Community Context

Harris County, home to the city of Houston, is located on the upper Gulf Coast of Texas and is the third most populous county in the United States. The county is geographically spread out, but with increasing density as the population grows. While a rich history of an oil-based economy drove tremendous growth and in-migration of people to the area, today the economy is fairly diverse with a robust health and social assistance sector, as well as education; professional, technical, and scientific services; hospitality; and other sectors. However, over half of the middle-skill jobs in the area are at risk of automation and respondents described some ups and downs in the oil and gas economy in recent years.

Each county in Texas is governed by a Commissioners Court, though local governments do not have authority to pass public health ordinances. Politically, the county has consistently leaned Democrat, particularly in recent years in a majority-Republican state, which has resulted in some conflicting priorities between levels of government. The county has faced several devastating natural disasters over the past decade and recovery assistance continues to flow to the community. The top chronic diseases include hypertension, obesity, arthritis, and depression among others, and racial and ethnic disparities are evident across many health outcomes.  Access to healthcare and health insurance are limited for a significant portion of the population, due in part to Texas not adopting Medicaid expansion. Food insecurity and severe housing problems, including overcrowding and residual storm damage, have been ongoing challenges. The COVID-19 pandemic has also severely impacted Harris County, as the county experienced multiple waves of infections in 2020 and 2021.

Harris County’s Journey to Promote Health, Well-Being, and Equity

Through progressive collaboration across sectors, organizations have addressed some systematic factors that bear on health and well-being.

Five years into the Sentinel Communities Surveillance Project, community capacity to promote health, equity, and well-being is grounded in the efforts of multiple sectors with a strong presence of public health and healthcare, nonprofits, local government, and higher education institutions as well as philanthropic funding for health efforts. Stakeholders in Harris County were working on several large initiatives to support well-being of community residents that started before 2017, focused on livable communities, economic stability and workforce development, and care coordination, many of which have continued over the past five years. New large-scale efforts have been initiated with a focus on addressing issues across sectors such as the social determinants of health, equity, food security, and housing. Regarding the health narrative, Harris County’s efforts have become more focused on collaboratively addressing the social determinants of health and equity over the past five years, though increasing access to healthcare remains a priority. Relatively isolated efforts to address health equity in Harris County gained momentum over the past five years, as elected officials became more vocal about the issue and additional partners in healthcare made formal commitments to addressing equity.

Lessons Learned: Where is Harris County Five Years Later?

Harris County’s journey to promote health, well-being, and equity is one that illustrates the critical importance of collaboration and shared commitments to equity, as the community worked to develop the necessary structures and shared values over the past five years. Prior experience with natural disasters provided a foundation, but COVID-19, coupled with strong county and city leadership that often conflicted with state priorities, was perceived almost universally as a turning point in the county’s orientation. While the long-term effects of this inflection remain to be seen, other communities can learn from Harris County’s approaches to make these changes, as well as the challenges they encountered, to inform their own journeys. And as COVID-19 recovery continues, with historic funding flowing to local communities, future research could consider the ways in which momentum around health, equity, and well-being influences community health narratives and decisions moving forward.

Harris County has leveraged past disaster response and new leadership and collaboration to begin to make progress on health and well-being goals. Yet the county is challenged by its vast size, significant unmet needs, and governance challenges, resulting in siloed efforts that have proven difficult to align.

Facilitators:

  • Experience with disasters facilitates collaboration

  • Improved city/county collaboration

  • Pandemic-related expansion of community engagement

  • Data and evaluation partners highlight community needs

Barriers:

  • Large population with significant need

  • Fragmentation of efforts

  • Multiple healthcare systems and public health authorities 

  • Data capacity challenges for community-based organizations

  • Misalignment between state and local governments