Supreme Questions

Thanks to Kathryn Gunderson for the yummy flag!

The Supreme Court of the United States has affirmed a new and hopeful framework. In effect what they have said is that it is appropriate and constitutional for the United States to have an inclusive health policy. But….we don’t know what to do about poor people. “What to do about poor people” was poorly thought throughout the negotiating and passing the Accountable Care Act by the Democrats in Congress. The vast majority of that negotiation blather and drama was focused on keeping the insurance and big pharmaceutical industry from going into full-blown attack. They were paid well for their reluctant complicity. They looked eager to revert to the other side throughout. The rest of the time was frittered away trying to get one or two Republicans to cast a thin veil of bipartisanship over the process. It is not surprising that the final Act was wobbly in its detail about poor people—they were not the point. Everyone was thinking about what the rich people could be persuaded to allow, not what was ideal and effective for the poor.

I wanted—and still want—a simple, inclusive universal coverage amplified by the strong multi-sector prevention and public health framework, especially tuned to the fundamental determinants of health that affect the poor the most.  That was never the point of the negotiation that produced the Affordable Care Act so it is appropriate that the Supreme Court choked on the parts of the bill that were, in fact, poorly thought through. If we thought as hard about the poor as we did about the insurance and pharmaceutical people, we could figure that out.

The historic gift Thursday was that we can focus on finishing, not restarting, the hard work of extending health to all.

Good Samaritan with Medical Center in the back.

It was a profound experience to watch the news in the presence of 18 health systems who were meeting in Loma Linda University Health Science Center to talk about exactly this bold hope. Loma Linda University is the thought leader of the Adventist faith-health movement—the belly button of the global movement. And Adventists tend to live pretty much forever. But two miles away their people do not; indeed, nearly every possible health indicator is terrible. So they are crossing the moat (the I-10 freeway, actually) reaching for every possible kind of partner to achieve a “collective impact.” They are modeling and learning in real time.

That is pretty much what the other 17 health systems are trying to learn to do, too. Each is way above the norm in terms of spending their own money on “community benefit” and care for the poor. But we gathered out of humility, not pride, for we know that none of us has “succeeded” in aligning our mercy, justice and science as is so obviously possible. Now that we know that we will be working in a context of pretty decent health policy, we can really get to work by answering four questions:

1. What do we have….to work with. Not just money, although, we are each spending dozens of millions of dollars providing very expensive care—mostly in our emergency rooms—to people whose health could be dramatically improved much cheaper by going to neighborhoods proactively. We have a lot more than money to work with—the heart and brain of the idea of “religious health assets.” (http://www.arhap.uct.ac.za/). The most interesting assets are relationships, science, trust, thousands of paid and unpaid humans and the qualities of trust. This broader view shifts the role of “management” from carefully titrating “our scarce stuff” to aligning the superabundance of complex partnerships and assets. This is way more fun and useful, but a new skill for most of us.

2. What do we know? We have more data than any platoon of wonks has time to read. But that is just the beginning, as we have even more intelligence among our partners. Blending this –hear the word again—superabundance of intelligences is the challenge. Organizing this knowledge—and teaching partners—depends on smart compelling questions. Such as….

3. What can we do? Aaahhhhh, the magic question. The pool of pretty good, if not “best” practice is deep and wide; accumulating for many years (at least since 1992 when the Interfaith Health Program started at The Carter Center).  We learned at there that once you figured out how to ask the question, every single imaginable problem has been addressed with some degree of success by someone somewhere, usually in places even tougher than your neighborhood. But so much of what is possible rests on a social infrastructure that blends complex shared effort sustained over time. The hard part of the question is not finding the “do” but nurturing the “we.”

4. The question of “we” links the other three, not just the doing part. Understanding assets and knowledge also depends on the illumination of multiple bright minds. So the critical question throughout is “how are we connected.”

We came within one vote of devolving into competing tribes with radically different human prospects. But the Supreme Court narrowly decided that we could be one people, albeit with profound and continuing tribal tendencies. Dr. Fred Smith told us Friday afternoon that even after the decision we were like David facing Goliath. “You are 18 health systems, 228 hospitals, $43 billion in revenue, but you are not big enough!!! You must go out in the name of the Lord, vanquish the giant of disparities, crash the gates of privilege and claim the land.”

Feel the five smooth stones; know they are enough and go out. It is our time.

Poiesis (formerly known as work)

 Jim Cochrane and I are up in North Georgia for a few days before he flies back to South Africa and I fly to Loma Linda, California and then to North Carolina on Monday to begin my  life at Wake Forest.

If you follow this blog you’ll know that I spend much of my waking hours working in various ways to try to help institutions and organizations do the right thing, which is to lend themselves as instruments of God’s imagination for the health and wholeness of the world. 

At least that what I try to do. What actually emerges from all the constant flurry of activity are books, papers, memos, committee meetings, plans, budgets, programs and more programs, events and more events….and from time to time, something that even looks like…..change. It almost never solitary; almost always a team sport. Sometimes it is two or three as when Jim and I wrote  a really good book over a period of years (Religion and the Health of the Public: Shifting the Paradigm)(which you really should stop and buy on amazon right now….). Sometimes it happens in formally constituted organizations, such as the 11,0000 employees of Methodist LeBonheur Healthcare. Increasingly today it happens in informally emerging networks such as the “health systems learning group” meeting in Loma Linda (18 health systems co-convened with the White House office on Faith and Neighborhood Partnerships). People form around things they fear and things they hope for. I am usually part of the latter.

To call that kind of hopeful activity “work” doesn’t quite seem right. It often feels every bit as much play, in the creative sense of generative delight and surprise. I probed Jim’s imagination on this and after consulting friends from Seattle to Africa, he suggested we talk about Poesis. That activity that so stirs soul, is work, but needs a new name to capture its radically hopeful and realistic nature.It gives energy; seems to create it. There is always laughter.

We can find no English word for this, but consider “Poiesis” from the ancient Greek term ποιέω, "to make". The same root word underneath "poetry", it was first a verb, referring to the action that transforms and continues the world. Poiesis is not just technical production nor creation in the romantic sense: poïetic work reconciles thought with matter and time, and person with the world.

Poiesis is, in short, what a great leader does with those he or she loves. It is helpful to think about past poïetic transformations other leaders like you have already been part of and to see the fruit of their lives as far more than an assembly of technical constructions. It helps us to hope for the fruit of our lives, too.

Jim teaches me that  Martin Heidegger refers to this kind of holy labor as a 'bringing-forth', using this term in its widest sense. He explained poiesis as the blooming of the blossom, the coming-out of a butterfly from a cocoon, the plummeting of a waterfall when the snow begins to melt. The last two analogies underline Heidegger's example of a threshold occasion: a moment of ecstasis when something moves away from its standing as one thing to become another. It is the sprouting of an acorn that could be a great oak.No wonder our heart stirs when we grasp what is possible

And, oh, does the world so need just that.

Let’s get to poiesis!

River of Life

Comments offered on the occasion of the meeting of the Division of Faith and Health, Methodist LeBonheur Healthcare to close my seven years of my service as Senior Vice President. Gary Shorb, Bobby Baker, Niels French, Teresa Cutts and Donna Tosches offered blessings on my move to Wake Forest University and sent me out to spread the power and spirit of the Memphis Model of faith and health. We exchanges pictures, they giving me Larry Pray’s painting of the Mississippi River Rail Bridge at Sunset and me leaving the photo of the leading causes of life red leaf.

You have given me an astonishing array of gifts. Let me leave this one sixtieth of a second of time and light with you, this picture that I took near my North Georgia cabin that is on the cover the the book, Leading Causes of Life.

This seven years has been life changing. I have experienced as minister, thinker, writer, colleague, executive and Christian all five of the leading causes of life. I began writing that book before coming to Memphis, completed it with Larry Pray in the first year on the Delta and now can testify that life finds a way. And it thrives and spreads when it has a web of trust on which grow like a trellis, bearing fruit of wondrous variety.

This picture holds many meanings. I only realized the complexity of the play of light, color, flow and form once I looked at it back home. Now I see something else is going on in it every time I look at it seven years later. So it is with my blessed experience sharing in the life of this Division, this great healthcare system, this beloved community of Memphis. I am sure I only will appreciate the complexity of what has been going on here in and around our live when I can see it from some distance. But even at first glance, it is beautiful. It has been a blessing and a revelation.

I once quoted Revelations and the fragment of the verse about the “leaves of tree being for the healing of all nations.” I see now the whole passage is true by the great river that flows beneath the bluffs nearby:

“On the side of the river stood the tree of life, bearing twelve crops of fruit, yielding its fruit every month. And the leaves of the tree are for the healing of the nations. No longer will there be any curse. The throne of God and of the Lamb will be in the city, and his servants will serve him.  They will see his face, and his name will be on their foreheads.  There will be no more night. They will not need the light of a lamp or the light of the sun, for the Lord God will give them light.” (Revelations 22: 2-5)

It has been so.

Let it be.

Gary Gunderson

June 21, 2012

Center of Excellence in Faith and Health

Hair on fire

Joseph Campbell quoting Sri Ramakrishna, said that one should “seek illumination as a man with hair on fire seeks a pond.”

Anyone in public health, faith, academic medicine or healthcare has hair on fire. Where is the pond?

For many years academic medicine has thought that the pond was the great pool of knowledge about an every-growing panoply of pathological its: cancer(s), sickle cell, diseases of the eyeball and toe and the astonishing kinds of it that collect in our arterial plumbing or lungs.  And who could forget the terrifying varieties of viral “it?” Then we begin to think about the chemical it-things we humans have invented that turn out to cause breakdowns and flare-ups that weaken and kill. I’m thinking tobacco, here, partly to not think about the thousands of industrial chemicals.

Focusing on the pathological it creates a warrior mind tuned to threats and maladies. And they are there to fight. We have built vast castles of learning designed to penetrate the veil of complex secrets that threaten us, all in the service of defending individuals against whatever it likely to kill them. If you are walking around over 40, you’ve probably benefited from this kind of knowing.

Partly because of all this accumulated it knowledge many it problems have shifted being treated and fixed to conditions that can be managed, often over a period of years, sometimes for the rest of one’s life. That’s good. The it of diabetes or sickle cell doesn’t go away like a broken arm; it can be managed. The it takes place amid a phenomenon called a life. Because you can’t begin to apply all the sophisticated it knowledge without they knowledge.

This is all difficult for academic medical centers (AMC) like the one about to employ me because a vast and expensive apparatus has been developed and justified on the basis that its research into it would  save the world (or at least extend the lives of its people). The reality is that an AMC is an expensive way to provide evidence base care compared to a integrated system of care that can focus purely on applying what is already known, especially to compliant it type problems. Think about surgery and notice all the outpatient free-standing surgery centers in your town. They just do the procedures and leave the research to others.

The AMC is only a bargain when you need to learn something new or push the edge of technology, practice or …integration to a new level. Then you need all the smart and wise people you can hire.

AMC’s today need to turn our attention to the life journey of people and a more expansive breadth of their lives to get the fruits of 21^st century science into those lives. AMC’s know about bits and its, but not much about life. Hence, the burning hair.

This is true at even the most basic issues: why poor people choose to come to the emergency room instead of a perfectly nice and convenient clinic built just for people who are poor. We need to understand they. (And why don’t they act like we expected?) Science is befuddled. What kind of relationship would we need or want with them? This is a lot better than thinking of people it-type problems. But you can feel how far it is from knowledge one could act on.

A few weeks ago the senior management team of Methodist Healthcare met in one of our churches in a zip code we knew contained the largest number of our charity care patients. Chuck Utterback, the regional representative for CIGNA attended and turned on the lights for us by pointing out that that same zip also was home to 8,970 of their members who we cared for, including 1,791 FedEx workers, 1,724 Memphis school employees, and 1,466 people who worked for the city or county government. Oh, and 459 of our own employees! We not only have hundreds of church partners in hard places. We came to find them and found….us.

The pond that is the answer to our hair on fire is finding us.

It should be a lot easier to learn about the life we part of than about a microbial it. There are extraordinary springs of data that can tell us, not just what zip codes to learn about, but the neighborhoods, streets, homes. And we can see who else we already know – our churches—lives down the block to help teach us what together we could do. And the payoff is much quicker and more predictable for everyone –the full us.  Way better science alive in more lives cheaper. And, I think, closer to what God had in mind.

Healing Menagerie

The human spirit is more complicated than a ford tractor engine, which is by itself quite amazing to behold.

"Do you believe that spirituality is a factor in health?" The question came from  Dr. Greg Burke, who leads the Public Health Science Department of the Wake Forest University School of Medicine (one of my many new bosses). We had been talking over some Thai food about the "Memphis Model" of large scale congregational networks and especially the rich stream of data that shows significant effect over five years and thousands of individuals. I had shared that data with the Board of Directors the evening before, including the fact it held some inconvenient good news. The good news is that CHN delays the return to the hospital by 39% over all comparative diagnoses -- 426 days compared to 306 days for non-connected patients. That's what you'd want for your mother.The bad news is that hospital won't ever be paid for that good news. The reasons is that it is much better news than the payers are asking for, including the Center for Medicare and Medicaid services. They are focused on just 30 days and are about to start punishing hospitals when people fail to stay out of the hospital for that long. Ironically, CHN patients doesn't show a lot of difference in that short run. The effect is dramatic--but in the long run.

This all seems very hospital operational to Greg, which prompted the question about spirituality and the possibility of proving its effectiveness. It felt like a change of subject because most research into spirituality and health is focused on very small groups, even individuals.

The problem is that spirituality is a very sloppy construct intellectually. So if you mean the "things we think we think" about God, the ultimate, or nature,  it has little demonstrable affect. This drives researchers crazy because it is obvious that something as ubiquitous as spirituality should be useful for something measurable. But it is simply too complex and nuanced. The initial problem is that much of what we think we think, we don't--especially under stress such as in a health related crisis.

I noted that most of the research in this area is still done by highly educated men, which is the same kind of researcher which tends to have a lot of challenges in researching....female sexual response. Those researchers' minds tend towards instrumental and repetitive process, partly in order to develop interventions to increase whatever. The phenomenon is, well, complicated as even men have begun to notice. Viagra works for men; not so much for women. Go figure. Spirituality has a profound affect on life and health, but in ways extremely difficult to map or stimulate.Go figure. (Mary Roach, my favorite science writer, wrote a book "Bonk!" that explores these themes in case my male readers need some catch-up.) Back to spirit.

The spirituality that is demonstrable is what we see in Memphis. It creates social assets mobilized at large scale expressed through a rich tapestry of relationships. This social spirituality creates relationship beyond blood and money and is a healing miracle. Here, too, it is easy to get very instrumental about something quite nuanced and subtle. Spirituality has its its affect through relationships of trust, respect, care, unpredictable giving; not just functional "social support." That sounds random to those who want to believe in repetitive, invasive, therapeutic interventions. But it is not random; there are patterns and practices that nurture, sustain, express and channel exactly that kind of social spirituality.

It is large enough in scale to look like a public health initiative. And the data is clean and smart, so it looks like research. The clinical affect is significant enough to look like a service line. But it is a spiritual movement (I almost gave away the argument by saying "intervention.") It is the Spirit that moves. That is what we want to spread to North Carolina and why I am going to see if it be done on purpose.

I am a follower of Jesus, at least to the extent that someone with my excessive education and privileges can possibly be. So all this reminds me very much of what you see in the healing stories of Jesus, which almost always happened amid a menagerie that surrounded him. On Sunday I preached what was probably my last sermon at my home church in Memphis, St. John United Methodist. Reflected on Jesus' relentless way of calling people away from dependence on simple, official relationships into freedom, grace and healing. He offended almost everyone in the process including, in Mark 3, his own family. He considered the ragged and recovering menagerie which were drinking deeply of the freeflowing spirit to be his family. That's where the healing happened.

CHN is such a menagerie, blending the most wildly unpredictable people; Baptists, Church of God in Christ, Methodists and all sorts of those with more complicated identities. It has even brought healing to a Senior Vice Pharisee.

The full text of the sermon is at:
 http://dl.dropbox.com/u/9944473/Jesus%20and%20the%20Healing%20Menagerie

Hero Farewell June 1

The slight

Feathered

Gesture

As light as breath

Reaching for one last touch

Of the polished steel urn

Resting on the edge of the concrete cavity;

Tornado dark sky,

Crackling lightning

Horses startled at the caisson.

Soldiers, ignoring wind,  

Shoes so polished,

the birds above visible in their shine

as they snap the folds

in Spence’s last flag

a long way from Inchon.

Every step, glance, word,

tone, salute, prayer.

All twenty one guns,

And then  aching silence

Exact, planful honor.

Brothers, sons, children, friends, chaplains, soldiers

pause.

Hearts clench

At the feathered reach of his woman’s hand that could not touch again.

Claude Wesley Spencer -- "Spence"--was my brother in law, married to my sister Judy.

Book! Book! Book!

How can the world need another book?

The question occurred to Jim Cochrane and I many times over the last four years as we have subjected friends, vulnerable students, bosses, family and work colleagues to all the collateral damage that a book creates.

In a time when every possible answer  to every possible question can be found instantly on your phone, why bother writing paragraphs, chapters and then struggling to order them into a book with hundreds of footnotes from hundreds of sources?

But.....when you need a whole new paradigm, it takes a book. And that is what we do need amid the broad clutter of practices, vast array of institutional assets, extraordinary flow of finance, high drama over policy and, finally, the human pathos of illness, the humans delights of health that all of us journey.

Although rich enough in stories to be useable by most reading adults, this book is unabashedly about theory--why the ones we have are failed and why a new one will help us transform the world. That's what theories do and we really need one now.

It is good when good thing happen, even when we don't know why. So when something "works" in a hospital, HIV Aids clinic, church or public health program, we are happy. But if you want it to happen again, you have to have an idea of what you did right. And to know that, you need to know why it was right and how it relates to other things that work, too. You need a theory.

The goose that lays the golden egg of practices, technologies, choices and policies that transform community is good theory. Not everyone thinks we have time for theory. This is why the most powerful theories are the ones you don't know you have. When a Chief Finance Officer says "let's be realistic" he is acting out of a theory (although most would hate the thought). Thus Jim and I spend some time taking apart the old paradigms, going back to the history of faith and health to find the repressed threads of coherence we need to reweave.

But most of our time is invested in stretching widely around a body of ideas that have taken hold in the bitter struggles with HIV in Africa and intractable poverty on the Delta. These ideas are already illuminating the way forward on their own, but wrapped in a more adequate paradigm, the ensemble promises far more. So we revisit the ideas of healthworlds, religious health assets, leading causes of life, strengths of congregations, boundary leadership and the global political economic context of our work. Hence all the footnotes! It is a bold, maybe foolish, intellectual presumption that we could do it. It wasn't easy for the publisher, Palgrave, to find anyone in the whole world willing to review such breadth. Someone will surely do this better eventually, but we've given our best to the work as is.

The theoretical work has been tested constantly against the realistic demands of our daily efforts to build the network of congregations in Memphis and then the craft of evaluation and analysis of the outcomes. Likewise, in Africa where any intellectual work is immediately tested in that most severe climate.

Over the next few weeks I'll be doing blogs on most of the chapters and suggesting some ways this could be useful even for you. The book is available most everywhere, including Amazon: (http://www.amazon.com/Religion-Health-Public-Shifting-Paradigm/dp/0230341527/ref=sr_1_2?ie=UTF8&qid=1337527203&sr=8-2 ). Some of those reading this blog are over 30, so may enjoy the ebook with its larger type when it is available in a coupe weeks.

Jim and I did our best to blend our thought well, but we draw from a rich community. So we dedicated the book:

In memory of Steve

 and in gratitude to the many warm friends and colleagues
with whom we have journeyed along the way
from the Interfaith Health Program,
the African Religious Health Religious Health Assets Programme
and the Center of Excellence for Faith and Health