Stakeholderhealth.org – garygunderson Blog

Good start

Five hundred and six pages. Thirty-three authors. A big book. So, a warning, this is sort of a big blog.

It’s about the Handbook on Religion and Health: Pathways toward a Turbulent Future (Edward Elgar, UK), which focuses on the complex way that faith at social scale, for better or worse, shapes health and well-being … so that we can make the choices that lead toward life for the people and places that are ours to love. That itself is a big sentence which hints at the need of a big book. The Handbook dares to mark a pivot toward a whole new phase in the intellectual understanding of faith and health. All of its authors, many well known in their fields, were asked to step away from what they already knew and look forward. They did that.

There have really only been three eras before now defining that relationship. The first lasted three billion years when the dimensions of what humans eventually called faith, which eventually evolved into religion and even more eventually science, were simply and utterly part of the whole.

That first era was capped by a flurry of thinking once we humans accumulated enough frontal matter that we could name ourselves boldly homo sapiens sapiens (the human that knows it knows). For all this time religion, including faeries, YHWH, Jesus and all the saints and scientists were in one intellectual stewpot for better—and often for worse in the hands of the powerful.

The first phase lasted roughly up till the “Enlightenment” in the 1700s, during which pretty much everything thought to that point was unthought. It became obvious to every rational intellectual that we didn’t really need religion at all to map what was known and knowable. Religion was intellectual detritus that obstructed clear thinking or, at best, needed to be shown to be reasonable.

The Enlightenment glow went out in the middle of the last century, seared by murderous gas ovens, nuclear blasts and, now, 129-degree summers. We’ve been in an intellectual wilderness of post-modern, post-industrial, post-constitution, post-language, post, post, post, post everything. The boundaries have evaporated including, to the dismay of the left-over Enlightenment thinkers, the rise of religion entirely untethered to any social or political norms, logic or facts.

A friend sent me this picture from National Geographic that so vividly indicates there is way more going on then we ever thought.

The echo-chamber world of academic health research with its pristine peer-reviewing world of double-blind control trials ignored all the dismal wilderness outside (making it triple-blind). But late in the day, this era acknowledged minor claims that religion was a variable in human health. Each of these footnotes squeezed through a tortuous process that fundamentally considered any signs of religiosity to be a false signal, better explained by a bio-chemistry or abnormal psychiatric phenomena. In fact, the American Psychiatric Association had disease codes for religion until the 1970s.

It is important to remember that the simplifying secularists had a point; much of what is attributed to religion—by both believers and those who scoff—is a false signal, often harnessed for tribal, parochial interests that can be stupid and dangerous, especially at political scale. And it’s important to not trash the traditional research models that were superb at knowing what they considered knowable partly by rigorously excluding things not.

Still, the end of this era was marked by the article in Journal of the American Medical Association two years ago (Balboni, VanderWelle, Doan-Soares, et al., 2022). The Harvard team laboriously sorted through thousands of articles that claimed findings of spirituality in health for the few meeting the very highest standards of peer-reviewed studies. Only a thin gruel could pass through the thin intellectual mesh, but even those findings came as a shock to the field. It is also important to note that one of the problems in associating spirituality as a variable is that nobody agrees on what it is, which suggests that maybe it doesn’t exist at all.

That study would not have happened without the four pillars that begin with the earlier Handbook by Larson and Koenig, followed by the basic texts of Oman and Idler. This is why the JAMA article marks the end of the era, making possible a new beginning.

This brings us to the 506-page start of the fourth era, the Handbook on [Formerly Known as] Religion and [Formerly Known as] Health: Pathways for a Turbulent Future. I add ‘formerly known as’ deliberately. The new era lives in the science of complexity, and multi-variant phenomenological study of complex phenomena that begins with the assumption that humans are in our every facet biological, psychological, social and spirted. Most of the traditional gatekeepers do not think that way and remain especially uncomfortable with taking the phenomena “formerly known as religion” seriously. Dr. Paul Laurienti addresses this in his chapter in the Handbook, noting that those fields are busy “harmonizing” research methodology based on the old accepted processes that methodologically exclude any surprises. “Who needs a new era?” they would ask.

The Handbook is disruptive in another whole way because it grows from the Leading Causes of Life. Even the spiritual part of the last era was driven a great deal by the spirituality interested in death, dying and the closely linked clinical chaplaincy. The era has more to work with. The Handbook (Ch. 28, pp. 456-57) argues that

“Looking at humanity as a living system invites us toward an integrative generative practice that does not collapse in the simplicities of upstream-downstream instrumental intervention. To be deeply accountable for the whole of the social watershed invites the immediacy of picking up one’s own trash before it can contaminate the lives of those to whom it would otherwise flow. And it invites humility before all that we have received for good or ill. This posture of always being both recipients of blessings we did not create and stewards of the blessings that will flow through us is what the Leading Causes of Life call intergenerativity, or simply blessing. When we are conscious of being in this right relationship–recipient and steward—we feel something like awe, gratitude and being in the right place.”

This is not good news to all the traditional researchers who have based their careers and methodology on the previous models. Even those intellectuals talking about complexity do not quite honor the complex generativity of the psycho-social-spirited phenomena. We are not an interplay of calories or protein but consciousness of the whole becoming more vital and prosilient. This is part of how “what was known as religion” functions in synergy with the thing “formerly known as health”—the vital phenomena, not just biochemical or material, but consciously alive on all levels.

While the traditional researchers will perhaps not be happy to find that their academic cheese has moved, this Handbook is a three-pound thrill for the next generations of hard thinkers. And it is happy not to conclude anything:

“Perhaps we have only begun. Neither religion or the health sciences quite thinks this way about its work or way. This is not how we collect or analyse data and thus not the way we regard the possibilities of what we might learn from research (maybe we say, formerly known as research). But even asking whether we could learn more and thus be more accountable for possibilities and cannier about risks shifts us just a bit. As is evident in other chapters in this handbook, new methodologies, new norms of transdisciplinary dialogue and analysis will emerge, just as new shared language does in El Paso, Texas, and other borderlands—objective and subjective—around the world.” (Ch. 28, p. 457)

This may not be the last 506 pages needed. But it’s a good start ….

// The Handbook on Religion and Health: Pathways for a Turbulent Future is available in hardback immediately (priced for academic libraries!), with an eBook coming in a week or two (~$48) and, we hope (not yet confirmed), a paperback to follow later. Most of my friends will wait for the paperback or eBook! I’ll let you know when they are available.

Pathway

There are times when, amid what seems like chaos, clarity comes, is named and made visible. People respond, turn around, and make choices that lead to life. The closing months of 2024 are likely this kind of time.

When the times comes—some call it Kairos—one hopes the intellectual muscles are trained and ready. It takes time to think hard, and not possible to do alone staring at tiny screens. (To get anywhere intellectually is just like hiking: “to go fast, go alone; to go far, go together”).

Friday morning, we learned that Handbook on Religion and Health: Pathways for a Turbulent Future was published. Only 1,155 days ago Jim Cochrane was asked to consider editing a volume on religion and health. TC encouraged him: “Yes! Do this and blow the field wide open!” Eventually, 33 authors from around the world typed 502 pages of very hard and explosive thinking that none of us could have done alone.

TC and I celebrated the publication at a Glasgow pub. “What’s it about?”, asked a bewildered friend, trying to be respectful. The question has come about everything I’ve ever written. The answer makes it worse, especially in a loud pub: “It’s about the intersection of faith (no, not that dumb kind!) and health (no, not the pills and machines!).” The real answer is almost too audacious to say out loud, even in a pub after more than one pint.

It’s about the leading causes of life, here, now.

“The first step in such fundamental research,” we wrote in our concluding chapter of the Handbook, “would be to understand the nature of the living system in question.In a nitty-gritty practical kind of way, confronting an ugly and terrifying contagion of polio, Jonas Salk of polio vaccine fame, knew he had to learn how to think like a virus or, as he put it, follow ‘the biological way of thought’ (Salk, 1972, pp. 7-15), before focusing on all the symptoms and damage the virus inflicts. A virus may not think in the way a human does, but in its own way it makes choices, indeed patterns of choices, as it adapts, moves as an organism inside and around the human creature that is also making choices and patterns of choices to create the ecology in which the virus finds its way. Something like this nesting of living systems is happening in every component of every living system. Part of what a virus must “consider” or “think” about is how it understands its relationship to the larger ecology of systems including the human one.

Maybe the virus has a more accurate view of what constitutes the human living system than do most humans; perhaps even those thinking about the health of the human public. A virus “sees” any one human as an inseparable part of a meshwork of other bodies offering a rich array of slightly different bio-psycho-chemistries linked in a connected social network that allows the virus to move around the entire living system as a single, if differentiated and variable, whole” (p. 453, Ch. 28: The Watershed of Life: A River Runs Through It).

The implications are profoundly hopeful for us humans. We have the intellectual leverage to break out of our doom loop of compounding stupidities. We are alive. And life has found its (our!) way for roughly three and a half billion years.

And even more hopefully, we have more to work with than any other part of the living system. We are capable of knowing ourselves (sapiens sapiens), but even more since spirit gives us the capacity to see dynamic emergent complexity that is us, in the spirited cosmos that is built for life.

“Public health science and public religion,” we also write (p. 456), “are best understood as co-creating components of a kind of consciousness of the planetary human phenomenon. The first immunizes humanity from the disease of premature certainty, the second from hubris and heart-heartedness. Science animates the religious ethical imagination by clarifying the boundaries and possibilities of mercy, while religion holds science accountable to serve all, not just whoever paid for the research or technical gizmo. Science protects religion from simply making things up, while religion protects science from overlooking the most obvious things—we are children of one family.”

The Handbook is published, but as an invitation to the hard thinking we need, it is just beginning. The official release is in Washington DC on September 27^th and 28^th, with other events planned in Minneapolis, La Crosse, Winston-Salem, Houston, Cape Town and elsewhere. The baobabs on the cover, on the website of the Leading Causes of Life Initiative , and for the preceding African Religious Health Assets Programme, are not just pretty. At every intellectual step we have figuratively gathered in the African way under the shelter of the ‘tree of life’ where we can talk deeply with each other about what matters most.

I’ve been thinking of the many people who have carried me on this spirited intellectual current, such as Reverend Larry Pray who came into my life as part of the CDC funded Institute of Public Health and Faith. The Handbook ends with the story of when he called me at the hospital in Memphis, urging me to grab the Bible he assumed (wrongly) I had on my desk. Liz Dover had one, so I was able to follow Larry to Ezekiel: “And on the banks, on both sides of the river, there will grow all kinds of trees for food. Their leaves will not wither, nor their fruit fail, but they will bear fresh fruit every month, because the water for them flows from the sanctuary. Their fruit will be for food, and their leaves for healing” (English Standard Version Bible, 2006, Exekiel 47:12).

*Double rainbow over the University of Glasgow*

Easily overlooked is the humbling chiding for us humans as the vital flow rises over our heads: “Hey, do you see the flow?” (47:6). How could we miss it? It is life itself.”

/// The Handbook on Religion and Health: Pathways for a Turbulent Future is available in hardback immediately (priced for academic libraries!) with an eBook coming in a week or two ($48), and, we anticipate (not yet confirmed), with a paperback to follow later. Most of my friends will wait for the paperback or eBook! I’ll let you know when they are available.

Community Perspective on CalAIM

Life is generous, although most humans don’t notice.

*Sunrise in God’s Acre in Old Salem, March 31, 2024*

I offer evidence, if you failed to notice the azaleas, not to mention the rising sun. I’ll point to a full bloom of creative generosity where you might not expect it—in a complicated partnership between government, healthcare and hundreds of small community-based organizations in California.

This week Stakeholder Health released some careful research into a radical innovation in how the state of California is providing health care for the poor.

Here is the link to the webinar.

Here is a link to a two-page summary of the research.

Here is a link to the full report.

In most places government and healthcare are built proudly with nonchalant acceptance of the fact that the poor live demeaning lives and then die in humiliating pain. Sorry, there’s just not enough to go around, says the hard-hearted god of the castles. Even when the poor can slither through the doors into the emergency rooms, they have little access to 21st century preventive medicine. For decades it has been clear that most of the drivers of disease and suffering are not medical and need relatively inexpensive preventative care. Most conditions that look medical are best managed by something social, mental or spiritual before leaping to the expensive pill or carving up a body part.

This is technically called the social determinants of health (SDOH) which is unhelpful language because they go way beyond social work. Everything that happens in human life has biological-psychological-social-and Spirit drivers and implications. Duh. Humans are complex and wonderfully made (Psalm 89). Even straightforward medical problems—say a broken leg, which my kid is still recovering from— has a four-fold a healing path. It works the other way, too: childhood trauma shows up as wickedly complex biological issues decades later.

The healthcare industry is not organized this way. Governmental programs usually take the head off the body and put it over in the mental health agency, then detach body parts in thousands of reimbursable codes. Everything outside one’s skin goes under a totally different set of social services agencies leaving a scrap for public health to inspect the food, chase rats and get ready for the next pandemic.

BUT now California launched the first really large-scale trial (CalAIM) using Medicaid to treat humans as they actually are—complex and wonderfully made and living in communities that are complex human systems that can care for each other. The technicians in government (usually called bureaucrats) leaned into all that complexity and got the federal government to grant a “waiver” to spend Medicaid money on a wide range of SDOH drivers. North Carolina had been lauded for talking about this. California has done it in a state five times larger following science to embrace 10 times the range of SDOH factors. Bold.

AND they are spending that money through the extraordinary array of community-based organizations. In reality, these groups have only had scraps of money from bake sales or philanthropic largess (social justice one chardonnay at a time, says Dr. Suzanne Henderson). CalAIM has put $4 billion in motion, which, even in California, is a lot of chardonnay.

AND the innovations continued by investing millions in helping community organizations strengthen their capacities to interface with governmental funding procedures. This would be impossible except for the last innovation—the government folks listen, adapt in real time and change their way of doing things, too. Note the research was paid for by CommonSpirit Health, one of the largest healthcare systems in the nation. It is rare for such systems to even be curious about the reality of community organizations, much less partner in learning. It is head-breakingly difficult to blend institutional cultures and ancient practices. Easier to shame, blame and whine. Not here.

The initiative has released creative energy and imagination through changing the work of many hundreds of organizations. Many of the groups were built from faith, which is supposed to believe in generosity and even resurrection, but settle for much less. The Stakeholder Health panel included Lutheran Services, which has been doing this kind of work for many decades, now accelerated with the partnerships. And it includes “Pneumacare” (spirit—get it?)—a collaborative that grew out of a ministerial association, now managing millions of dollars to provide care that that cares in partnership with CalAIM. And yes, the healing is for everybody of every kind of faith and no-faith, skin and language. It’s California.

You have to watch the video to hear the story of real resurrection going on and be amazed at the technical skill making it work. (Here’s the link.)

This is smart generosity, not dumb give away. It is obviously smarter to invest in what people actually need when they need it will prove less expensive than the obviously dumb current idea of waiting for their life to blow up so completely, that they then end up in an emergency room. This kind of work is hard with many technical challenges. You have to do the right things right. It breaks every day and is fixed in real time. The research reveals a bold effort still underway.

California chicken from a generous california hen.

The only unforgivable sin is to accuse God of creating a world broken from the beginning without enough for everyone. All the disciples of every religion can’t work around that because it assumes that inequity is inevitable; God’s fault, really. That sin is the root of every angry political movement. If they would open it, even You-Know-Who’s $60 Bible tells of a God who did a good job for everyone and expects us to do so, too. Turn on the lights to the most the most obvious thing in the world– there is enough for everyone. Everything works—politics, faith, family, health, food systems, housing, education—if you begin with that most obvious fact. Witness California.

Labyrinth

Lit by the light of the Milky Way, the four of us held hands to find our way through and around the labyrinth. The Ramadan moon has not yet risen, and the African air was dry enough for the light to mark the sandstones against the dark gravel. We moved in toward the center, then to the left, followed the long loop and around before heading back in and around again. The pilgrims included myself, Marcellino, a South African community activist and researcher, and TC, my Bride of many years, as well as Bastienne. She is a Greek scholar who said that we should have been dancing as the Greeks did. We did well enough. Once at the center, we paused to look up with wonder at the thousands of stars, knowing there are billions beyond our sight and depth far beyond our capacity to imagine, much less grasp. We moved back out, turning, turning, seeking, seeking. Finding our way.

Most find the labyrinth a place of personal spiritual way-finding. Who and where am I in life? Holding hands, if not quite dancing, this was not personal; it was a hint of a greater whole moving in a social labyrinth. For today it is the whole that is seems needing to find a way. More likely to see that way by starlight instead of the stultifying glow of our screens and their chattering distraction.

I have been coming to Africa for nearly forty years, always amazed by the gritty tenacious people who simply won’t give up despite ever new complexities layered on historical traumas. I’ve sat with Thomas Sankara, the iconic young leader of Burkina Faso still seen as a wayfinder by youth today because of his fierce integrity. He renamed his country “land of upright people” and then made it real. Through the blowing red dust, he told of their victorious “commando vaccination” in which they mobilized the whole society to vaccinate every child in the country (and the thousands that were brought across the border by their mothers). Killed cynically, probably by the French, his life still resonates decades later with youth desperate for heroes who might show a way in and out, back and round, maybe even forward.

This particular labyrinth was on the grounds of Goedgedacht, a bold experiment in rural development an hour and a half north of Cape Town. The name means “good thinking,” and it is a good place to see clearly how much good thinking we will all need to find our way. Here we see radically different lives in a spectrum of whites, blacks and browns speaking far more than the eleven official languages. The local poor were already poor enough without the arrival of immigrant workers from all over Africa now competing for the scarce and difficult jobs. And the local rich were rich enough without finding new ways too exaggerate their privileges. Goedgedacht grows olives from the tough dry soil to finance the rural development efforts in the villages. But it can’t qualify for the valuable “organic” label because of the pesticides that drift from the farm next door, which is literally covered in plastic to shelter their luxury crops from the blazing sun. Their neighbor’s private dam shining like a jewel out of place in that bright sun is filled from a pipe drawing water from a river 15 kilometers away. All this bizarreness is possible because of the specialty grapes and clementines grown to be shipped abroad. Nothing local about it. Maybe I’ve had one of those clementines in the US.

Only a four-dimensional labyrinth could map the difficulties of navigating such complexity. But that is what the South Africans are doing by light of the Southern Cross. Shock after shock (AIDS after Apartheid, ‘state capture’ after freedom, then COVID, then ….). Layers of ironic betrayals that would shatter the heart of any lesser people left Mandela, Tutu and millions that hoped with them in tears. But the people do not quit. They do not stop putting one foot in front of the next finding the way by not stopping.

We were at Goedgedacht to convene some of the Fellows of the Leading Causes of Life Initiative. I once thought those words were too happy and American to even speak here in such a mystifyingly difficult place. The Africans taught me that life is the only thing tough enough to work here. No simplistic professionalism, no shallow plans, brittle schemes or mere interventions. Only life can live here. Only it can find the way.

Marcellino, Sandy and Beulah helping each other find the way.

And how does it do so? By what light? We gathered around the hunch that it might be fueled by something more like joy, let us dare to say dance. The English word “joy” falls so short, but still comes closer to the way we move with just enough light to see to the next turn on the path. Never one by one; always in small groups who would be lost entirely if not held by slender and improbably threads of trust.

One of these improbabilities that lights up the sky is the Christian Institute of Southern Africa, which Goedgedacht has honored with a peace grove of 28 olive trees for the founding giants who suffered with some dying in the bitter decades of struggle against Apartheid. Built with what we now see as the sinews of life, it defied the massive structures of Apartheid. Nobody involved had any clear thought as to how it could be ended. They gathered and spoke such vivid truth that the government banned them all, preventing them from being together or even be quoted in public. Tiny, nimble and fragile looking, they nonetheless persisted, gathering support all across the globe, creating channels for funds to flow into the struggles for justice, dignity and integrity. They won their day in ways that inspire us to struggle with very different demons in ours.

We walk in their light today because they kept weaving thin webs across borders, time zones, political snares, theological lines and impossibilities of every kind. Like the Milky Way constellations, the dozens whose names we know reflect millions who we do not know who also risked everything for a future that drew them beyond the possible. Most in the movement did not get an olive tree memorial garden or even a footnote.

What do we do with this light? Their specific answer and ways of struggling are not ours. It is unlikely they were any smarter than us. Or that they would be any better than we at figuring out how to move through the current labyrinth of collapsing climate with political systems so easily gamed and tamed by the cynical powers.

We are here now, not them. And we are in our struggle, which is not exactly theirs. Their problem was nationalwith some hope to be found abroad. Ours is planetary with no help on the way at all except for the next generation. They are rising quickly, but time is short.

What can we learn except like them to act as best we can; to risk as wisely and boldly as they did with those they trusted with their lives and with the life of their hopes.

Neither they nor we could know if our very best would be enough or in time. Who can ever know that?

Hold hands with a few you trust and put one step in front. Turn, move, turn again and yet again, grateful for the light of billions of stars.

That Jesus

We pause on a day almost certainly not his birthday to consider a strange carpenter-teacher who lived two millennia ago. He was always inconveniently good news. Long before germ theory, telescopes or electricity, Jesus lived a short life before dying as a political criminal. We know about his life through scraps of stories and vignettes no longer alive to us except through translations of translations. The stories of the birth that “magnify my soul” are all radical signals of protest and defiance against the oppressive cabal of religion and empire.

Said to be the oldest baptismal pool. Naples, Italy.

Jesus was not a member of any Christian group and would probably not recognize most of the religion that claims him. Paul, whose writings shaped much of that religion, villainized and persecuted Jesus’ earliest followers before converting, never met him. Although a student of the Jewish texts, Jesus was not a writer. No home, much less an office. No wife, apparently, or kids. We don’t know his sexuality. He apparently had a brother.

He healed people seven days a week with no business model. The only times he showed up at worship, he got thrown out. He never voted or sought political power. But he was regarded by Empire and its religious toadies as a threat to order. He had no school, but did accumulate disciples. Before his movement backslid into bishops, those following him were said to follow his “Way.”

That’s the clue. I want to move through life in that “Way” and with those on that Way.

He prayed some, mostly by himself, apparently to strengthen his capacity to stay on the Way.

He said that Way was narrow and difficult, which some think means we should go single file through life. I think it means we are to walk like the Reindeer we associate with Santa, but who are also symbols of radical resilience. The early Mediterranean Christians thought of Jesus as the Lamb of God, stressing the sacrificial metaphor. They didn’t know anything about Caribou and how the herd saves each other.

Caribou–they who move through impossibly difficult circumstances following many paths that weave together and then apart and together again. I have walked their narrow, braided paths on the tundra shelves flanking the frozen Alaska rivers beneath the Brooks Range. They are called Caribou in Alaska but have the same Way that they have followed for thousands of years, moving as a company of thousands, trusting each other to find the paths across and through to where the Spirit of life draws them.

The mesh of trails suggests a social complexity beyond our simplistic theory of networks.4 This helps me imagine the adaptive possibilities as Spirit sets us free while remaining social, safe while remaining kind.

I, too, pay attention to my trusted ones on the Way: Chris and Bobby, Enrique and Maria, TC, Jim, Tom, Fred, Jeremy, Jerry, Dora, Ron and a cloud of witnesses on the move. We trust each other to stay on the journey and in sight, sometimes protecting, sometimes finding safety. The world is a dangerous place. Safety only in motion, together, on the Way.

I wonder what Jesus would say about all this. I suspect he’d wonder about all the churches from which I was not thrown out. And all the clutter I’ve accumulated beyond his one cloak and borrowed mule. My offices. All the stuff I did not give away. All the healing kindnesses left for other obligations.

I hope for grace.

And pray for a Spirit to move me onto one of those narrow paths closer to the edge of the herd as we move together over tough land for another season of life.

//// adapted from my book, “For God and the People: Prayers for a Newer New Awakening.”

*Sunset from Monkey Valley, South Africa*

Relevant Science, Mature Faith

If we ask the wrong question, our answer won’t matter. Many ask the wrong question about how to resolve the conflict between religion and science. The useful question is more nuanced: how do we embody our most mature faith and the most relevant science to inform the health of whole people? Good question. But you have to see somebody do it to understand the answer.

*John Hatch, Jeremy Moseley and Teresa Cutts asking the right questions.*

Last week about 200 people asking that question gathered in Rocky Mount, North Carolina for the Eighth Annual John W. Hatch FaithHealth Lecture. And to celebrate Dr. Hatch’s 95^th birthday. Not many black men live to be 95, so we should have a party for every one that does and think about how they did so. John began by picking his parents and grandparents wisely. They were fierce for him, believed that he should be a professor (his grandmother even considered his goal of Governor). Just as important, was inculcating him from his earliest age that his life intelligence, energy, courage and heart belong to the people God so loves—all of them. Good pick, John.

Two weeks ago THE American Public Health Association Caucus on Faith and the Public Health honored Dr. John Hatch as the first recipient of the Flame Award, given for a lifetime of keeping the flame of justice, mercy and healing alive in a hard-hearted world. We did that in Atlanta by Zoom, but Barbara Baylor, the chair of the caucus and a student of Dr. Hatch, came to Rocky Mount to give him the award in person.

The interwoven fields of public health and faith have been embodied in many significant lives in the past several hundred years as public health science has emerged.

For example, in 1737, James McCune Smith became the first African American to earn a medical degree, awarded by the University of Glasgow in Scotland. The local schools didn’t admit him, so his church connections found the way. A gifted orator and writer and social entrepreneur, he was also a mathematician. He used his statical analysis to take down Senator John C. Calhoun who was citing the US census to show that poor health of slaves reflected their inferior stock and poor behavior. Dr. Smith’s widely published scientific article showed that comparative data on free slaves and poor whites to had identical outcomes.

A binary star as our North Star—mature faith, relevant science, John Hatch embodies the most relevant science of all, the one that sets people and communities free by undergirding their own power. I’m sure he learned this science from his family example. But as I thought of him, I picked up my precious copy of “Closing the Gap” published in 1987 by Oxford Press. This CDC Conference was the idea of Jimmy Carter and Bill Foege who convened the hundreds of scientists to figure out how many years of premature death could be prevented based on what we already know. There is a lot of confusion about what we already know. Said Carter in the introduction: “This is particularly true for an issue as complex as health. Too often, Americans are confronted by messages about health that leave us with little or no hope…. Frequently, there is no mention of what I as an individual, or what we as a society, can do to arrest this relentless onslaught on our health.” The answer is about what John’s grandmother would have said:
“Approximately two-thirds of all reported deaths can be delayed, which means that 1.2 million lives and 8.4 million years of life can be preserved each year.” That next three decades dramatically increased our preventive knowledge as well as some relatively minor increases in curative science.

But science without hands, feet and heart doesn’t move from the lab to the streets. That takes mature faith, the kind that lets the science flow through generous lives to where it is needed most. Like that of John Hatch.

Shortly after their landmark report on Closing the Gap, Bill and Jimmy convened another meeting of several hundred diverse faith leaders to see if they could grasp the urgent moral moment posed by the prevention science. They also created the Interfaith Health Program with major funding from the Robert Wood Johnson Foundation as well as some from Templeton Foundation. And they hired me. I quickly learned about John Hatch, who knew every bit of this science and carried it with his body into the toughest places that needed it the very most. This included Mississippi, where he and Jack Geiger created the first (or arguably second) community health center that is still more radical than most of the 3,000 that followed. And he came to the University of North Carolina and continued his landmark work with the 1,600 churches of General Baptist State Convention.

When I say “embody” science and faith, what kind of body do I mean? Whose bodies are best suited—let us say designed by God—to be the ideal carriers of this science that could prevent two-thirds of all unnecessary and thus, scandalous, death. Who did God put in the world for that purpose, to save, dare I say, it? Well, your body and mine, of course, just as well as John’s. Why can’t you and I be as brave, smart and fierce?

*Dr. Goldie Byrd of the Maya Angelou Center for Health Equity and Dr. Hatch of the UNC Gillings School of Global Public Health*

But I think there is an even better body designed for this mature faith and relevant science. That is the social body of the church, synagogue, masjid, temple or wherever people gather to be made whole and sent out again. That’s the body that formed John. And that is the body designed to carry the science the world needs. We were, of course meeting in just one such body, the Impact Center and Tabernacle, embodying the saving science and faith in a tough town in a tough part of a tough state.

The science that saves us—at least 2/3rds of us—is for the world God so loves. It is hard to monetize and turned into money by healthcare organizations, even those trying to use value-based contracts to do so. It won’t put hundreds of billions in the basement or pay big bucks to interventional physicians or those who organize the organizations who so successfully monetize other branches of science. The science that fits mature faith perfectly is that of mercy-making, justice-doing and love that teaches people and communities that God has made a world in which 2/3rds of their suffering is within their control. This science is considered the lowest in the academic hierarchy with a tiny fraction of NIH funding. But it is the highest of all sciences because it liberates, releases and sends out the whole body of faith.

That science is relevant once it finds the right body to carry it to the streets.

The John W. Hatch FaithHealth Lecture is coordinated by Anita Holmes with support from the FaithHealth Division of Atrium Health Wake Forest Baptist. Cosponsors include the Wake Forest University School of Divinity, the General Baptist State Convention of North Carolina, Maya Angelou Center for Health Equity, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Caucus on Public Health and the Faith Community of the American Public Health Association, Community-Campus Partnerships for Health and the National Association of Community Health Associations.

More information at FaithHealth.org or StakeholderHealth.org

Potbound

Sometimes a houseplant will get too large for its clay pot. You don’t notice at first but it slows its growth as the roots circle sideways around and around in a futile strangle. Even in a new a new pot the roots will keep circling and hardly notice the new soil. Not really dead; a withered version of itself that lost the plot.

I’m talking about hospitals here, most of which were created a hundred years ago by faith and community groups who saw that the simple science of their time could benefit their communities by providing healing and justice at large scale. Hospitals were uncomplicated enough for church committees by the dozens to consider starting one with donations, led by pastors and nuns, linens sewn by congregations. Today, these roots circle inside massive brick pots, out-scaling every other local non-profit organization by a quantum; way beyond the capacities of pastors and nuns to keep them on task.

Non profit hospitals are supposed to be kept on mission by a legal tool called “community benefit,” which works about as well as a fig leaf in the Arctic. The idea of “benefit” dates from when “mission” meant giving away urgent care instead of the goal of community-scale well-being that health and social science now make possible. A recent report from the National Academies of Sciences makes the missed opportunity painfully clear (National Academies of Sciences, Engineering, and Medicine. 2023. Population Health Funding and Accountability to Community: Proceedings of a Workshop. Washington, DC: The National Academies Press. https://doi.org/10.17226/27258).

Kimberly DiGioia, a program officer at the Patient-Centered Outcomes Research Institute, provided an overview of findings from her research on the effects of Medicaid expansion on community benefit (DiGioia, 2022). About two-thirds of hospitals in the U.S. are nonprofits, spending between 8 and 9 percent of their total operating expenses on community benefits, which seems impressive. But she explained that the vast majority of community benefit spending goes toward charity care, and unreimbursed Medicaid services while a small amount of this money goes to community health improvements. This includes educating its own health professionals, subsidized health services, medical research, and smallest portion, cash and in-kind contributions to community organizations.

The passage of the Affordable Care Act, DiGioia said, raised optimism that hospitals would report more revenue and less uncompensated care and thus spend more on community health. Indeed, the evidence has shown that the more Americans are covered, the more hospitals reported increased Medicaid discharges and decreased uninsured discharges. There was indeed a decline in uncompensated care, but this was offset by an increase in unreimbursed costs associated with caring for Medicaid patients. They charged more for less care and as a result, “community health improvement spending did not increase as expected.”

Pot bound.

Instead of growing into the rich soil of community health science, health system roots just circled the pot. This is a failure of hospital governance and timid government policy, not lack of science or administrative skill. Boards never fire a CEO for bad community health; the government settles for health fairs and a mobile van.

Thousands of highly skilled administrators and staff came to the profession expecting to grow like an oak in deep soil (they don’t mention the pot in school). These are honorable people trapped in doing small things. At a recent medical school reception honoring TC and I, Dough Easterling reminded us of when we traveled across the country in a Winnebago testing the idea that “everything we hope for is already happening.” He quoted us back to ourselves:

“We traveled with the sharp awareness that we are among the privileged class, linked to institutions among the most privileged of all—academic medical centers. It is striking how little is asked of these vast organizations. In most every community the healthcare organizations are pretty much busy with running the hospital. The staff might be kind in the ER and diligent on its wards, but not likely to cross the sidewalk in solidarity with the poor and suffering. There are exceptions in every hospital, but as institutions, the expectations remain low for a reason.” (Road Trip, Stakeholder Health, 2019)

Jim, TC and me in Wilmington NC —our 29th stop 2,600 miles after leaving San Diego. Everything we hope for is happening, but often trapped in small pots.

There are three ways to approach this withering, this tragic failure to fulfill our missional DNA.

One is to ramp up community benefit regulations. Not many hospitals have the internal capacity to know how to do that kind of work, so give local public health authorities power to get intimately involved in deploying hospital funds into serious programs of prevention, social determinants and chronic condition management. Don’t count “loss” on Medicaid and Medicare or training their own medical providers. The political screaming will be deafening as the ones that own the pots resist.

Two is to simply let non-profit hospitals remain inside their acute therapy pot, but give up the pretense that their efforts have much to do with community. Treat them like banks with some, but minimal, expectations of community good. Banks have to invest actual cash in the communities they previously damaged by redlining. Hospitals should do the same in the same communities as well as providing decent access for urgent services.

Third, create a special legal category for mission-driven hospitals. The 21^st century work of advancing health at community scale needs a whole new pot. These hospitals would be like Community Health Centers (FQHC’s) that get preferential reimbursement for services that make them sustainable once they are built. Hospitals would need what they once had—preferential and protected access to borrowed capital so they could have modern technology. Treat them like missional utilities with no advertising permitted and community people on their governance Boards. True accountability is needed for meaningful integration with public health and social services, both governmental, private and faith. Restricted pay disparity between highest and lowest staff. Built for mission.

The National Academies report notes that Community Health centers offer much of this logic, but built for primary care, not acute hospital services. But why not? Every one of the major hospital systems have some hospitals they don’t actually want, that won’t ever make much money. Why not flip them to this different model?

We could do so much more with what we have. But our communities have almost given up:

Contrasted with the high enthusiasm when the hospitals were created, “the low expectations of (of hospitals) were striking—maybe for more health fairs, slightly kinder financial assistance policies, or free parking for clergy. We didn’t hear any calls for transformation, hardly any for solidarity. Yet those of us inside the institutions know how much more might be possible.” (Road Trip: Soundings. USA: Stakeholder Press, 2019).

We’ve been circling the pot. We need to break it, point the roots to deep soil and get to work.

Lost bee, found bee

That’s me on the upper right trying figure out how to talk to the guard bee at the entrance.

Forty thousand honeybees live above my parked car, which is often cluttered with beekeeping accoutrement that smells of wax and honey. It is common for a few bees to tag along for the ride. Beyond two or three miles and they can’t find home so they will circle a bit, tasting the air for a waft of nectar, resin, honey from a hive nearby. They can sense a hive vibrating with life that might welcome a lost bee laden with honey or pollen from the back of my car. Honeybees are a practical lot, unlike wasps that tend to chew up visitors.

A honeybee shares a mother with thousands of sisters with a random assortment of absentee sperm accumulated on mom’s one big day on the town. A bee is so fully integrated into the superlife of the three-pound hive that a solitary bee can hardly be thought to be imagined unless they accidentally drive away in a car. The bee has a tiny brain devoted to life and death issues such as where the nectar is, what the hive box looks like and her immediate job at hand. No brain synapses to waste on lingering affections, so in about three days she will not remember her sisters. The new sister will learn to dance among thousands of new kin until her her wings wear out in a month.

A worker bee lives about eight weeks collecting a twelfth of a teaspoon of honey. You and I live 4,750 weeks often, without producing anything as helpful. Humans exaggerate what can be done in a season, while cynical about longer transformations. Impatient foundations often force recipients to promise transformation in three years while cynically avoiding commitment to the city-sized transformations that could be realized in a half generation. Ask any bee.

I found myself thinking about these issues when I noticed that a bee was riding with me on the four-mile drive from the hospital where I used to work to my new home on the Wake Forest University. This was my hive once—I can see my freshman door room out my office window. And while academic guard bees notice my hospital scent, I do carry the equivalent of pollen for the young ones (a new course on Leading Causes of Life). And friends from South Africa, Germany, Texas, California and even Finland with sweet nectar (ideas) that might help the hive. Here’s a link to the Baobab conference we just hosted. I’m already forgetting the old ways.

Bees don’t try to teach humans anything, given our short and unpromising evolution. But they allow us to observe and notice their practical balance between intense selflessness and short term memory. We humans exaggerate our individualism, thinking that the skin-bag holding our squishy parts and three-pound brain is a functional whole. And, opposite of bees, we nurture unhelpful affiliations long after they are are relevant to our future. A bee forgets in three days; about five years for humans. This may be a bit quick for our species.

Bees are a bit ruthless in their commitment to the future, but we should also focus on the neighborhood in which we now live and the people with whom we might thrive. I’m thinking of the tortured shore east of the Mediterranean. The sad futility of my dad’s old political party. The pathetic rending of old religious groups voting about other people’s sex. Hospital systems tethered to old therapeutic techniques instead of modern population health science. Seminaries teaching the same stuff they did 180 years ago. Universities organized the way they were when I was a freshman; for that matter, when my father was a freshman and his dad, too.

(Don’t mention these last two to my new guard bees; winter is coming and I need a hive.)

Soul sick

Lisa Lumb, artist. In dialogue with her twin sister.

I am not sick to my stomach. I am sick to my soul.

The first job of any religious person is to try to make their own religion safe for the world. Every religion has a dangerous side which has at various times in the evolution of the tradition provided cover, sometimes even encouragement, to the most obviously horrible facets we humans are capable of doing to each other. Every king, thug, despot, gang leader and e-gazillionaire has a chaplain willing to cheer them up when they are sad and encourage them when angry. Every castle had a chapel, even when it did not have flush toilets.

As a follower of a Jewish man named Jesus, I am sharply aware that people have done, in the name of my religion, some of the same repulsive things done in Israel this week. Hamas didn’t do anything that the Crusaders hadn’t wraught a millennia ago on the very same land.

My daughter is married to a Jewish man, with both my grandsons raised to respect and participate in the rituals of Jewish life. We just built a Sukkah shelter together that we bought on Amazon. They are San Francisco moderns, sophisticated and proud of lots of things no longer believed. They let a Baptist sit in the Seat of Elijah for the circumcision. And those kids are more likely to go to Burning Man or a trance music festival in Israel one day than church.

I am sick to my soul.

This weekend a couple dozen authors and scholars from Africa, Europe and the US will gather at Wake Forest University to blend our thinking toward a book published next year about religion and health. We meet in sharp awareness that many would wish for no religion at all.

I can’t blame anyone who looks at history and concludes that we should try a culture with no religion of any kind. I thought we were heading that way, as rational secular science-based logic was all the rage way back at the end of the 20^th century. It turns out that there is something in the human being that simply must tether beyond ourselves to ultimate meanings. Call it Spirit. Homo sapiens spiritus. We all have an ember that will flame for good or evil beyond all imagination.

Any of us brave enough to accept identity with one of the great traditions is responsible to see that the others of that tradition do not use that religious cover for heinous actions toward people of other religions; or those who are simply going about their life down the street in Hroza, Gaza or Winston-Salem. We say clearly that any religion—especially our own–that is comfortable with gross inequity in the distribution of things God intends for everbody should be rejected by the larger world as fraudulent. If one’s religion is not good for the whole world it obviously is not linked to the God who created the human species with nearly infinite variations of thought and imagination. Any religion that is not good for the whole world is dangerous to our small planet. Let us not leave that to secular people to say; it is our responsibility.

Practically, only a Christian can engage a dangerous Christian. Same for every other religion. This is not without risks, as some of the most virulent emotion is between people who share the same religious identity. But only an older white male Baptist can deal with the leadership of the minority group of older white male Baptists showing dangerous tendencies in public toward people within punching range. No Muslim, Jew or Sikh can sort out a crazed Baptist. That’s on us Baptists. And I’ll count on y’all to keep your extremists away from my grandsons.

The heinous savagery degrades all religion. Every faith favors humility, hospitality, kindness, generosity and peacefulness—especially toward strangers. And every religion violates every one of those time and again when it fails to hold itself accountable to its own teachings.

Today a kind of prayer beyond words lives in my soul, sick with sorrow.

Social, now

The top floor of Baylor Scott and White hospital is dark wood, deep carpet and lots of glass, out of which one can see Dallas stretching to the dusty horizon. A physician noted that the people visible to the southeast near the Ferris wheel tend to die about 12 years sooner than those on the other side the same distance from the hospital. This is why I was there talking about the “social determinants” of health and what religion has to do with them. You’ll notice the phrase has two problems, “social” (when it really means “non-medical”) and, worse, “determinants” (when it really means variables). Hospital leaders hear about these factors a lot these days, but nearly all the problem and possibilities called social lie on the other side of the sidewalk outside their control.

The school is way more important than the hospital. Two scholars (Case and Deaton) sifted life expectancy data to clarify that people who don’t graduate from college tended to die 8 years younger. It’s not because the books would have taught them health-related tips. College is a social marker, mainly about one’s parents social position which is a big boost toward the student’s. Hospitals are pouring money into new IT to see what social determinant things such as food and short-term housing that their patients need. That is nice but misses the point. And it misses where to work.

It may surprise the well-educated, but not those on the downside of the data. The two thirds of Americans who did not go to college know all about early death; no wonder they are angry and vote with fury.

Social is the thing that happens when people talk to each other. In this case, at Tova Coffee House in Lubbock, TX

In 2008 the World Health Organization commissioned a global study on these poorly named factors, led by Dr. Marmot, who was famous for noticing that life expectancy decreased in a step-wise factor with each click down in social position within bureaucracy. The 2008 report said sharply that “social determinants can be more important than health care or lifestyle choices in influencing health.…studies suggest that SDH account for between 30-55% of health outcomes. ….the contribution of sectors outside health to population health outcomes exceeds the contribution from the health sector.” We’ve wanted to blame the doctors and the hospitals when the problem falls on all the rest of us.

The critical role of social drivers has two inconvenient implications for hospitals and one for people of faith. Hospitals have been happy with the assumption that they are the key to extending the health to everybody who can see their large buildings. Modern healthcare is mind-numbingly expensive. The business model draws from a deep well of borrowed money from nervous bankers requiring vast reserves to ensure they are paid back. The weird irony is that hospitals look like they have a lot of money, but it is reserved for the banks, not the neighborhoods. Everybody hates this.

Hospitals are legally obligated to provide “community benefit” but nearly all of it pays for expensive free care offered inside their tall buildings. Some count medical education (of doctors, not the patients). In some states they count the loss between what government pays for Medicare and Medicaid and the actual cost. Less than a nickel of every community benefit dollar goes to anything in community. Everyone involved hates that, too.

We should release the hospitals from the unrealistic expectation they can do what they’re not designed to do. They deserve tax benefit for giving so much care to people who can’t pay. We don’t want citizens dying, writhing on the streets. But—and this is the inconvenient part—we should no longer pretend that hospitals can solve what all the rest of us need to be accountable for. If hospitals can’t do it, they shouldn’t get political credit for pretending to try. Let the money follow the science to where health is created: especially the schools, social supports and public health that advances the health of everybody.

The day after speaking in Dallas, I was on a Stakeholder Health Zoom, a sophisticated group that knows all about this cruel reality. We we talked about how to get the money and attention out the door and into the streets. One promising clue is the rapid spread of communities using the Vital Conditions and the Thriving Together document to approach the radical complexity of assets in community. This has already sparked an extraordinary 53-agency Federal Working Group to advance health for “all people, no exceptions” at that level. We just have to do the same at the local level.

As I was preparing for the Dallas lectures, I came across a note that President Carter sent me when I was leaving his Center to go over to Emory University. He was not impressed. And he would not be any more impressed with my recent move to Wake Forest University Div School.

He hates needless theory when there is something practical to do. And he hates pretending that someone else should do what we can do any Saturday. Science says that health comes from people being in the right relationship to each other. It always has.

That the power of the social.