Wednesday, April 27, 2011

Predicaments of trees and turtles

A week of profound passages: Heather Ion convened sparkling minds exploring "the epidemic of health," KD's 90th, my 60th and Jesus rose again, too. Too much to think about, so I am mulling on the predicament of trees (in real forests) and turtles (crossing actual roads). The tree first.

Walking down the gravel road alongside Fighting Town Creek, we passed under a young oak bent a perfect arch. One of the pines killed by the bark beetles a couple years ago fell in the heavy spring storm, tangled with the oak, weighing it low, caught.

I thought all day about the improbable things that happen to real trees, so unlike the pictures we paint. In real forests (and neighborhoods) anything physically possible just might happen no matter what the predictions based on averages might expect. I was intrigued by the tangle off the ground that held the bent tree captive to the fallen on and even walked back later near dusk to find the predicament more improbable than I thought. The pine didn't just topple over, it snapped in the wind, caught its upper branches in the young strong oak, which bent but held the severed trunk a foot off the ground like a grey ghost might hold a troubled mind. The things that happen to trees ... and people.

Nathan Wolfe, a virologist Jonas Salk would have liked a lot, joined Heather's exploration of viral metaphor by phone. Nathan is named by Time Magazine this week as one of the 100 most influential people in the world (and on a much shorter list of influences on my daughter). Sparked by Heather Ion, he noted that virus are instructive for humans in how they "generate novelty" by combining and recombining genetic information constantly and promiscuously. Novelties (innovations) are tested against reality--also constantly--and those that work better stick long enough to generate more novelty. That's how viral life works, with some clues for us mammals.

I'll wait for a fuller posting on this until Heather has a chance to edit the transcripts. But you can see why it matters in the real neighborhood where you live.

Humans mash ideas together constantly, too, because we face not just threats but opportunities. As technology and knowlege move, it turns out that reality holds more possibilities for life than we had known. We are not contained by what has been possible yesterday, or even this morning. We can generate novelty, too. Indeed, the lives of all we love depend on the adaptive innovations that come from how our lives combine with others'.

Less than a month ago I was measuring my steps against geological phenomenon, noticing that I lived barely longer than one of Nathan's virus. Better generate novelty fast, for life is quickly passed on to others. The thoughtful community philanthropist behind our "epidemic" meeting passed on just last night. But Richard Cornuelle knew his ideas had combined with those of Jonas Salk (who passed on a handful of years ago himself). Lives are good when they leave a vital process more alive.

In the meantime, notice that turtles (and people) have predicaments that can be helped now and in very straightforward ways.

This is the patch of clutter where I moved a box turtle from his precarious rest two thirds of the way across a gravel road. Safe in his armored skin, he probably thought this an unnecessary novelty. But he didn't know about cars and I did, so I moved him unasked. He did not tarry to thank me and was long gone when I walked past again 45 minutes later. I thought of Loren Eisley's "star-thrower", walking the beach at dawn chucking stranded starfish back in the surf. Turtles are less poetic, but probably a lot more alive.

In Rock Hill to celebrate KD's 90th, I noticed an off-brand Baptist church announcing "Jesus stripped, shamed, tortured, killed...for you!!!" (Happy Easter). The ultimate Vital Novelty lost amid the violence. What wondrous life is this, asked the song, more helpfully astonished at the combination of divine and human. I wonder what it would look like if we believed it?

I thought of Bobby Baker, his Navigators and Liaisons intervening in the lives of hundreds of people (mostly moving slowly as turtles) every month getting them to where they need to be to have a better shot at health. Many of those lives are as unlikely as the tangled tree and many just as obviously exposed as the turtle in the road. Their hope is the novelty of competent compassion--hundreds of mundane but creative acts of vitality done quietly and a system that puts people in positions for life giving novelty.

- Posted on the journey

Monday, April 18, 2011

Ready... aim, aim, aim...

Boston is a city of revolutions past--and maybe future. Sometimes revolutions are simply things that just need to happen and are overdue. This is certainly the case with the "triple aim."

Among health wonks nothing is more obviously righteous as "the triple aim"-- lowering cost, improving quality and improving population health. Originally advanced by the Institute for Healthcare Improvement under Dr. Don Berwick, the triple aim is embedded at the very root of the current federal health care reform legislation. It also pops up at state levels such as Oregon (

Just beyond the water over yonder is Bunker Hill; to the left behind the glass towers, Boston Commons. A more wonkish revolution is under way now, which is why a group from Memphis was here for a couple days. We were drinking deeply of the IHI / triple aim cup along with a hundred or more other folks from around the country. Representing both major hospitals in Memphis, the Med and The Church Health Center we listened to how these goals were being reached at large scale in upper Wisconsin and Oregon.

Of course the new triple aim is a footnote to the original one in Micah 6: "you know what the Lord requires already (some 2,600 years ago): do justice, love mercy and walk humbly." If we had done that, we would not need the new triple aim. The new triple aim is related to Micah a bit like the plumbing is related to Amos' prophecy that justice will role down like mighty river. Don't take plumbing lightly. Just because it depends on gravity, doesn't mean it is easy or obvious to get it to work. Same with health care.

We learned about CareOregon, a managed care organization for the poor that actually manages and actually cares. With tenacious decency, they use data like a righteous sword to carve waste and silliness from the lives of their members and providers. The result is dramatically more efficient services that are proactive, comprehensive, quick and responsive to what people really need. It passes for brilliance these days to notice that the most expensive patients needing the most medical services can be predicted by asking simple questions about substance use and family problems. And it passes for innovation when you do something non-medical about non-medical issues. Micah knew that would help, but did not need the cost savings to justify it.

Rebecca Ramsey, of CareOregon, shared how the basic revolutionary idea came from the SouthCentral Foundation in Alaska, which has built a large health services network on the highly participatory wisdom of the Native people. They (the people!) turn out to be pretty smart about the way people's health is connected to their families, community, decency and ... spirituality. The Native spirituality got left out of the story but the moral commitment to decency sure didn't. The key is that the embrace of those with the most complex conditions (almost often involving the snarly mix of substances, interpersonal violence and mental issues) is way cheaper than pretending the complexity isn't there. Mercy is cheaper; justice even more so.

These lessons are crucial for Memphis where we sit on a never-ending well of wicked disparities and poverty. We could be tempted to think we can't face the inherent complexity of multi-generational cascade of race and class. "We'll just do what we can; we can't afford world peace." Actually, IHI, Oregon and Wisconsin seem to say that world peace--taking it all on--is cheaper and more managing than trying to operate a hospital blind to the quiet violence of our patients' lives. We are way off the national curve for unneeded hospitalization that can be effectively managed only by getting involved in the complexity of those who have no real alternative. We are even further off the curve for expensive and futile care at the last months of life; that can be managed not by harshness, but by the gentle-kindness Micah aimed at. We're in a world war; why not work on world peace?

In the meantime, we can at least do a lot better. Micah thought he was only asking for what was obvious and doable: "you already know what God asks.....". IHI lives on the wonk-ish side, finding a buzz from the data and flowcharts. But they are talking about the same mercy, same justice and, ironically, the same humble seeking for what is possible on this earth.

- Posted on the journey

Saturday, April 9, 2011

Adults behaving badly

In what appeared to be one its last actions before closing down in the fact of stampeding Vandals, the White House Office on Partnerships posted an article about "the Memphis Model" on its website. The Vandals thundered past to no affect, but may return at the walls next week, so you might go quickly to
to read the brief piece by Mara Vanderslice.

You've read the basics here before: hundreds of congregations connected to the big three faith-based treatment systems (Methodist LeBonheur Healthcare, Church Health Center and Christ Community Health Services) and pretty much anyone in town that wants to partner.

This would seem to be a fragile model for such wild oscillations in public policy. I could fill pages with simply lists of fundamental variables affecting the choices of all institutions involved. Given our 330 covenant congregations and these 3 key partners, there are at least 333 long lists of unknowns with big upsides and downsides that raise uncertainty to the 333rd power.

So we do the best we can on most days to consider the limits of what is possible to imagine and try to move that way with whoever we can do so that day. We try to respect each other and expect the best of all involved, and we are usually right. It is not pretty, but real.

However, we are not naive. We do not expect all the adults to behave well or to be able to keep to their best intentions, sometimes not even to keep their promises. In other words, it fits the times in DC and Memphis.

We muddle, which is what is possible for humans to do in complex and uncertain times. But we muddle while talking constantly to each other, making every incremental good choice we possibly can. It is not all that might be possible in the abstract, but all that are possible on this small and wild planet.

Sometimes the stars offer up an opportunity to move in big leaps. We are considering trying to become a model city for application of the Institute for Healthcare Improvement "triple aim." But that model seems to think that we could and should get all the powerful and smart people to agree, first, then act. The "memphis model" that appeals to the White House is more untidy and yet more ambitious. The heart of the Memphis model is to take advantage of every opportunity to bend the arc of justice in the right direction. It might work. And it might not. We continuously improve our aim and never give up.

In a week when we are told to be grateful our government employees are even going to be allowed to come to work, that seems pretty good.

- Posted on the journey

Friday, April 8, 2011


Talking won't end disparities, but learning might. It depends on who is learning (and to a lesser extent, who is teaching).

Monday was April 4th, a sacred day in Memphis where Dr. King was murdered 43 years ago just down the street from the Center of Excellence on Faith and Health. In recent years we have joined with other organizations in town in a broad array of events, preaching, worship, lectures, march(es) and odds and ends. We shared a logo and a theme: "we are the beloved community."

Our patients and employees look like Memphis in terms of race so we aren't dumb about the subject. We are a very large organization serving hundreds of thousands of patients a year through the efforts of 10,000 Associates and a couple thousand affiliated physicians. Dr. King died before many of our staff were born yet the scandal lingers in the continued dramatic differences in the health of Black, White and Brown. Why? And what can we do?

So this year Methodist Healthcare decided to honor Dr. King by doing the labor of learning, seeking discernment about what our unfinished work is in removing disparities in the patients, families and neighborhoods we can influence.

We met in the Innovation Studio, seeing this as a most profound work of innovation. Led by Dr. Joyce Essien, Dr. Fred Smith and Dr. Elizabeth Williams we talked of the pain (and privilege) that are the lenses through which we are learning. We borrowed the IHP "4 frames" to keep our imagination from collapsing into simple "train everybody" reflex. Structure?How are we structured for disparities? And how could we lay down structures for equity? How might we use our symbolic role in Memphis? (The committee is called "equity" not "disparities," for starters.)(And we met on April 4th....). What does power have to do with it and us. How could we use our power? We will meet again, but the organization seems to be at a true learning moment, tuned to hear what is possible. And then do it.

That evening most of us went to the April 4th Foundation Gala, a very Memphis thing that always crackles with gritty power of history and hope. This year Dr. Jeremiah Wright keynoted and chose the power of cool analysis rather than the fire and thunder he is known for. He reminded us of the "dangerous King" who wanted the Movement to help put out the "house on fire." He channelled King's clarity about the three demons of America--race, militarism and materialism. The history we gathered to honor was still around us; and still ahead of us.

I was just a high school kid in the Baltimore burbs when King fell. And nobody in my family felt much sorrow as we lived in the soft racism of the unaffected. A few years later when the triple demons of America finally caught my attention, I dropped out of ROTC, sought simplicity and began to see race. I thought I would have to dump Jesus, too, since my old god seemed so complicit (he was!). Richard McBride, a Wake Forest chaplain, gave me books of Berigan and King, telling me that I needed to see the Church was bigger than my tame little god.

King blew a hole in my soul that let me out into the real world--the one God so loves; the one God has still not given up on. Everything else in my life has been a footnote to that.

Thursday night was a normal night in the hospital, which is to say that the place is electric with learning. In the Innovation Studio 85 people were learning the art of spiritual accompaniment--how to truly be present amid the illness of another. (Chaplain Jonathan Watkins had them shout "It's not about me!") (We should to that at executive meetings, I thought.) Down the hall in the Medical Arts Auditorium another ninety were learning the practical arts of caring for those living in dementia, led by Dr. Teresa Cutts and Chaplain Belisle, but illuminated by the experience of nearly everyone present. Another 40 people were attending via video-conference from our Germantown campus.

Although the 330 CHN congregations are hugely ecumenical and multi-hued, for the most part Thursday night feels like Black Church. It is. These are the ones whose brothers die too young and whose mothers will die much younger than mine. So the night closes in shared prayer filled with pathos and power.

This goes on week after week after week, pretty much all year round as the congregations open themselves to knowledge respectfully offered up in the hopes it is smart enough for their tough streets.

Nobody was just talking this week, not the equity committee, not Jeremiah and, for sure, Thursday night. Fred talks about education as the work of "shalomalization." That's what all this felt like to this white guy, grateful to be carried on the movement.

Can we learn the ways of shalom? Enough to do it, know it, let it fill and move us? Jesus cried at the question as he pondered his town. I'm a bit more optimistic. Yes, I am.

- Posted on the journey