundation's Reach Out program learned that most of the patients cared for by the clinic's volunteer physicians were employed by small businesses unable to afford health insurance for their workers. He volunteered to help the clinic raise funds to cover its administrative expenses from the local business community. And a Senator from the Southwest was so affected by the work of a program battling substance abuse in one of his state's small communities that he returned and chaired a Senate subcommittee hearing there on substance abuse problems along the U.S.-Mexican border. The list of such stories is long and continues to grow.

The Foundation and philanthropy in general also benefit. Ours is an "industry" regulated by Congress, and the Connect initiative serves to enhance our accountability. It gives members of Congress and their staffs the opportunity to talk with Foundation staff members arranging the visits and to gain insight into how foundations work and the special role that they play in American life. We invite local reporters and correspondents to the visits; and everyone involved benefits from the resulting coverage, including the media, which thrive on interesting stories. If the grantees also have support from local foundations, we include their representatives in the visits and the publicity, thereby sharing the benefits even more widely.

One of the Foundation's current objectives is to create an environment that fosters building on experience, our own as well as the accumulated knowledge and experiences of others. The Communications Department's contributions to this learning environment-in keeping with our strategy to share information from our work and that of our grantees-are the Foundation's Annual Report; our quarterly news publication Advances; the Foundation's website (www.rwjf.org); the Foundation's Information Center; and two projects I oversee jointly with the Foundation's vice president for research and evaluation, my department's Grant Results Reporting Unit and the annual publication To Improve Health and Health Care: The Robert Wood Johnson Foundation Anthology.

The Annual Report serves a blend of purposes. It is a historical record that, by virtue of its distribution to 22,000 individuals on our mailing list and to countless others through posting on our website, serves our commitment to make the Foundation accountable and accessible. It offers the why, the whom, and for what purposes we made our grant and contract investments; our audited financial statements; selected excerpts from the bibliography of information materials produced with Foundation support; the names of trustees, staff, and others, including national program directors, responsible for the Foundation and its programs; guidance on applying for grants; and a biographical sketch and tribute to Robert Wood Johnson, whose vision and generosity created and put the Foundation into motion. The Annual Report's final ingredient is the President's statement, a platform each of our three presidents-David E. Rogers, Leighton E. Cluff, and Steven A. Schroeder-has used to add intellectual and moral context to our work and mission. Each has penned his own essays, and the quality of the thinking and writing in this now-substantial body of work is as much a tribute to the trustees who have selected our presidents as it is to the authors themselves. One man's opinion, but I believe both groups have set extraordinarily high standards for their successors.

Advances, focusing principally on the work of our grantees (and not our staff), is now mailed to between 40,000 and 60,000 people (we add special groups to the core list depending on featured topics). In readership studies we do every three or four years, Advances consistently draws good reviews; invariably, there is a surge of requests for other Robert Wood Johnson Foundation publications after they have been featured in Advances; and each month we receive approximately 120 requests from individuals to be added to the Advances mailing list, which more than offsets attrition.

The Foundation's website offers a near-limitless collection of news and archived information about the Foundation and its grant-assisted projects, including the text and graphics of all the print materials we have produced since 1996 and some basic materials from before that. At this writing, the content is the equivalent of 46,000 pages of text, growing at the rate of 276 pages weekly, and the site is receiving more than 16,000 visits per week, up more than 50 percent from the prior year. Handling information on this scale is a formidable and costly enterprise. We're proud of what we have achieved, but the site is still a long way from where we want it to be. Critics tell us that it should be more user friendly. Navigation is daunting; there is too much foundation and academic jargon; and too often the contexts and perspectives are the Foundation's rather than the public's-"Too much inside baseball," one critic put it. We continue to make improvements, and we've learned that in the fast-moving worlds of technology and the health sector, a website such as ours will always be a work in progress. Nonetheless, in 1998, e-mail messages via our website surpassed U.S. mail as the means by which we receive most requests for Foundation publications. And the transition from a passive bulletin board and file cabinet of information to a place of interactivity and community building began just over a year ago with creation of a joined-at-the-hip website for the Last Acts program as a virtual section of the Foundation's website.

The Anthology, now in its fourth volume, features case studies and analyses providing in-depth looks into the Foundation's own processes and the programs that it funds. The book is mailed each year without charge to more than 12,000 individuals with key roles in the philanthropic and health sectors, including all current grantees, and then marketed and sold by the publisher, Jossey-Bass. All the volumes are also posted on our website.

The staff of four in our Grant Results Reporting Unit supervises the work of almost 70 freelance writers and editors preparing accounts, from one to sixty pages, on grantee accomplishments with Foundation funds. To date, the unit has produced summaries and analyses of projects and programs encompassing more than 700 grants, all posted to our website. This work is now hitting its stride, and reports encompassing another 500 grants are in production. This record of what has been accomplished with the Foundation's funds is being mined for lessons, and is already sparking change internally. The reports also offer potential grant applicants insight into our funding interests and strategies, and promise to become a rich source of data and information for other grant makers and for historians, health service researchers, and other scholars.

The Information Center undergirds all of the Department's activities, and much of the Foundation's program work as well. In morphing from library to Information Center, this unit has undergone an electronic-age revitalization. The web and other electronic services now lead print materials by a 2:1 margin as sources used by Center staff in filling the 100 or so staff information requests processed monthly. Center staff members also conduct specific electronic searches periodically to inform Foundation officers of new developments in their fields. And Foundation staff members have access, via their desktop computers, to the Information Center's card catalog, Lexis-Nexis, updated lists of work-relevant websites, and a variety of other electronic databases. But print lives on: in addition to a book collection of more than 3,000 volumes, the Center circulates 313 periodicals and processes 150 requests monthly for books and journal articles via an interlibrary loan system.

Although foundations have resisted using communications, powerful forces for change are underway that make communication vital to their operations. These forces are moving foundations into more active, broader public engagement-to build funding and issue alliances on behalf of their own program interests, to support their own role in the modern world, and to enable them to respond effectively to their grantees' needs-and they are stocking communications toolkits essential for this work. The driving forces include:

That last point contains the seeds of what I believe are the most powerful forces propelling private foundations to embrace strategic communications. Go back to the halcyon years of foundations-the 1920s and the next several decades-a historical period I studied and came to appreciate when I was a program officer at the Commonwealth Fund and later when I served as vice president for communications at the Rockefeller Foundation. This was the period when the first of our country's foundations came to prominence and gained renown for the social change they sparked. Modern medical education, the entire field of public health, the elimination of hookworm in the South, the Green Revolution-these are hoary stories that old Rockefeller Foundation coots like me tell our grandchildren and foundation officers new to the field. In those good old days, a Rockefeller Foundation could single-handedly take on and defeat a world-class problem. Why didn't these golden years continue into the present?

As my examples imply, the most powerful way that foundations can spark social change is to use their money to fund the creation of new institutions or fundamental change in existing institutions. The first column in Table 2.2 is the 1930 operating budget of a number of important American institutions and programs, together with the federal government's overall research and development budget and the total of Rockefeller Foundation grants.

It's clear that in 1930 the Rockefeller Foundation had the financial means to exercise the strategy of building and reshaping institutions to a fare-thee-well. But by 1995, column two, the proportion of Rockefeller funds to the other budgets had become altogether different, and it had been so for some time. No longer was the Rockefeller Foundation a powerhouse for social change using the strategy of institutional creation and change. Nor was, or is, any other foundation today.11 An amount of money equal to The Robert Wood Johnson Foundation's annual grant making comes and goes in this country's current trillion-dollar-a-year health expenditures between midnight, January 1, and dawn of that first day. The strategies for social change we must use today-research and policy analysis, training, demonstrations, advocacy, as well as coalition building and attempts to leverage the actions of others-are all heavily dependent on effective communications. So, too, are the funding and grantee coalitions that are ubiquitous today. Further, compared with those earlier years, our country is almost awash with foundations, public charities, and government agencies, all competing for space and time in the proliferating channels and numbing volume of public and private communication-additional drivers for the use of strategic communications.

There are signs that all these factors and trends are turning the foundation world toward the acceptance of strategic communications as a tool for advancing program objectives, whether they be in health and health care or in the arts, education, environmental sciences, or any of the myriad other fields in which foundations labor. Foundation annual and special reports, grant guidelines, newsletters, and magazines fill office in-boxes. Foundation-sponsored PBS programs and NPR reportage have become commonplace. Foundations and their grantees sponsor town meetings, community and statewide coalition building, and grassroots organizing across the country on everything from the future of Social Security to the protection of children from substance abuse. Foundations by the dozen design, post, and link up their own websites.

Within the field, regional associations of grant makers are busy helping their member foundations, small as well as large, learn more about communications, while both the Council on Foundations and Independent Sector have launched large-scale communications efforts. When the Council held its 50th annual conference, in 1999, the theme was-you guessed it-communications. And the Communications Network, which began 21 years ago as an informal gathering of foundation communications officers, has grown into a nonprofit organization whose mission is to help foundation trustees, CEOs and program officers, as well as communications officers, sharpen their communications thinking and skills.

Only slowly, however, are foundations learning to be strategic. This means, in bare-bones terms: (1) having a vision for how some segment of the world might be better; (2) mapping the field in terms of forces bearing on the vision; (3) choosing and pursuing one or more specific objectives that seem doable and whose potential for moving the chosen segment of the world toward the vision seems greater than alternative objectives; and (4) harnessing the power of communications to support this work.

The greatest void in our communications realm is knowledge of its effectiveness. We have included evaluations in specific communications efforts with varying degrees of success. We have print, radio, and television "clippings" from news conferences, survey results from periodic polls and readership studies, and a variety of other such indices, but almost never do we know with much certainty the degree to which our efforts have sparked change. Partly, this is because of the smallness of what we do compared to the vastness of information flows in health and health care. Partly, because of the difficulty of linking cause and effect in this complex, crowded domain. And partly because information is but one of the factors influencing change. The evaluative tools we have for measuring effectiveness are also relatively crude, as is our understanding of how to use them effectively. For example, as described in the previously cited 1998-99 Anthology chapter on our radio and television grants, two separate measurements of audience effect by the 1994 NBC special on health care reform-evaluations designed and conducted by highly respected academic researchers-produced conflicting findings.¹¹

The difficulty in measuring the effectiveness of communications is just one part of the larger difficulty in measuring the effectiveness of all philanthropic work whose intended outcome is social change. For us, hope for improvement lies in an effort of the Foundation's staff, still under way at this writing, to define measurable outcomes indicating progress toward program goals. These outcome targets will facilitate our developing similarly measurable, intermediate outcomes for our related and supporting communications work. Hope also lies in efforts just begun to incorporate more rigorously the thinking and the processes of social marketing in the Foundation's work. This will bring to bear the marketing techniques of audience research, segmentation, and analysis; exchange strategies; and information and communications targeting designed to shape perspectives and motivate action-all designed to produce substantially improved health and health care outcomes.

In addition, plans to continue increasing our use of Internet and web technologies may play a role in helping us to gauge the effectiveness of our communications. These technologies-besides offering relatively inexpensive, swift means to give people access to vast amounts of information-make possible heretofore impossible interactivity between the Foundation and its key publics. Out of this interactivity could come new insights into how information is used, and the effects of using it.

As one who is fast approaching retirement, I am optimistic that these anticipated efforts will materialize and go forward as planned, but I am mindful, too, of uncertainty. As that great American philosopher Yogi Berra once observed, "The future ain't what it used to be."¹³