Bobby Milstein, PhD, MPH – Director, System Strategy at Rethink Health

Bobby Milstein leads several ReThink Health projects focused on large-scale institutional change, including ongoing development of the ReThink Health Dynamics Model and other tools that allow leaders to negotiate their own scenarios for transforming regional health. Previously, Bobby spent 20 years planning and evaluating system-oriented initiatives at the Centers for Disease Control and Prevention (CDC), and was the principal architect of CDC’s framework for program evaluation. He received CDC’s Honor Award for Excellence in Innovation as well as Article of the Year awards for papers published in Health Affairs and Health Promotion Practice. Bobby earned a PhD in public health science from the Union Institute & University, and an MPH from Emory University. He once was a documentary filmmaker and also contributed storylines for The West Wing.

He is interviewed by Gary Gunderson, Vice President for FaithHealth at Wake Forest Baptist Medical Center, Secretary of Stakeholder Health and author of numerous books, including the newly published Speak Life.

 

Gary Gunderson: We’re here with Bobby Milstein in downtown Oakland. We’re both on a national academies roundtable on Population Health, which in my case is always a humbling experience. It’s a couple dozen stunningly brilliant people in which we spend a day listening to a mix of things that we’ve never heard of before, some of which are embarrassing that we never heard of before… so obvious as in Baltimore, where there are hundreds of thousands of kids who can’t see, and what do you do about that? Well, you go inspect their eyeballs and give them glasses, and that passes for a breakthrough novelty. You’d think in 2018 we would have figured that out.

So that really gets me to the heart of the question. You’ve led a career, a really bold and brave career in CDC and all sorts of intellectual pursuits in the service of making obvious things actually happen, and also seeing some things that are just unthinkable be thinkable. So ReThink Health, tell me where that came from and talk a little bit about the difference between thinking and rethinking.

Bobby Milstein: Yeah. Actually, it was the articulation of rethinking as a focal point of practice, that’s what drew me to the organization. I didn’t invent this word. It was actually created under very deliberate circumstances, where Laura Landy, who’d been the head of the Rippel Foundation, reached a point of frustration, thinking about what does it really take to be effective in a world where we all are given particular named problems, afflictions A through Z or disease in body part, and you start to recognize that it becomes pretty hard to see the end game of success in any one of those things within a system so badly designed and manifestly dysfunctional. And so she drew together a number of veteran change agents who’ve really been able to spark real change in the world. This includes Don Berwick, who had led the quality movement in healthcare, and Marshall Ganz who had been an organizer with Cesar Chavez and been instrumental in helping to elect Obama, Elinor Ostrom in the years even prior to winning her Nobel Prize for how we can govern common resources.

That group met quarterly to think about what do we know, what have we learned about how to achieve large scale systemic change, and it was that group that named themselves ReThink Health. They identified that as the most poignant moment of leverage for people who do care about success and making a difference, but also having the discipline to step out of the way things are going and not just do more of the same in hopes of getting a better result, but to actually have a moment of rethinking, which is almost no stopping rule to where that goes. You can rethink your tactics, you can rethink where you put money, you can rethink your relationships, you can rethink your goals and even your own ways of learning. And so rethinking is this kind of great moment of possibility. Some of it is about inventing things that have never been done, and some of it is about remembering what we might have lost or overlooked along the way.

What I sort of saw in that obviously could be an existential question about how do we, any of us, make a difference? But we also saw the possibility of making that a practice, right? Bringing a discipline to the rethinking, because it doesn’t really happen well with the unaided mind.

Gunderson: So what I’m struck of, with those other names and what I know of you, is the interplay between imagination, courage, and having a reservoir of possibilities, that you know this could happen. So imagination, courage, known possibilities, that seems to be a triangle that bounces in there. Tell me a little bit about the courage part of this.

Milstein: Yeah. Nothing changes without people doing it. Right? Systems are not given from elsewhere. For the most part, everything we experience came from somewhere, either the choices of people before or sort of the primordial forces that shaped a fragile earth. There are circumstances that we inherited, and if those aren’t working very well, then it takes a fair amount of courage to decide where is my place, or our place, in trying to make a difference? Sometimes that can seem pretty daunting and a other person’s problem, not my job. It’s a lot easier to stick within the boundaries and color within the lines and hope that other people are going to do their part, which is a pretty good way of perpetuating the status quo. So it does take some courage to say, “I am sort of a citizen of this bigger system and I’m going to focus on my role of system stewardship.”

Gunderson: So talk to me a little bit about the practical labor of getting people who frequently don’t know each other, don’t know what the other one knows, imagine whole new futures at large scale. Part of the audacity of your work and that group’s work is actually thinking at scale.

Milstein: Yeah. It begins with the individuals of course, right? People have to be able to see themselves viscerally, often, as embedded in a bigger system, and then that opens the way to rethinking their own role in that system. A big part of the way I experienced this work personally is as an insider. I learned a little bit about anthropology early in my life, and have never been able to shake that sort of dual sense of a participant and an observer, and then recognizing just the sheer variation in culture, that we create a lot of our lives together, and that can be recreated when necessary, particularly when our vital interests are concerned. So the ability to play at scale really comes from an understanding that we’re already participants in a vast enterprise, and it doesn’t take that many people to try to steer it in a new direction, but they have to have to know what they’re doing and they have to be quite disciplined about how they meet the world as it is in order to steer it toward the world as it could be.

Gunderson: I mean, those folks you described are… I just think of them and they’re brave, and they’re imaginative, and they’ve actually done stuff. You put them in a room together, something ought to happen quite differently. But of course, Don Berwick and Marshall Ganz could do that. What about someone east of Amarillo? You’re going to help our See2See Road Trip. How do you see this happening in places that aren’t famous with Nobel Prize winners?

Milstein: Well, I mean, of course that’s the danger of lifting up one person who names something that really all people do. You know, Elinor Ostrom more than anything, and she won a Nobel Prize in economics for talking about essentially politics and democracy. Right? There aren’t Nobel prizes in political science or how we relate to each other. What she was saying is how we govern the common resources that we depend … our lives and livelihoods depend on conditions that get managed, and when those are managed through an economy, there are questions of who participates in that and how does it get structured. And to kind of totally oversimplify her career’s work, the answer was that the best way of preserving fragile resources, not just temporarily but over generations, is not a strong state or an unchecked market. It’s an elaborate, vibrant democracy where people actually work out rules for how they’re going to work together or be willing to call each other when people’s individual, short-term interests are eclipsing the lives and livelihoods of others.

Gunderson: We’re in such a weird, bizarre time about exactly that sentence.

Milstein: Yeah.

Gunderson: Tell me where you’re finding the courage to do this work like today.

Milstein: I think it’s part of a recognition that, for all of the divisiveness and isolation that we feel, the flip side of that is the deep sense of belonging and interdependence. It’s really the illusion of separateness that’s the source of a lot of our troubles, and it’s the experience of interdependence that really is the source of most of the joy and courage and dedication that people feel.

Gunderson: So say that again, it’s the illusion…

Milstein: Of separateness.

Gunderson: … of separateness.

Milstein: It’s hard. If you’re really thinking pragmatically about my life, my experience, my future, or the prospects for whoever me and my people are, you don’t have to look very far to see how that’s bound up in others, right? We are not really truly separate-able very much, and this scales from making a life at a neighborhood level or in a family. I mean, we come from families. We are dependent people from day one and we are interdependent throughout our lives.

Gunderson: Who are the people in your mind when you were saying those sentences? I mean, the problem with Bobby is, you’re so, so exquisitely articulate. It’s almost like poetry. Who is in your mind when you say those things?

Milstein: Yeah. You know, it’s interesting because I can pretty quickly flash across those scales. Right? So, as you were asking that question, I was thinking about my dad.

Gunderson:You know, I could see it in your eyes.

Milstein: I really was. But at the same time, I thought about what my dad experienced in his life and the way he read the paper cover to cover every day and thought about the world that we were creating. He went to war in Korea and was… He was a photographer. That was his job in the Army, was to take pictures of the MASH units. It was actually a lot of his photography that was the source material for when they made the movie, and then the television show MASH. So he saw and photographed kind of the carnage of war, and came back and devoted his life to being a medical documentarian, and how is the growing sort of… You know, sort of medical industrial complex that we’ve built was a romantic dream that we really could be agents of healing.

In my time, I see that with some admiration. At the same time, we’ve grown a medical industrial complex and skipped our obligations to actually create healthier conditions, to actually build a society that needs less acute care and other vital… other urgent service. So I think my dad, in even in his own life, you cross scales, and then that goes on. And so the question is, in the end, where do you find your place? Where do you play? What’s your sphere of influence? For most people… everybody has to confront that one way or another, and you can make massive change from starting anywhere.

Gunderson: So last thing I want to ask you. When I was looking over some of your identity that is available Googling online…

Milstein: Oh, dear.

Gunderson: …the part I love that made the most sense was that you had furnished the plot lines for West Wing.

Milstein: Oh, well.

Gunderson: Okay, so we really need some plot lines right now. Could you give me a plot line from here to somewhere else?

Milstein: Well, first, I think asking that question is a great one because it allows people, even myself or you or folks we meet along the road, to be authors of a different story, right? That’s the

genesis of rethinking right there, and I lately, I guess I’ll say, the plot line that has most encouraged me is the recognition that there are definitely some divisive topics, and we have a media industry that’s sort of in business to amplify those things that are kind of most divisive. That’s what plays. And so if we listen to that, sort of the siren songs of what you hear on cable TV is one plot line.

The other plot lines are what I’ve come to see as kind of living legacies, renaissance stories of people who are actually truly committed to making a life together and not just living live and let live, like just ignore the neighbor. It’s really live in a way that allows others to live as well. That ethic is pretty alive and well in America. It’s not functioning, like our practice of doing it is got lots of obstacles along the way, but that plot line that when confronted with problems we tend to find solutions and stop talking about right or wrong, true or untrue, we should be talking about what works for whom, under what conditions, and that can unleash a kind of American pragmatism that is almost boundless. And I say American, I don’t even mean it to be nationalistic. The point is, a lot of American culture is… that’s a sense of building a commonwealth that we have lost as we’ve kind of constructed a marketplace that is hyper-individualistic and has eroded civic life.

Gunderson: So you, Tyler Norris, and I, we’re all roughly the same age, and from time to time … here’s Tyler, who suddenly has this just unimaginable opportunity was with cash assets to bring together a band, really of superstars. It’s like being given hundreds of millions of dollars to create Fleetwood Mac. That’s pretty cool…. Pretty cool. And you’re helping cast the plot line for what it would look like if you got the grownups together who could really do something,

Milstein: Maybe the container is for those people who have resources and institutional power, but what’s most energizing is how young people come to that. There’s a conversation that’s begun in the last several months with Youth Radio, who actually see a different kind of solutions-oriented journalism, because that’s not the story of their lives that we hear on cable TV. We live in a moment when people can tell any other kind of story they want, as long as they get together and name it.

I did spend some time with about 350 young people in Alabama, fifth grade through twelfth grade, talking about this question, about what do you depend on to be healthy and well to reach your potential? And the most poignant question that we talked about, I asked them all, “Where do you want to live when you get out of college?” They all want to go to college, of course. And they all had easy answers. “I want to live in New York City” or, “I want to live right here because this is where my…” And I asked them, “Why, what makes that place so special? You could go many places,” and they had immediate answers. This is where my family is, I want to see the world, it’s all amazing. And then I just asked them, “How do you know that in 15, 20 years, all these things that you think are so special are even going to be there?” And not many people had a good answer to that, and it really resulted in a sense of, well, I’m going to have to be part of that solution.

The last question I asked was “How do you feel about knowing that you have a lot of hard work to do?” And about a third of them answered undaunted, like I’m ready for it, bring it on. Others felt sort of unprepared, in which case … I mean, here you are in school with teachers and a world of potential capacity building around you, so go get ready. And others were unsure. They just … like, I haven’t thought about it enough. This is a new revelation, but that’s what rethinking is. You don’t make a decision instantly. You actually think it through and decide, how am I going to fit in this work? So there’s a place for everybody no matter where you encounter the scale of the problem. The narrative that has me interested is in participating in some solution.

Gunderson: Yeah. I find that story pretty exciting. A hundred kids out of 300 in Alabama. You know, John Lewis came from Alabama. He didn’t have a hundred kids with him. That’s a fair fight.

Milstein: Sure. We live in complicated times, but you think about the founding of America, how many people actually participate in the American Revolution? It wasn’t every resident of the colonies, it was a core group of people who dedicated themselves to revolution and they brought others to contribute into that work. And on the other side of it, we have a democracy that allows … or at least an appearance of a democracy that invites people to do public work together across differences.

Gunderson: So we could talk all morning, and actually we probably will talk all morning because we’re going here from onto another meeting at a roundtable. But I want to give you my book, this shameless self-promotion.

Milstein: Well that’s good.

Gunderson: But Speak Life: Crafting Mercy in a Hard-hearted Time.That’s the definition of what I look at you doing. It says, “To Bobby, who’s brave life speaks the future.” That’s yours.

Milstein: That’s great. This is going to be a page turner. And I already ordered it.

Gunderson: There we go.

Milstein: This is the perfect thing. So I’ve got this one from you, and I’m going to pass mine on to the next person I find.

Gunderson: Bobby, thanks for taking the time.

Milstein: Thank you.

Gunderson: Appreciate it.

Tom Peterson: Thanks for joining Stakeholder Health and this conversation with Gary Gunderson of Wake Forest Baptist Health and Bobby Milstein of ReThink Health. Look for our upcoming podcast, and be sure to visit stakeholderhealth.org. You’ll find a link to ReThink Health in the podcast notes. See you next time.