Doug Easterling is a Professor in the Department of Social Sciences and Health Policy at Wake Forest School of Medicine, and served as department chair from 2005-2015. His research and consulting focus on community-based approaches to improving health and quality of life, with a special emphasis on the work of foundations. Over the past 15 years, he has served as an evaluator, strategic advisor, learning coach and facilitator for more than 30 national, state, and local foundations. Prior to joining the faculty at Wake Forest, Doug served as the Director of Research and Evaluation at The Colorado Trust, a health foundation in Denver. For seven years, he oversaw the foundation’s evaluation process and developed initiatives to build the research capacity of community-based organizations. Doug holds a Ph.D. in Public Policy and Management from the University of Pennsylvania, an M.A. in Quantitative Psychology from the University of North Carolina (Chapel Hill), and a B.A. from Carleton College.
Interview with Gary Gunderson
Gunderson: This is Gary Gunderson. I’m talking with Dr. Doug Easterling in his office at the Innovation Quarter. He was part of the public health sciences division here before it was in the Innovation Quarter. Been here at Wake some time, at UNCG before that, a long history in the field of public health. But an unusually thoughtful perspective on public health. And a lot of your work these days, which we really want to focus on, is what I would call at the intersection of different forms of privilege with different structures that are supposed to be designed for the good of the public. So, these are not patient, individual-focused structures, these aren’t clinical operations for the most part. These are structures really designed to achieve a public good. And that’s a little bit different frame than most public health scientists would think of. And lots and lots of public health science is either focused on clinical operations or the formal structures of public health, public health agencies. And it seems to me your work, especially since I’ve known you, over the six years I’ve been here as a colleague, is at an even more interesting and sort of ambiguous place between privilege and structure, but still for the good of the public. So, how did you find your way into this life? Give me a little journey map of how you came into this work.
Easterling: Okay. So, probably the place to start would be actually right after I graduated from college, this is Carlton, Minnesota, and like most liberal arts graduates, I was sort of lost and clueless, and thought that I…
Gunderson: “Lost and clueless.”
Easterling: I tried a couple job interviews with corporations, and flunked. Essentially could not answer the questions.
Gunderson: Yeah, I’m not thinking that went well.
Easterling: So, it’s like, “What’s plan B for someone who doesn’t know what they’re doing?” And that turned out to be going into VISTA. So it’s 1978, so Marge Tabankin and Sam Brown are heading up the agency that ran VISTA. And a lot of us at Carlton ended up at VISTA, and community organizing, because of a professor we had there, Paul Wellstone.
Easterling: The first thing you think of with Paul is the tragedy of his death, but so many of us were touched by him in ways that gave us a sense of something larger in life, and our own responsibility, and especially coming from a liberal arts school with a lot of colleagues — not myself, but a lot of colleagues — who came from wealth. How do you use that? What’s your responsibility going into the world? And how do you actually make a difference with all that? So, not that VISTA told me how to make a difference, but it at least got me immersed in the world, and was a probably deeper education than I’d had at Carlton. So, that gave me an orientation towards community organizing, community development, and the value of working at a community level. I bring that up simply as sort of context for the journey that took me into research and eventually took me into public policy, thinking that policy was the way to get to high-leverage impact, especially for social change.
I didn’t actually get into public health till I left college. I was focused on environmental policy, but ended up at a health foundation in Colorado in 1992, Colorado Trust, which is, we’ll talk probably later about health conversion foundations, but was one of the early ones.
And its emphasis was on helping communities identify, name, and solve their own problems by providing resources, frames for decision-making, consensus-building expertise, some funding. But much more than that was the idea of actually creating a platform and a forum for people to come together across lines of difference and kind of grapple with things that were bigger than they normally do in life. And so, that’s my orientation to public health, is not so much the health aspect of it, but the community change piece, and communities working together in ways that they don’t normally do, to get to larger purpose and larger impact.
Gunderson: So many people in public health, particularly those on the research side of public health, would find that that body of thought impossibly large, and boundless, and therefore unresearchable, and because it’s not researchable, really unthinkable. And therefore, unactionable. And you would say?
Easterling: I would say, that’s where I was for the first five years of this work. No, actually, it just causes you to think about, quote, “an intervention” at a different level. So typically, public health people think about intervention in terms of educational interventions or policy change. Policy is an intervention, a new policy. And that’s different than how clinicians think about how you get to health improvement.
But when you work in a foundation, and you think about how to use money to incentivize people and organizations to do stuff differently, you can either just give away money through requests for proposals or talking to your friends and talking about what you might do together. But the idea is, can a foundation actually design a way of solving problems, or a way of building the capacity of organizations that deliver these services?
And to the extent that that can actually be codified in a replicable way to say, “Yeah, here’s the theory that tells us how organizations develop, how community work well together or not.” That’s the theory, what kind of practices are aligned with the theory as being good practice? Which are antithetical to getting to impact?
And then, the foundation’s job is to bring that together, instill it in a way that actually is actionable, and then put that out as either a required way of doing business, or suggested way of doing business. And again, use money to incentivize people to try something they never would have on their own.
Gunderson: So, you and Allen Smart, another dear colleague of ours here in Winston, wrote a gorgeous piece for Stakeholder Health book, and we’ll put a link to that piece when we post this podcast. But part of what you and Allen did that I found really helpful, in that body of work is sort of mapping an ecology, which I would now call an ecology of privilege, that can be, should be held accountable for the results of its privilege. And your work, especially recently, has focused very particularly on the smaller local, regional, and state foundations, but also Clinton Foundation. So the range of these different foundations. How do you regard the state of the field? Is the thing called a foundation a good thing for a society to be allowing? Should we just tax it, and put it into governmental public health? Does this turn out to be the right way? A lot of very successful, sort of the young billionaires, are frequently bypassing foundations. I’m thinking the eBay enterprise of going directly towards a social investment strategy for change. How are you feeling about …
Easterling: So, there’s a really important piece that appeared in Business Review in 1999, by Michael Porter and Mark Kramer, on creating value. The same Mark Kramer that came up collective impact years later. I have a lot more love for the first one than I do for the second one. That article made the point that foundations essentially live in a privileged position, partly because they’re wealthy, but mostly, from his standpoint, because of their tax advantage. They don’t pay taxes on the wealth that gets diverted to a foundation. Their argument in this article was that foundations have to do the most they can to maximize the value-add of their investments. So you can think of it as return on investment, but I would think of it more as creating value for the investment, social value.
And they had a nice little comparison of the simplistic transactional approach to philanthropy, where you just give money away to folks that you like. You know, your own favorite charities. It’s essentially transactional, checkbook philanthropy. And the value from that is essentially, you put a dollar in, you get a dollar worth of services, and the foundation is essentially just a pass-through for making things happen. That article set the stage for the rethinking of what foundations should be doing, and how they should think of their money, and kind of ushered in strategic philanthropy. Which is, how do we find leverage as a foundation, to make bigger things happen than we could have by just giving money away?
And there are a number of things that we’ve learned over the past 20 years about the unique position foundations are in, through things like advocacy, awareness raising, convening, capacity-building. All these things that essentially allowed the work to get better, as opposed to simply throwing money through it.
The downside to this is, as foundations think they can do more, their heads get even bigger sometimes. And then they imagine that they are the center of the universe, and that everybody should essentially get on board with their ideas. And so, we’ve seen some forms of strategic philanthropy that are bad ideas gone amok, where they put money behind it, they roll the money out, they get people to do things they wouldn’t otherwise do. And those are not good things. Those are not things that are in line with their mission, or even add to social value. They may subtract.
Gunderson: I can’t help but share with those listening. So, as we were setting up the microphones, he used the phrase “drunk on wealth.” And I’ve been mulling on, “Well, you know, there are different kinds of drunks. Some are sort of friendly and happy drunks, and sort of fun for their friends to be around because they buy beer for them. And there are angry drunks and proud drunks, and sort of aggressive drunks.” There are different kinds, there are different ways. But what you’re mapping is, there are different ways that foundations can be disoriented by their very privilege.
Easterling: Right. And I think one thing that foundations have a very easy time doing is getting people to come to their table. So they invite people in. And sometimes they’re just inviting them in for a conversation that someone else is facilitating. Sometimes it’s relationship brokering. But sometimes they invite them in to a table that’s essentially the foundation’s preferred way of solving problems, or what they’ve learned from the literature. And some of what foundations did, especially 10 years ago, around comprehensive community initiatives and place-based philanthropy, some of that work was essentially inviting people in to a toxic process where you take the turf issues that naturally exist among nonprofits and you throw money into it in a way that causes people to just get vicious with each other. And that’s, to me, a great example of how foundations can do harm by giving away money, and why it’s so important to be not just, quote, “strategic,” but to be sensitive, to be informed, to be responsible on the front end.
Gunderson: So, what’s public health science have to do with this? I’m sort of … In some sense, as we talk about this, much of your way of speaking reminds me of an anthropologist and the particular species you’re interested in are these people who work in philanthropy. How do you hold this change theory accountable to public health science, and vice versa?
Easterling: So, probably one of the easiest ways to talk about that is kind of what public health can tell us about where health comes from, or why some people are healthier than other people. And we talk a lot, now, about “your zip code matters.” So we recognize that the social context within which people grow up, the neighborhoods, the schools that people go to, whether or not healthy food is available locally, versus just 7-11s, all those things make a huge difference in terms of what people have access to and what sorts of norms they grow up with, things like that.
So the more we learn from public health about where health comes from, the more it gives insight as to where there are points of intervention, and what any of us, any institution, can do to essentially make a difference on health, as opposed to either just deliver services or give away money. So moving that to a science, from simply epidemiology to intervention public health, the question is, again, what kinds of strategies are effective in moving people, organizations, communities, societies, policy to being more health-promoting, life-promoting?
And so, that’s where the science comes in. A lot of it that I do is essentially trying to evaluate the strategies and the interventions that foundations often just come up with on their own. Sometimes foundations will actually adopt and disseminate and fund research-based interventions, at either a client, organizational, or community level. But that’s the interface between public health as a science and philanthropy and community health as something that we’re all trying to make better.
Gunderson: So I want to go a little different way, in the sense that public health as we know it is a field that emerged in a particular time of history, in a time of optimistic democracy, where we believed that we could create forms of collaboration, and even taxation, and public will and public structure, to accomplish public good. That sounds naïve and a long time ago, in a time right now where we’re in such a venomous and toxic culture, in which we’re filled with instructions to be afraid of different kinds of things and often afraid of things that don’t matter, and not to be afraid of things that really, really matter. How do you think about your work, in the context of where our democracy is right now, the viability of our public structures? We’re going to do the trinity next, and then… I don’t know when we’ll get this edited and podcast, but we’re 11 days away from an election right now, so it’s on my mind.
Easterling: Yeah. Am I free to go beyond philanthropy at this point?
Easterling: Am I free to go beyond philanthropy at this point?
Gunderson: Sure. Oh, absolutely. No, I just dragged you sort of out of sight of philanthropy, and into …
Easterling: So, I think the question is: do we need new institutions, or do we just need existing institutions to reform themselves and grow up? The thing that’s always challenged me is, if you’re looking at getting to society through a policy route, it’s essentially got clear pathways, and it’s got levers. And there are levers at the level of elected officials and government, and we assume that if we can get our elected officials to be responsive, and sane, and act according to the shared values that we all live by, or want to live by, that they’ll enact the right policies that will get the institutions to operate in the right way, and deliver the services we want, and we’ll create the sorts of laws that keep us working together and playing together, and loving together, in a good way.
So that actually kind of follows the personal trajectory I was telling you about. I went back and got my PhD in public policy, thinking that was a way to have positive impact on the world. And when I got back … When I left that program, and went into philanthropy, it was coming back to community. And the question is … I mean, I’ve got a lot of faith in community-level problem solving, and relationship building. The kind of conversations and deliberation that can happen at a community level are completely different than the politicized stuff that happens either in D.C. or in anonymized conversations on the web, or just competing TV stations.
But the question is kind of, what is the institutional structure that holds those community conversations, and what are the institutional structures that positive community conversations can inform? So, if we trust people in conversation to get to the truth of what really matters, how do those conversations get institutionalized? How do they get translated into not just structures, but norms, and relationships, and systems, and networks, that are the things that actually do keep us in bounds from kind of spinning out of control?
Gunderson:I was talking, I had this same format of conversation yesterday, with Dr. John Hatch, who is 90 years old this year and is an icon in the field of public health. I kept trying to get him to talk in more concrete institutional terms, and public health science terms, about what we ought to be doing, and what we ought to be prioritizing. And he just wouldn’t do it. And at one point, in sort of his gentle but clearly frustrated manner, he said, “Well, Gary, you know what it comes down to is, a community can’t possibly be healthier than its relationships and its values.” And it struck me as an extraordinarily profound observation. And I said, “Well, John, whose business is that?” A hospital would say, “Well, we can’t, that’s a little out of our scope.” And a traditional public health would say, “Uh,” and it would just sort of stall at that scope. But the idea that the work of those of us who care about the health of the public are in the work of creating the possibilities of well-lived lives at the scale of community, that’s a real different framing. But that actually accords. I know you’ve worked with small foundations that are very community-based, and have become integrated into the real texture and life of community, at sort of human scale. That’s a different way of thinking about your body of work, as a body of life work.
Easterling:It is. I love that orientation, and I couldn’t agree more. It fits directly with some of the social capital work that I was involved with with some of the community foundations. Going back to 2000, and Bob Putnam was in the middle of this process. This was when he wrote the book Bowling Alone, which, social capital was the driver of all sorts of things that make for the kind of life you want to live, whether that’s health, wealth, civic engagement, things like that.
Social capital is this notion of just how we’re connected to each other, and it has lots of different dimensions of it, whether we’re talking about the people who are like us that we’re close to, the people who are different from us that we’re close to. Putnam also kind of moves it into the realm of civic engagement, and being part of institutions and associations and things.
The part of social capital that to me has always been at the core is trust, this notion of how much we trust each other. And that’s something that we can think of both individually, so how much I trust you, Gary, how much I trust our CEO, how much I trust people across town who I don’t know right now. So trust can be thought of in that interpersonal way, and that’s often how we frame it as well. “I don’t know enough to trust you,” or something.
But trust also turns out to be something that’s endemic to ourselves. Each of us has a propensity to trust, and that propensity to trust others plays a huge role in terms of how healthy we are. It’s also tied to optimism and things like that, and it’s related to causes of life, it’s right in the middle of all that. So the question, then, is why do different people have different propensities to trust? How much of that is life experience? How much of that is growing up in deprived contexts, where you don’t have resources, where you really can’t trust the people around you, because of crime or something? But it points towards lots of things we should be doing to get to health. And I want to just kind of underline this by talking about the differences between the communities that took part in that social capital survey. There’s one question that was in the survey, which is a simple question. It says: “In general, do you think most people can be trusted? Or you can’t be too careful?”
So, both of those are reasonable responses, that makes for a very good survey item. You can’t just pick one. But people tend towards one or the other. And if you’re forced to make a choice, you’ll go to one or the other. And there are reasons that you would choose one or the other, probably good reasons.
The point is, if you aggregate the responses across a community, and say, “Well, what percentage of people believe that most people can be trusted in a community?” That on average is about 50 percent, about 50 percent of people are on either side of that. Well, some places that took part in the survey, it was 92 percent said most people can be trusted. Those tended to be small towns in South Dakota, where everybody looked like each other, and they all came from either Norway or Sweden. Some places, like Houston and LA, it was about 12 or 14 percent. And there’s a very direct correlation between how much racial and ethnic diversity there is in a community and how much people trust each other.
So, that’s a fact of life. We trust people who look like us. And if we’re living in communities where we all look alike and think alike, and came from the same grandparents or great-grandparents, there isn’t a whole lot of reason for us to mistrust each other, except, “That person never paid me back 10 years ago.” But if you go to a place like a city, that is full of life and diversity and all the riches that come from diversity, the flip side of that is that it’s a place where people are suspicious, and they don’t reach out to each other. They don’t lend a hand. And people don’t feel as supported and nurtured as you would in a place where you can count on your neighbors.
So, to me, that opens the door to all sorts of things that don’t feel like public health, but are at the core of what makes a person feel supported and open, and optimistic, in order to be healthy. And it creates opportunities for foundations, it creates opportunities for healthcare institutions. All of us have roles to play in hitting on that leverage point of health.
Gunderson: As you know, part of the pivotal experience in my so-called career work was in Memphis, which is one of the regions which, in that trust survey, is very low. And when we talked about the logic of creating a relationship between the faith-based treatment system, the hospital and the faith-based health systems, the congregations, we said the only way to do that is to create a web of trust. These are not relationships that can be purchased, or mandated. They can only be built at the speed of trust, and on trust. And the most astonishing thing, as I reflect back on that, is that the mostly African-American clergy in Memphis did not burst out in laughter at the preposterous idea that you could construct a web of trust. So, frequently we talk about trust as if it’s sort of a found asset, but you actually can create it. You can build structure, and maybe a trellis on which trust could grow, that would be strong enough to actually create a different prospect for community.
So, I’m sort of following the thread of your work, and that actually is a body of work. You could do it on purpose, you could do it well or badly, you can do it strategically or whimsically. You can do it drunk on wealth, or you can do it out of a respect for the assets of a community. I’m just really tantalized by the whole idea that trust is the key to health and you can work on it.
Easterling: So, one of the most fascinating, and challenging, and often discouraging, but in the end enlightening experiences I had was facilitating the ECHO Council in Winston-Salem, for five years. That was a very diverse group of community leaders, some clergy, some corporate, some nonprofit, from across the community, who were interested in building social capital, and especially trust. And it brought up this whole question of, “Well, how do you actually build trust?” And different people had very different conceptions of not only what trust was, but the process of building trust.
And one of the really interesting distinctions was a split down the middle between people who would say, “I’m not going to work with you until I trust you.” And for those people it was, “All right, in order for me to trust you, I have to know you. And so, we have to have conversation, I have to understand where you’re coming from. I have to be clear that you understand where I’m coming from, and that you respect that. And eventually, through that sort of shared conversation, we will come to a point that we begin to trust each other, and now we can start doing stuff together.”
Other half of the room, mostly business people, are like, “Get over it. That’s not how you build trust. You build trust by doing stuff together. And you do it together, and then eventually you start to get to know each other, and then you trust each other. But you don’t wait to do stuff together until you trust each other. You do stuff together, and you get trust out of that.” And it was just this kind of fascinating, yin-yang kind of thing. It was like, they’re both right, obviously. How do you marry those two things?
Gunderson: So this was a little while ago. I would expect that would be the more dramatically challenging today.
Easterling: Especially because we have become so divided that we cannot do things together with the people we mistrust. We’re just in different camps. We live in different worlds; we’re not even listening to the same conversations. If we don’t have these spaces for coming together with people who are different from us, we will never do the work or have the conversations that lead to trust.
Gunderson: Let me connect that body of hard-won wisdom with the current context, in which department of public health, the Medicaid agencies, every hospital, every philanthropy, is now moving under at least dialogue with the notion that social determinants are really the critical thing to get right. And so, we’re all moving out of our institutional confines, into community that is a place fractured without trust. So… what?
Easterling: What do you do?
Gunderson: Help, Doug.
Easterling: The point of reference here is the study that Robert Wood Johnson funded us to do. Thirty-three health conversion foundations formed through the sale of a nonprofit hospital health system, that are focused on social determinants. And the point of the study was to figure out, “What are they doing? What kind of progress are they making?” And one of the interesting things was — this ties back to the notion of being strategic — that the idea of going upstream is viewed as a strategic move on the part of a foundation. It’s like, “Well, we don’t want to just fund the same FQHC year after year, and subsidize their services. It’s great that the FQHC is there, that they’re doing work, but our money needs to be creating something bigger and longer-lasting.”
And one way to get additional leverage is by saying, “Well, let’s look at what truly is making a difference on health.” So I go back to exactly the same conversation, around the social determinants, education, economics, do people have a job. Do they have the transportation they need to get to a job, the kind of housing they live in, all those sorts of things.
And so, when, especially, the county health rankings and roadmaps framework came out that Dave Kindig was behind, and said only 20 percent of health is determined by healthcare, the rest is by this whole range of other things, largely personal behavior and social determinants, and economic determinants. The foundations said, “Yeah, that’s right.” And even though they came out of hospitals, they were broad enough in their thinking and their board representation to say, “We should be thinking about, focusing on other work.” So it’s like, “Yeah, we’re going to raise the social determinants flag. We’re going to go upstream. That means we’re being strategic.” And it’s like, “Well, sort of. You’ve kind of found a little angle that says yeah, there’s more to health than healthcare. Social determinants are critical. But you have not addressed the issue at all of how you’re going to make a difference on the social determinants. So, where’s the leverage in any of these things?”
And a lot of what the health conversion foundations are focusing on are education, whether that’s educational attainment, or early childhood. Economic development, whether that’s individual workforce development or community economic development.
But by far the one area the most foundations are working on was on civic infrastructure, community development, social fabric, all these kinds of things we’re talking about. And there’s a lot of experimentation going on out there. Some of it’s leadership development, so we’ve got more grassroots leaders. Some of it is about bringing people together in forums that allow them to have these kinds of conversations. There are some new models out there for communities coming to terms with the issues and the forces and the history that have divided them, especially true in the South. A lot of that involves hearing one another’s stories. This is the Community Heart & Soul project that we evaluated for the Orton Family Foundation.
So, there are ways to essentially bring a structured approach to, whether it’s community conversations or community dialogue or exchange, that intentionally creates a laboratory setting, or a hothouse for the work that needs to happen, that leads to the kinds of relationships that lead to trust, that lead to engagement. The challenge is, what needs to be in place before that kind of intervention ever works?
Gunderson: There have to be some seminal relationships, a little trellis of relationships that precede structure. I’m a person of faith, I think God has already implanted the seed of those in every community, so they’re already there. But you’ve got to realize how important they are, nurture them, and …
Easterling: And you’ve got to have enough people like that, as those seeds in the community, who are willing to put up their own trellis and say, “Yeah, I’m going to be the one who’s going to invite people over to my dining room, and we’re going to talk this through. And I’m going to invite people who don’t look like me.” And that becomes the basis for learning at least. Maybe those relationships take off and go deep, but at the very least, people come out smarter and wiser.
Gunderson: So, I was in Walnut Cove, a community that most of our podcast listeners will not know where it is, but it’s out in the corner of Forsyth County, that at one point was listed in High Times magazine as the best place to find drugs in North Carolina. And the pastor there had asked to talk to us, because he was really interested, had a real heart for his community, about both behavioral health issues, but just straight-up issues of dentistry and access to primary care. And we were talking about the challenges of dealing with radical difference, even in Walnut Cove. And I said, “Well, you know, really normal people know how to be kind to each other.” And he said, “Yeah well, Gary, the problem is, we’re running out of normal people.” But my hunch is, there are probably enough normal people at least to actually build back with, if we realize how critical that is.
Easterling: Yeah. I know Walnut Cove a little bit, enough to know that there are lots of Hairstons in Walnut Cove. And half the Hairstons are white, and half of them are African-American. And tracing back to the same plantations, a long time ago.
But the point is that some of these communities, the relationships are so deeply entrenched, and along with those relationships the mistrust, and the norms for how things get done. What’s been interesting, when we did the social capital work in Winston, is that it was largely people who had moved to Winston who were willing to jump in and have these new conversations. And I think that’s the question, is, who are the right seeds in any given community, to start the ball rolling in a way that just shifts our willingness to even trust each other enough to have a conversation? Which eventually gets us to the point of, “You know what, we could actually do something different here than we did in the past.”
Gunderson: I want to end with, go from Walnut Cove to South Hope. And you and Lucinda live in what is now, I think, the most beautiful valley in all of the Appalachians. And you’re there on purpose, and I know that’s restorative and healing, and strengthening, for how you live. You walk out of your back door and walk up Mount Mitchell, I believe.
Gunderson: You could, you probably don’t do that very frequently, but at least knowing it’s out there probably changes the way you see the world, and how you write. Tell me a little bit about where you are in your stage of life right now, what nature has to do with sustaining you.
Easterling: It has always been a major part of sustaining me, being able to get out. And in some ways it’s ironic, that I need to get away from people to do the kind of work I do, which is so oriented around people and community. But it’s, again, a yin-yang kind of thing, phases of the moon, whatever you want to call it. There are points where you just have to go inside, and sometimes that’s literally going inside yourself, but often that means going into sanctuary type of places, which for me are typically natural settings. Spent a lot of time in the Rocky Mountain states and lived in Colorado for a number of years. Go back there very often. And hiking is a meditative approach that is not only where the ideas come from, but where the sanity comes from.
Gunderson: Well, we’re going to end with this. I’m looking forward to continuing our conversation over pizza with TC and Lucinda in a little bit, but thank you for this time. And I know the folks listening in are going to appreciate it too. Thanks a lot, Doug.
Easterling: I really appreciated this, thanks.