Gary Gunderson and Dora Barilla are hosts of the Stakeholder Health podcast. Teresa Cutts, Ph.D,. is Asst. Research Professor, Wake Forest School of Medicine, PHS, Dept. of Social Science and Health Policy and co-leader of the Stakeholder Health Secretariat. She is the co-editor of the recently published book Stakeholder Health: Insights from New Systems of Health.
Dora Barilla: Hi, TC and Gary, great to connect with you again. I know the last time we spoke you were just about to head out for your sea-to-sea road trip and preparing for that and really sharing with some of our listeners what the purpose of that. And since then you’ve actually gone on your trip and had some great stops from around the country and we’re just dying to hear about the great fun you guys had and why you did this in the first place, where you went and what are some of the great learnings that came out of all of that?
Gary Gunderson: Well almost exactly two months ago we left from San Diego and drove 3,400 miles up through San Bernardino, over to Phoenix to Tucson, up to Lubbock, over to Dallas, and ended up in Wilmington. And the point of it, it was a little bit of a called bluff, maybe started out as a joke in which we said, “You know, everything we hoped for is already happening.” And those of us who work at national scale, either in really large health systems that are trying to make dozens of hospitals move into a new age, or with national groups like the American Public Health Association, or ReThink Health. Those of us who live in these national patterns all the time, think that things are not happening that actually are happening. And so, that was the heart of our curiosity, whether or not things were actually going on down at the root.
So, that is what we did. We decided to do the exact opposite of a national meeting. A national meeting is where you gather together 10 or 12 or 30 examples that are really inspiring and are producing amazing outcomes. You bring them together, and then you give them 20 minutes, they have a power point and they are on a panel, and we think we have learned about what we saw. What we did was the exact opposite of that. We drove to the sites. We spent time in little churches and little offices. Not in hospitals, not in hotel meeting rooms, and we didn’t have any power points. We met with people who had a lot of power, and they had a big point, were dedicating their lives, and we had a chance to listen carefully, in context, to what they were actually doing. It’s a very different kind of learning. I mean, we go to national meetings, and probably still will, but I hope we are humbled as so-called national leaders, by the intelligence and integrative practice that we saw all along the way across these United States, in those nearly three weeks of learning.
Barilla: You know, TC, offline you have just shared with me the hope that this has given you about our country. Want to share a little bit about what really gives you hope, and why was it so inspirational to go through this road trip?
Teresa Cutts: Well, happy new year, Dora, let me start with that. And say that, I had renewed hope from meeting with all these Stakeholders, because they all were just digging in, doing their work, despite the divisiveness that we are bombarded with all the time in the media, currently in our governmental leaders, et cetera. None of the Stakeholders that we met on the ground had that perspective. In fact, many of them worked in really highly contentious areas, with Stakeholders locally that had different views. For example, in Lubbock, they say that Lubbock is the most conservative city in the country, and we met with some fairly progressive folks at the health department, and community organizations. But they had a great sense of humor about who they were working with, how they could reach across these divisive issues, values, politics, and beliefs. They were just doing the job despite those potential barriers.
Gunderson: So, let me fill in a little bit of color to Lubbock. So in Lubbock… Imagine this, talk about divisive, the city fathers of Lubbock actually tried to abolish the public health department. They bulldozed the public health department office, replaced it with a fire department that was big enough to hold this big, mongo firefighting machine that they had bought that wouldn’t fit in their other firehouse. And then realized, “Yeah, well, we are still going to have Zika, we are still going to have a few public health problems, so we will have a little bit of public health.”
They hired this brilliant woman, born and raised in DC, married in Austin, came to Lubbock with her husband to go to law school. And she took on this challenge, as only a mom would, to in a sense, reinvent Lubbock public health. And, has built the department back up from, it got down to two employees, up to 26. You know, you don’t just do that by invading and declaring, and sort of forcing things to happen. You do it with all the interpersonal skills that it takes to succeed in a tough place. And she is like our… She inspired us about how people at community level are finding ways to work.
It’s not Pollyanna, it’s tough, but finding ways to work eyeball-to-eyeball with people who, if we were just believing the national scale divisiveness, you think it would even be possible. But at local community scale, people who do disagree with each other find ways to come together and do the practical work of caring for their community, and simply not allowing the abstractions to divide them. So we saw that place, after place, after place, after place. It was actually quite humbling to see it in motion.
Barilla: You know, as you ventured out on this, there was probably a lot of things that you were expecting to see, in terms of what was going right. But what surprised you the most?
Gunderson: Every single place had its own particular kind of surprise. One of the things that, I think humbled me and surprised me… Because I get invited to talk to national meetings about exactly these kinds of things, so I am supposed to know. But what I actually saw, was the canniness of local leaders. I’m thinking of the first place we stopped in east San Diego, with a group of pastors. They thought we wanted to hear about their cardiovascular intervention program and prevention program, just drop dead brilliant work. But what was actually going on in east San Diego, was way more than this.
This group of pastors had learned how to care and support each other, even while they were competing, all trying to grow mostly African American and Hispanic churches in a real tough part of town. They had found how to work together and create a web of trust, that was at the very moment they were talking to us about cardiovascular prevention, about a mile down the street which we passed in our Winnebago on the way, they were having a big street fair that was about street violence and interpersonal violence, and behavioral health.
While we were meeting with them, one of the pastors got a text that was donating 47 frozen turkeys and, “Do you want them?” And so he interrupted our meeting and sort of naturally said, “Do we want the turkeys?” “Yup.” “I’ll go get them.” Slipped out the door, came back, and was managing frozen turkey distribution. At the same time, they’re bouncing effortlessly from dealing with cardiovascular risk, violence, interpersonal stuff, and someone came in looking for food while we were there.
So, the actual integrative practice that goes on in normal local work, is considerably more sophisticated than the national, sort of abstractions we find. Where, you know, we tend to talk one issue, then that issue, then that issue. The actual integrative practice is already going on at community and it is wicked smart. The surprise to me, was how these local groups in every single case, sort of knew what it as that they thought we wanted to hear, and were able to craft the part of their very complex story to sort of fit what they thought was out narrow interest.
So they thought we were hospital people, and they would tell the hospital story. But what was actually going on, was way more complex, integrative, sophisticated, than one little slice of it. And once they found out that we were faith health, had the same sort of integrative, broad interests that they did, the story opened up quite broadly. And in every case, had both greater scope of vision going forward, and the history was much richer than just this or that, single issue focus that they thought we might want to hear. This has big implications for how hospitals relate to the community.
Cutts: And Dora, one of the biggest surprises for me was actually a validation of what we have seen in our faith community work. When we work with faith community entities, often times it’s the smallest and the least resourced group that is the most powerful. They do the most, they are the stewards of what resources they are able to pull their way. And we saw that. We saw that many of these tiny not-for-profits were just doing some incredible work on the ground. And that was both surprising and validating to us in terms of how is mirrors what we see in many faith community relationships.
Gunderson: One of the other things that should not have surprised us, but did, was many of the projects—I’m thinking especially in Phoenix and Loma Linda—that many of the key actors there had been at this work for decades, after decades, after decades. So what looks like a population health intervention, is actually just one more fruit of 50 years of patient building, of interpersonal trust across all sorts of lines. It’s way smarter, more tenacious, than just plugging in this project to that practice.
The work in Phoenix that we saw was, you know, looked like a mental health center. And there was brilliant counseling going on there, and a very smart integration with a federally qualified health center. But when you looked into, what is the story with these murals on the walls? They all go back to Cesar Chavez, and his initial great success in doing the organizing to outlaw the short-handled hoe. No one uses short-handled hoes anymore, but that was the instrument of choice for farm workers. And it’s back breaking, literally breaking the back of the workers. When that was outlawed, the therapist said, “You know, once you stay in a tradition that was able to do that, everything else is a lot easier.”
But the short-handled hoe also leads, in every possible direction, about what does the organized, systemic, deep values of a community that knows how to protect itself and care about its most vulnerable, what is possible for them to aspire to is way more than just one more healthcare intervention, or one little project. They have a very expansive vision. So the long momentum we saw in a number of these project was responsible for the long vision forward too.
Barilla: Yes, I know. I think that is so key, in terms of just a paradigm shift in our thinking, as we think about this. In so many ways, just in terms of the leadership skills that we think are necessary. You know, in an MBA, it is very different than working in community, and I think having that and really shining a light on that is so important, because this work is so complex. It’s not linear. You can’t always put in a nice Excel spreadsheet with a strategy map, from here to 18 months. I think just sharing that story was just inspiring to me. But also in terms of a paradigm shift, I often think we often do the mapping, and TC and I love the data, and to look at the data. But so often we look at what we call the hotspots, and these are the negative things that are happening in a community. And really, what you guys did was really identified the bright spots in our country.
So as you think about those bright spots, I’m sure you saw some patterns that we can begin to put on a map. You guys want to share a little bit about what those patterns were that you saw around the country?
Gunderson: One of the patterns is the bright spots grow from the dark spots. And that these are not the opposite, the bright spots. I’m thinking of every single place we went, but of course we stopped with TC’s family in Memphis, and went down to the amazing work of the Delta Health Center that John Hatch started more than 50 years ago. Well, it’s still going down there.
We went down there the day before Thanksgiving, and the docs were there taking care of people. And TC is the one who ought to tell that story, but there in the very heart of the most deeply entrenched, successfully oppressive white power, emerged this extraordinary bright spot. The very first community health center in the United States, there are now thousands of them. But that bright spot emerged where it was darkest, and I didn’t fully understand that story.
After going to the health center, TC and her brother took us over to where Fannie Lou Hamer is buried. We stood there at that grave of this amazing woman, who was radicalized in her forties, and became one of the most amazing voices on behalf of justice and mercy. She was fired, when she registered to vote, from working on a plantation. So her witness emerged from the darkest imaginable spot, and she and her husband became a brilliant bright light that all of us see by today.
Well, I didn’t quite realize that my wife, TC, and her twin sister were born about 600 feet from where Fannie Lou Hamer is buried today. And so, what I saw, what inspired me, was how closely you find the dark and the bright. They are not separate, they don’t come in different places, they are deeply linked. Maybe TC ought to tell that story better than me.
Cutts: Oh, I totally agree with that. And I would say that another common pattern that we saw in all the people that we met with, the wonderful organizations, and Stakeholders, and leaders, many of them from the grassroots, was that they just did the work. They plodded along, they kept their head down, they kept doing the work. When I think of Fannie Lou Hamer, she was a great heroine because she continued to do the work even though she was almost beaten to death in jail, lost her job, her home had been threatened with bombs, and been shot at many, many, many times. And almost every one of the Stakeholder groups that we met with in the different sites, had that sort of ethic of “We are going to do the work no matter what.”
We often site a poem by Marge Piercy, called, “Be of Use” that talks about people we love, the people that jump into the work headfirst, and they keep doing the work no matter what. They do what has to be done, again, and again. And that was sort of that work ethic, and that perseverance, and this care for the poor. “We are going to do what needs to be done for those that need it, no matter what.” That was truly inspiring.
Gunderson: I have to tell when we visited with Larry James, who was the real iconic leader of City Square in downtown Dallas, and Larry and I have known each other a long, long time, well before Stakeholder Health existed. In the conversation, this very complex, kind of national scale model of excellence and large scale work in downtown Dallas, I asked Larry, I said, “Well how on Earth does all this happen?” And he just sort of looked at me, and he said, “Well, we come to work every day. And then we work all day. And then we come back the next day.”
As we were talking with his other leaders there, I thought of my spiritual icon Walter Rauschenbusch, a great author of the social gospel in the 1900s. I commented to Larry, I said, “You know, Rauschenbusch died in despair after leading one of the greatest movements in American history, that still informs how we do our work today.” I said, “What do you think about that?” He just looked at me. We were quiet for a while, and he said, “I could understand that.” He said, “But I would rather die in despair, than live detached from reality.”
I think part of what we saw was the witness that people in many different settings, who purposefully extended their lives into a place where they are daily experiencing the traumas and the pains- in many cases I’m thinking of the Precious Miracles Ministry, the traumas and the pains that have continued over centuries. Not just a couple bad years, or a downturn in the stock market, but intentionally subjecting to live in tension with some of the most bitter realities in these United States. And they do it year, after year, after year, after year. So they are sustained by a kind of spirit that goes way beyond this sort of happy chatter that frequently we hear from microphones. But these are very tough might-ed people that keep themselves soft and exposed to people in great need.
Barilla: Yes, you know, I think that is so important to identify that, Gary. Because as you look at this work, and the importance of it, and really understanding that… I work in Providence St. Joseph Health, and just looking at the amazing work that the sisters have done throughout the years, and really their encouragement, and their attention to being present to those that you are serving, just so important. So thank you for sharing that story, that is just beautiful.
As you know, large health systems want to support a lot of this work, and other organizations. You talked about some of the great heroes that you saw along the way. Any recommendations to big systems, and larger organizations that want to support the great work that is already in progress? You know, what can we do to support it, to not make it so hard, but not to mess up the great work that is going on?
Gunderson: I guess I come away from this trip, and it’s important to say, we are still discerning, we are still getting back the corrected site visit notes, so we are recording this a little bit before we have fully digested in, so consider this whole conversation a bit of a first draft. But I work in a health system, and Stakeholder are all these well-meaning health systems trying to do the right thing. But we are very wrong if we assume that our communities see us in the way that we see ourselves.
For the most part, the community partners that we visited with, they were a little bit surprised that we actually wanted to really hear their story. Many of them are accustomed to thinking of our health systems not as allies, but as potential donors, but as potential funders. And they don’t really have a very high expectation that we share their values of mercy and justice enough to disrupt our normal way of doing business. And frankly, I think as the arrow of population health moves forward, and we are deeply aware of the scientific implications of the role of social drivers and health outcomes, we are just barely one little toe into the future that is going to level the relationship between healthcare systems and those who share the work really embedded in the social realities of our community.
Right now, we are treated like donors, and we sort of treat our community partners a little bit like supplicants. That is not scientifically grounded, it is not adequate. We are going to have to do way, way better than that. And we will know we are getting somewhere when we are as transparent with our community partners about the cost and value of what we are really doing, as we expect them to be in grant applications or partner applications. We have to move into a much more radically transparent relationship with our community partners than any hospital I know of currently is.
Cutts: I would just add to that, that for health systems, the recommendation would be to try to develop and cultivate a humble spirit. You know, try to build flat, horizontal, more equal partnerships with people in the community, instead of as Gary said, the sort of donor-like relationship. Where community organizations come with their hands out begging for things. That is big order for a health system, of course. But most heath systems still use their own language, they see community work as running a project, or even setting up a service line, which is crazy idea, of course. Gary often says, you certainly wouldn’t want to live in any community that was run like a hospital service line. I think that community groups to have the intelligence, and health systems need to begin to recognize that, and honor that, respect it in these partnerships. I frankly think if we could figure any way to measure it, many of these really small, struggling not-for-profits probably have 100 percent more effective stewardship in terms of their return on investment dollar-for-dollar and what they are able to do with their meager resources than many hospitals. So we can learn from them.
Barilla: Yes, that is really key, TC. I think one of the things that we have been thinking about, in terms of thinking about data, and how do hospitals and communities always want to measure that? I have often though that it is really about the relationship and the partnership that we should be measuring, versus the health outcome. Because if we don’t get that right, we are not going to get the right health outcome.
Gunderson: Dora, the other thing I was going to say, is as I am reflecting on this trip now, I came away somewhat radicalized about how to live in my own life, and how I am living my institutional life, beyond what I was previously. I think it is important. We started this trip while the Paradise fires were burning. So one of our Stakeholder partners was just watching a community they love, and cared, and served literally melt right in front of their eyes, in just a horrific manner. We ended this trip in Wilmington, literally in tears with a group of chaplains who were telling the stories of trying to serve a community and a hospital that was literally underwater. You can drive for miles in the environs of Wilmington, and you will see 10-, 15-foot high piles of debris of communities that, frankly, don’t have any chance to come back.
The radical nature of the large scale forces bearing down on us, and I am thinking of climate change and the human role in this, and the profound role that hospitals play, not just as the largest employers, but often one of the largest environmental consumers of energy and resources of every kind. Those of us who work in healthcare today are in enormously privileged positions, and we have not given a full accounting of our stewardship for our privileges and roles. We have just got to go way more.
So I was standing on the Wilmington beach, and this is the most minor footnote imaginable, but I stood on the Wilmington beach, and I said, “You know, I have got to change my life.” And Jerry Winslow, who frequently meddles as only an ethicist can, had pointed out to me that if I quit eating meat it would be just like driving an electric car. And if I wanted to do something real that would remind me every time I sat down to eat, of a commitment that began to change my life slightly, I ought to go meatless. Ever since I stood on that Wilmington beach on the 28th of November, I have been a vegetarian.
Well, you know, that doesn’t mean anything. Unless, it also means that I carry that consciousness into my role of influence as vice president of a health system. And with the other Stakeholder learners I bring that consciousness into the learning about how we can collectively lead our institutions to live into this very radical moment.
Barilla: Well, the thought of Gary being more radicalized is a little bit frightening. This trip must have been really influential, but I look forward to learning and hearing more about that, because I think that you have really inspired me to get out. I’m going to dust off my Winnebago, and I’m sure you are inspiring others. So as we go out into our communities, maybe we want to hear the power points in very different ways, in terms of listening to our community’s wisdom and power, and hearing what their points are.
Any wisdom to those that are wanting to do this? Or if you were to do it again, what would you do differently?
Gunderson: We are sort of eager, I think this was like a first draft of a different way of learning, and one of the things we didn’t quite get right, is how do you collectively do this learning? When we do this again, we want to have it be something that would be easier for a number of the Stakeholder partners to sort of come along, or visit with us, or meet us in different communities. I mean, we engaged hundreds of people along the way, but it was still pretty much just a handful of us actually doing the traveling. So we are looking for a way to do this more collaboratively.
You could do a See2See road trip in any one county. Our Texas friends, we said, “Well you could spend two weeks, three weeks, four weeks, five weeks in a Winnebago just going around Texas, and learning almost as rich a variety as we did across the country.” We actually talked with dear friends at University of Texas El Paso, about doing a sort of cross boarders See2See literally walking from site to site, but crossing the border, being on both sides of the border, and doing the same sort of careful listening that we drove to do. You could actually see worlds that overlapped this contested border right now. We literally sat in a conference room in Texas, El Paso, and looked out the window, and you could see the border. 4,000 students, every single day walk across that border and come to class, and walk back. Well, I would sort of like to walk with them, and sort of demilitarize the border, and make it transparent for the kind of learning that would change us all.
Barilla: Yes, you know, as you think about the narrative that you guys are sharing with me, and just the narrative that you say is going on around the country, what recommendations to you guys have in terms of, how do we scale this narrative throughout our country? And what do we need to start thinking about and doing differently in our community work?
Cutts: That is a tall order, Dora. You know, one of the thoughts I had when we were corresponding offline, was that the narrative that I would love to scale is a very basic one. Which is that compassion and care for the underserved or the poor or the least of these, and that is insert whatever vulnerable population you would like to there, is really alive and kicking. It’s dynamic, it’s not dead, it’s vital. It’s got its own spirit.
Gunderson: The way I would frame it is, anytime you hear yourself, or you are in a meeting, or you are in a committee meeting, that anybody says, “Nobody is doing-” and then dot, dot, dot, dot. You can assume that somebody is actually doing what it is you think nobody is doing. And that includes, nobody is listening, no one is integrating, no one is trying something, no one is being bold enough. The fact is, everything that we hope for is actually happening.
It may not be happening everywhere, but literally in every community large enough to think about having a Starbucks, probably there is many of the components of some of the most sophisticated, integrative work that we would hope for, is going on. And they are not waiting for grants, they are not waiting for a national consultant, they are not waiting for a national healthcare system to tell them that they ought to do it, or how to do it. They are just plugging in and doing it. And in many cases, they have been doing it with quite sophisticated local integrity for decades.
I think the real counsel is, we have to be humble. It’s easy to talk about these big, integrative strategies at national scale. Where it is really hard to do it, is on the streets of northeast Lubbock. And, it turns out, people are trying to do it on the streets of northeast Lubbock. If we would humble ourselves, pay attentions to the actual practices that they are pursuing in order to do that, we would learn a lot.
Barilla: I think of, you know just always being kind and gentle in what we have to do today. And Gary and TC, you have really inspired me to be bold and unflinching in the calling that I have in my life, and hopefully for other people. How can we be a better, more loving and more just way in the world? And I am looking forward to your notes, and to learning. But also, really helping to spread this type of learning, Gary and TC. So, any kind of next steps? Or engagement with Stakeholder Health, or engagement in local communities, that you can recommend so that we can think about this being bold and unflinching in our leadership, and in really helping to support this new way of learning.
Gunderson: I don’t think we are going to try the Winnebago again, I think TC may have mentioned that it was a whole lot like driving a U-Haul across the United States, and it was a little bit like being inside a washing machine inside a U-Haul. So it wasn’t the long, kind of thoughtful dialogue that we had anticipated. But I can promise you, we are going to get back on the road again. And I am very eager to have a rhythm where, at least within Stakeholder Health, we can be asking ourselves, where is the next journey of learning that we are going to be doing together? Instead of, where is the next national meeting?
I would love to start in Seattle and drive to Minneapolis, and almost any place you dropped a thread along the road you would find a whole new set of surprises and amazing people who don’t know they are amazing, to learn from. So I am pretty sure we will be back on the road again. We will have the trip notes from this ready to share, we are hoping in late February, maybe early March. The Stakeholder Health Advisory Council meets at the ACI meeting in Chicago in middle-March. We will probably have this report ready for them and be eager to share it.
Cutts: And just to add to that, one of the things we would love to do is see other people take up the gauntlet to do these micro See2See tours. As Gary mentioned, you could do one across a county. And, frankly, the cost of even going across the country and even with a much larger vehicle, and unwieldily vehicle, than we needed actually, was much, much cheaper than it would have cost us to run a national meeting for even 50 to 100 people. So it’s very resource-savvy, I would say, this strategy.
Gunderson: So, Dora, I can’t end this interview without thanking the leaders and the supporters of Stakeholder Health. We really did this with some money that came from healthcare systems, a little bit of left over money from an earlier project that we did, but this turned out to be an efficient way to learn. So, we are going to do this some more. It’s always true in Stakeholder, that the first dollar in comes from the learning health systems themselves. And they continue to give all of us in Stakeholder an enormous amount of latitude to be brave in following our learning curiosity where it leads. I never thought I would be in a Winnebago across the United States, but there you go. If you really care enough to want to learn something transformational, no telling where it will lead.
Barilla: I am thinking of incorporating this into a new standard in our frameworks for community health needs assessments, Gary, that could be our mark to look at. “Did you do the See2See tour in your county?” And really, really encouraging that different way of learning. But I think also, Gary and TC, another way for us to continue this See2See tour, is just our continued podcast, and going and talking to interesting people and having conversations about what is happening.
I look forward to continuing that with you throughout the year, and picking up until we have our next See2See road trip, Gary, and learning all the great things. And I know that, TC, we are going to be talking about data in the near future, and just really thinking about all of this work in a different lens, and really supporting some of the great stuff that is already happening.
Cutts: We can’t wait. Let’s do it.
Gunderson: That is a great, I think that is a great last note.
Barilla: Yes, well you guys have a great day, and thank you. I’m sure our listeners are going to be excited to get the notes and look forward to hearing more.
Barilla: Thank you.
Gary Gunderson: Thanks, Dora.