Health – garygunderson Blog

Trellis

The Surgeon General of the United States explains why his four biggest opportunities to advance health need relational infrastructure built on faith and community partners.

On Wednesday and Thursday this week, a wildly diverse group of leaders met in the White House to explore how to accelerate the growing alignment so necessary to advancing health and well-being of communities. Surgeon General Murthy laid the foundation with a sketch of a framework he will unwrap later this week in detail. But you could guess the outlines, which are pretty much the same priorities John Wesley laid out in his book, Primitive Physic, years ago, written before germs were invented. The reason this is new today is not because we have a new machine, but because have the possibility of new relationships of high capacity, capable of operating at scale. Keep saying that: building capacities for scale. They require what is now possible; rich interconnection between systems for food, mobility, the more complex systems of legal and illegal substances and the almost infinite array of systems relevant to emotional and mental balance. Oh my!

The challenge is the opposite of what you’d think: too many partners, not too few.

A trellis fits the plant it is intended to help find the light. Plants just need old sticks.

Tom Peterson tells me there are at least five million non-profit organizations in the world today, most of them created in the last half century, and almost every single one formed to do something somebody thinks useful for improving their community. It’s worse than that! Many more millions of for-profit companies have been formed in this same time, hoping to make money, but also to do something good in the process. Just check out kickstarter.com to get an idea. The ecology of human forms of association is rich, complex, interconnected and adapting at the speed of electrons. This is terrific if you need lots and lots of relationships. It is daunting if you think someone should be in charge of organizing them.

The Surgeon General does not aspire to organize 5 million of anything. But he does hope they (we) can organize ourselves in ways that can make it more likely that 21^st century science (including, but far beyond everything Wesley knew about) can get into the lives of people and neighborhoods.

Many trellis builders think a lot more about their wooden art than they do about the plants.

One idea that has been popular, but rarely successful, is forming a backbone organization to achieve “collective impact.” I think it’s the wrong body part for the job, preferring something more like the intelligence of the liver or gut. But it is often useful for relatively small problems with simple answers, such as building a lot of homes in a particular city. When used for big and complex challenges, the backbone is often overwhelmed by all the partners and ends up simplifying things by leaving new ones out. The backbone’s limited number of vertebrae is the same list of privileged partners that always end up around the table. The idea of a table at which things are decided is part of the problem: you can’t fit 5 million people around any table.

On Thursday we tried on a different mental model better suited for organic complexity: the trellis. A trellis is not a miracle; it’s just useful to support the miracles of photosynthesis so that plants do what they want to do—bear fruit. The gardener (and the movement organizer) trusts the process, but doesn’t make the process do all the work. I like wine, and know that good wine needs just the right soil (developed over many thousands of years) and just the right rain (which depends on picking just the right valley and sun, not too hot and not too cold), so that magic happens. But it helps if the vines don’t just run every which way on the ground, so they have developed a near science of trellis design to fit different grapes.

Some trellis are built for the decades the vines mature through.

A movement is more complicated than grapes—and right now we have vines running every which way. It would help if we did the humble work of building some trellis on which could grow a rich array of relationships to bear the fruit the Surgeon General imagines possible. There are four main kinds of trellises:

Conceptual. Stakeholder Health emerged as a learning group, which collectively created a monograph to map the conceptual trellis on which healthcare systems could fulfill their missions. It is really good, but like other kinds of conceptual trellises, it needs to be rebuilt for a new season of work (stay tuned on stakeholderhealth.org). The learning community will need to be much larger and even more interdisciplinary than the intellectual gaggle that did the first one. It will need a relational trellis on which grow (and prune) those fruitful concepts.
Programmatic. The Surgeon General’s call for broad activity is not a call to do 10,000 different things, but to find alignment around four that could be transformational. Thousands of us can find a coherent role in food and we can understand our work as linked. Nobody is exactly in charge of it, but a well-built programmatic trellis helps us we can find power and meaning in contributing to a very large collective change.
Institutional. The YMCA is 3,000 local organizations, which have changed quite radically from the original shelters for young men to today’s iconic role as suburban fitness conglomerates. Now it is changing again, to embrace its extraordinary role very aligned with the Surgeon General’s vision. There are many other examples of old structures finding new relevance. But in every case, it is tough work. The 3,000 Y’s have 900 local Boards!

Some plants (like some types of congregations)(yours, Michael Minor!) are so smart they can grow up a string. But the string still needs some support.

Michael Minor is the midwife of the National Baptist Convention’s 60,000 congregations move toward health; but every one of them has its own Board of Deacons that will need to catch the same wind of the Spirit. So, too, the 33,000 United Methodist churches, hundreds of Jewish Community Centers and dozens of faith-based hospitals. “Can dry bones live?” asked Ezekiel. Can an old trellis bear new fruit?

Narrative. We humans live by story, far more than objective data. A movement with capacity and scale needs a narrative trellis, so that each of us, in our many roles as members, leaders, citizens and healers, can locate our personal story in the thread of a great story. We need the bards, writers and artists to help us tune ourselves to resonate to a greater tone.

Community Health Assets Mapping, here led by Teresa Cutts, makes visible the assets already alive in a place. This enables the community leaders to imagine a new kind of trellis of relationships. And then they can build it. — Community Health Assets Mapping, here led by Teresa Cutts, makes visible the assets already alive in a place–the stuff that wants to grow. This enables the community leaders to imagine a new kind of trellis of relationships. And then they can build it.

We watched the video of the murmuration of the starlings, a mesmerizing image of complex beauty (here). Are we like starlings? They dance in the sky forming patterns beyond words. But they are all starlings and know how to act with each other. We are not alike (Kirsten Peachey said the group is more like a dozen starlings, and a hawk that eats starlings, and a horse, pig and potato). Not as pretty in motion. Or maybe it just takes time to find our common energy. The International Science Times, reflecting on the video, says that the way the birds dance is managed “by constantly avoiding collision. Generally, they were taking their lead from the bird directly in front of and below them, rather than the birds to the sides or above.” If you can’t understand how that metaphor applies to humans, you have never tried to lead a committee.

And we watched a YouTube video about how reintroducing the wolves in Yellowstone are changing not just the wildlife, but birds, berries, beavers and the flow of the rivers—the whole ecology (watch it here). Maybe we can change more than we think! So we howled (literally, we howled, which may be the first time that’s happened in White House since Andrew Jackson let in the rabble from the streets!).

Arvind Sindal used his many creative meeting structures to unleash a torrent of transparent brilliance. This is the "fishbowl" with healthcare providers in the middle. Pretty smart, but the questions from the outside were the real brilliance. — Arvind Singhal used his many creative meeting structures to unleash a torrent of transparent brilliance. This is the “fishbowl” with healthcare providers in the middle. Pretty smart, but the questions from the outside were the real brilliance.

Or maybe we are just human grown-ups influencing our own complex systems as we try to live our way into the new possibilities. Many of us this week find our story in the Great Story of faith; we think we are agents of a redemptive process that has never quit, despite entire centuries of bleak reversal. We think that God is not quite done with our tiny planet or even with us, flawed and tiny people.

As we were meeting, astronomers were reporting more evidence that the ingredients for life are astonishingly abundant in places beyond counting at distances beyond imagination. The vast reaches of reality are swirling with the ingredients of life. The places once imagined as impossibly cold and hostile are just waiting for the right relationships to emerge. “Life finds a way,” said Jonas Salk, who was one of the first who thought that life rode into Earth on the comets.

Life is still finding a way—even in the hostile barrenness of Washington DC. It turns out there is a richer array of the basic ingredients than we’d been led to expect. But don’t make the process do all the work, unless you have a few million years worth of patience to move at the speed of stars.

I turn 64 Monday and need to pick up the pace a bit. It is very good news that we don’t need to invent the life. But we do have to thoughtfully craft the trellis. Let’s get on with it.

Carolina tears

Sprouts find their way through the bullet holes in an old refrigerator in North Georgia.

Hearts break today in North Carolina.

I think of atheists as slightly over-educated modernists who are harmless, almost quaint, in their ardent non-belief. It had not occurred to me that non-believers were inclined to shoot people over parking slots. But now the Associations of Non-Believers have to explain, just as we Baptists have had to do for centuries, how their style of belief in UnGod can make one mean enough to be kill.

Of course, Atheism doesn’t make you mean any more than Islam, Christianity, Bhuddism or Hinduism. But every one of those structures of meaning have given harbor at some time to dangerous people who kindled the energy of belief into the fire of violence. Belief—and unbelief—can warm or burn.

Someone who believes in nothing is indistinguishable from one who says they believe in God but who do not believe in what that God tells them to do toward others. Groups of people, whether Islamic or Christian, can claim to follow God, but actually believe in their guns, banks, drones or grinding, blinding anger.

No French cartoonist, or student trying to park their car can be entirely safe from delusional nutters. Mental illness often hides in the fog of ardent belief and unbelief. It deserves pity, prayer and, often 21^st century pharma. Turning this man’s delusions into a reason for religious or anti-religious rant only serves the demons.

The most dangerous nutters are the ones who gain control over the instruments of state power. The mentally ill man who shot three students in Chapel Hill is not as scary to me as the elected wackos 25 miles away in Raleigh where an unhinged legislature is considering a bill to prevent Muslims from imposing Sharia Law on the good Christians of Northern Carolina. These guys have a whole police force, not just some guns in a closet. They don’t want your parking place; they want the whole enchilada.

We Baptists remember times when we were strangers in this land, too, and know to fear any government that thinks it is holy enough to know who to punish on behalf of God. The first duty of any Christian—or believer of any other faith—is to work to make their own faith safe for the world and especially for anyone who does not share your faith. You or your children might be a refugee someday, too. This is why every religion that lasted longer than a few seasons raising high the priority to care for the stranger, the weak, the poor, the widow or motherless child.

The actual followers of Islam who pay taxes here are mostly students and a previous generation of students now serving as our doctors, nurses, dentists, computer programmers and anchors of our civilized way of life. There is no clinic or hospital in the entire state (or any of the other United States) that could operate an entire week without the medical professionals from many faiths well beyond my own Christian circle. Our community strategy of “proactive mercy” depends on the powerful faith of saalam-seeking healers of Islam. So our grief extends to the families and friends of the UNC students in a double portion because we share their commitment to the healing arts their entire family so obviously embraced.

I’m a Christian, trying to follow Jesus. He said that God would sort out the right and wrong, sheep and goats later on. The twisting plot of the story made clear God’s decision would surprise everyone involved. Don’t guess God. In the meantime, love mercy, do justice and walk humbly.

Cry with us and lend us with your prayers of mercy.

New blade

Six decades later I can still hear the screaming whine of this saw as my dad crafted cabinets with it.

I peered through a hole in our basement wall into a cloud of sawdust where my father fed a piece of wood into the spinning blade. The sound was painfully high loud and powerful, such that I can still hear it, now almost six decades later. I was two or so and learned later the wood was pine, as was all the rest of the cabinets in the home I grew up in, crafted with a mixture of love and parsimony by Dad. The saw, made by Rockwell, eventually became mine and used for most of my adult life as I, too, ripped, spliced, joined and paneled every place I’ve landed. The saw was a primal link to Dad, but over time whined, smoked and wobbled more and more. Once, back when I was earning my living with it doing remodeling, I was moving it from a job site when it bounced out of my nearly-as-old pickup truck, breaking on the pavement. Ken Sehested, knowing my despair, found a friend to weld the key cast iron gear back together, so it lived to wobble on in my life. But eventually the damn thing could no longer hold an angle, sometimes cutting a perfect 45, but more likely 50 or, the other day, 60 degrees. This makes very ugly joinery.

Now wobbling, smoking and whining, the saw prevents, not enables, good work. Dad would not be happy.

Dad would have hated the crappy quality the saw made inevitable and surely would have found any link with him something of an insult. I finally had to distinguish between clinging to nostalgia and actually honoring my Dad’s woodcraft. So I went to Lowe’s, channeled his spirit, and bought a solid Kobota table saw. I’m in the last stages of a new bathroom in TC and my condo near Old Salem and now have a chance at doing the finish work in a way that the Moravians and Dad would find acceptable.

Our lives are filled with the artifacts of those in whose shoes we walk, feeling our feet slightly too small for the journey. Just before Christmas I met with the ethics committee of the medical center, which had been established by the iconic surgeon, Eben Alexander, decades ago (he’s the dad of the recently famous one who wrote about “proof of heaven.”) The committee he started is still appointed by the chief medical officer, also a surgeon. Although medicine and the health sciences are less and less about what happens inside the medical hotel called “hospital,” the focus of the ethics committee continues to be almost entirely at the surgeon’s elbow. It thinks mostly about what the doctor should do or stop doing. Our current model of bioethics is not looking at the CFO’s spreadsheet, or COO’s deployment plans, or the Board’s capital decisions voting millions to build another office in the burbs, even those decisions shape the life and death for thousands of people over time. One can imagine Dr. Alexander shouting, “I started it; you go the next step!”

Surely dad is glad I finally put down the nostagia and picked up a decent tool for work that honors him. — Surely dad is glad I finally put down the nostalgia and picked up a decent tool for work that honors him.

Every nook and cupboard among the health field is filled with guilds, national associations (with local chapters!), honoring this and that habitual practice and committee that made some sense long ago. They all have founders and officers—and sometimes even endowments(!)—but have long lost their capacity to cut cleanly or make useful connections. They have not moved with the science that gives more and more power to the integrated strategies managing conditions over time outside the professional enclaves. We live a long time now mainly because of better food and pharma not because we get surguries frequently. So there are way more ethical implications in the price of drugs than when or whether a surgeon does a procedure. They obstruct and no longer aid the joining of good science to good intentions. We need to honor our moral legacy with a new set of intellectual tools nearly as much as I needed a new saw.

We honor those who have given us life by acting with the creative courage they showed in their time; not by doing the same things their courage demanded then, but doing what courage demands now. We grown-up humans build things out of brick and steel. And we craft habits and patterns of power that guide the flow of money and time to the new glass towers. All these artifacts look solid and lasting, but they are as blowing sand at the beach.

Twice a day the tides wash the in-between land of the marshes.

I am typing this at St. Helena Island, South Carolina watching another morning tide move another day’s load of sand a few feet up the shore. These are called barrier islands because they protect the vital salt marshes which the tides wash twice a day, nurturing its wildly generative life. Very little important happens on the beach; all the life stuff happens in the muck and goop where the shrimp and a zillion other things are born and nurtured before heading to sea. The sand islands protect this vitality because they constantly move and adapt dynamically to the next big storm and even the next shift in climate rising the level of the seas.

Old maps tell the tale: the beaches move; the marshes live on.

In the handful of centuries white humans have settled here, the islands have moved miles. From the top of the 132 foot high light house you can see a few miles to the waves north east where the old one once stood. This new one (1889) is built to move again. Geologists know the whole chain of islands have moved back and forth for millennia. They last because they are dynamic; they serve life because they change. They are like tools built for a season of good craft.

The scope points 8 miles away and a quarter mile off shore where the lighthouse once stood.

Those of us holding positions of influence in institutions like to think our work and our organizations are the key to the life of our communities. Smart people at Stanford play to this pretense by suggesting adaptive change is dependent on “collective impact” organized by “anchor institutions.” These ideas are not just wrong, but dangerously misleading. Living communities don’t need to be impacted, but nurtured; they don’t need more anchors but heart, muscle and guts that serve movement. They do need protection from the raw tides, heavy winds and bitter storms, but protection in the service of change, not protection from it.

What else does any leader have to do that protect the creative energy so that it generates life? Do we have something better to do than that. Whether we are stewards of a church or hospital or public health agency or community health center, the life does not come from the edges, but the heart. I learned in Memphis that if I could protect the creative space for those who usually don’t have much power, they would craft beautiful and useful structure perfectly joined to the possibilities the neighborhoods needed. That process is the “Memphis Model” not the specific apparatus that emerged at that point in time. Don’t confuse the craft (mercy and care) for the cabinet (the structure) and certainly not the wobbly saw (me).

Leaders give life a chance by protecting the generative spaces in which life emerges, especially when those spaces need the complex processes over time. Any human community is way more complex than any salt marsh.

This is almost exactly the opposite of the role big institutions want to play. The leaders of the big things like hospitals can always rent consultants who are happy to tell us to tell the neighborhoods how they should live and how they should change, not us. The model for this is the old way that beach engineers tried to build concrete barriers to stop the tides and the natural shift of the sand (sort of like the one now under 40 feet of water a quarter mile from shore). The more we think like anchors, the more we’re in the way of life, which will most certainly have its way with us.

Roots are a kind of anchor that serve for a time and then not.

This is why I find surprising hope in the small stirring of faith and faithfulness in the faith-inspired healthcare systems of Stakeholder Health. Just about the time when you think smart and cynical are the same thing, along comes life to surprise us. In reality sometimes, large institutions such as foundations and hospitals can provide some shelter amid the raw power of the market forces (the “hurricane” in my extended metaphor). We can be barrier islands against the forces of raw money power, preserving the neighborhoods’ function as the salt marsh where life flourishes and creates the next generation. It actually does happen sometimes. It could happen more.

Francis Rivers Meza, one of our faculty in the FaithHealth Division, shared an article by Patricia Fernández-Kelly (2012): “Rethinking the deserving body: altruism, markets, and political action in health care provision,” in the journal Ethnic and Racial Studies. (click here for the article). She explores the way that religious organizations, including the huge ones such as hospitals, sometimes choose to act against the logic of the capital markets, providing crucial buffering for neighborhoods of poor and often stigmatized people. And they do this on purpose with craft and skill year after year. The authors cite one of our stakeholder health friends, Baptist Healthcare of South Florida and their long term work in Homestead Florida, a place that knows all about the need for barriers against storms.

Life finds a way, Jonas Salk liked to say. Jason McLennan, writing in Yes! Magazine this month says, “If there is one thing that’s certain, it’s that the future hasn’t happened yet.” Bingo! Honor both past and future by helping life finding its next way, not by protecting our old way.

The lighthouse just across the inlet above the gull. Everything moves; life finds a way.

Mapping Curiosity

These are such interesting days for hopeful people in our wildly dynamic world. Never before in the history of the species have we seen more radical emergence of vast numbers and forms of relational webs. More than two million non-governmental organizations have emerged in the last quarter century. Most of those are now morphing into a complex ecology of financial forms, mostly somewhere in between the old distinctions of faith, government, non-profit and for profit.

The technical name for our current version of we humans is homo sapiens sapiens: we are the creatures who know. And we know we know. I actually think we don’t know….much. But we are absolutely curious!

Jim tells of the curious story of the role of faith in the novel idea of "health for all." — Jim tells of the curious story of the role of faith in the novel idea of “health for all.”

Jim Cochrane leads the leading causes of life initiative. He has long argued that play should be one of the causes of life because from our first breath we poke, explore, crawl, play with our everything we can reach. Yes we do!(leadingcausesoflife.org). In recent months he has pretty much been captivated by…Emmanuel Kant because of the way he places creative freedom at the very center of human capacity.

Hope is possible because we have the capacity to think of entirely new things, and bring them to be. Almost everything nearby you this very moment is product of that creative capacity. The flat screen monitor or iPhone you are reading on which you are reading this are evidence, but indoor plumbing reflects quite a large number of creative moments, too. And there is still profound creativity going on at that end (so to speak) of human process that dwarf the iPhone for life and death significance: check out http://www.peepoople.com/ .

Because it is human, this capacity for creative freedom is social. It is rare for any of us to have a totally autonomous seminal thought of our very own. WE are creatively free, not just me or you. And the root of that social creative freedom is curiosity. When we are young it looks like play, beginning, I think with our body parts: ever watch an infant discover their toes? They are curious about them; study them and then start to figure out. Walking and the long journeys of life come quite later once we learn to talk and read.

We are curious about each others’ curiosity, which is how great creative teams thrive. My favorite new book, “The Surprising Power of Liberating Structures” (www.liberatingstructures.com) is a users guide to the social micro-structures that break and hold open the social space for us to explore what is possible in social webs. What opens up that space is not first imagination, but curiosity about what the group as a whole might discover is possible.

What you know is less interesting than that tickle just over the edge of your knowing just as the eye notices things on the periphery of clarity. The mind notices what moves, quickly ignores anything that stays the same. This isn’t always brilliant, of course. We forget things that matter and are easily distracted. The reason why we have so many rituals and reminders is precisely because we so tuned to what it not known and what might be possible. Nathan Wolfe calls that “adaptive novelty,” suggesting that humans can learn about this strategy for the billions of years virus have used that strategy.

Our most vital relationships and networks form on on a map of our curiosity. This is the terrain we walk from what we know to what we might be creatively free to do. The map of that terrain is rarely conscious, almost never on paper or even scrawled on a wall. Why not invent curiosity maps? Those would be dynamically generative and inviting.

Criterion Institute is a place of such generative mapping, which will be evident as it gathers for one of its astonishing “convergences” in Connecticut this week (http://criterioninstitute.org/convergence/). Later this week a different–but intersecting– map will emerge at the intersection of faith, peace and health at Lake Junaluska in the North Carolina mountains (www.lakejunaluska.com/peace/ ). Meanwhile, Stakeholderhealth.org vibrates with a constant flow of curious new findings about what is possible for faith and mission-driven hospitals to…..do.

Old Salem is still a place where new things might happen.

FaithHealthNC.org is a riot of things nobody thought possible that turn out to be very doable–and that we are creatively free to do. Nobody is planning all of it. We are finding ourselves living on a map of possibilities that is being drawn in real time by unlikely people asking, “what is we did ……together?” We closed the Global Health Symposium yesterday full energy because we were beginning to tune ourselves to the social network emerging from our shared hopes relationships.

Do you want a map of the future? Do you want to know what’s possible?

Map the networks of curiosity. And then live into and on that map with those you find there.

Bugs in the System

The core idea behind FaithHealth is not even smart.

It’s just not dumb.

How could there be anything dumber than a system that assumes that when people are sick, troubled and vulnerable they should be able to figure out the wild complexity of professionals and providers to get the help they need at the optimal time? In our life’s journey, every single one of us will experience times when we are dependent on the compassion of others. Some of those people may be paid, but mostly not. And some of those most trusted (family and congregation) maybe competent as well as caring, but many not.

FaithHealth focuses on weaving together a fabric of compassion that is also competent and connected to the many, many parts of the system originally designed for the noble purpose of healing and health.

This is breathtakingly… not dumb.

And it leads to breathtaking vulnerability of the most unpredictable kind because there are bugs in the system. Sometimes those bugs are metaphors for the peculiar behavior of electronic medical record systems that can humble the smartest proudest academic medical system (we know this to be true). And sometimes the bugs are the kind we hate even more—the ones with little legs.

The leading edge of FaithhealthNC is in Lexington, a tough southern town. While care teams in most churches are led by nurses, the team at First Baptist is led by Jim Tate, the former police chief of nearby High Point. Jim isn’t afraid of bugs of any kind. Recently, a community member who needed a medical test came to the attention of the church. The man had a number of mental and physical challenges, the most dramatic of which was the terrible condition of his apartment. Jim called out the men of the church, including the preacher, to do the thousand things needed to get the man to the right place at the right time ready to be treated and for sure, not alone. (FaithHealth 101). And a few bugs came along, too. Of course they did.

Who knows this better than our environmental workers who are leading us out of our antiseptic walls into the tough and troubled neighborhoods? As this issue goes to press we will be blessing the hands of the “agents of health”—the workers agreeing to accept another level of training to equip them to be our eyes, ears, hands and hearts on those tough streets where health wants to happen.

People all over the country, indeed the world, are finding their way on this new path. In April, a meeting of hospital CEOs completed an 18-month learning process in collaboration with the White House and Health and Human Services. The learnings confirmed that their faith-based and community-oriented systems could fulfill their mission even in these tough times if they learned how to move toward the socially complex patients in their communities in large-scale “weight-bearing” partnerships and, finally, committed to funding proactive mercy instead of reactive charity.

Neither faith nor health can blink or look away from complex human reality, not in one person and not at the level of the community that God so loves. We are called to the tough places and tough questions. It turns out we do not go alone. We have friends there.