Dr. Soma Stout, a primary care internist and pediatrician, is Vice President, Institute for Healthcare Improvement (IHI),. She serves as Executive Lead of 100 Million Healthier Lives. Interview by Gary Gunderson.
Gunderson: This is Gary Gunderson. We’re interviewing Dr. Soma Stout in her hometown, in Scottsdale, Arizona. We’re at a meeting of the Governance Institute, where we’re both faculty, for a few days under the direction of Dr. Kevin Barnett, and let’s start right there. We’re meeting with board members. These are volunteers, significant community people, who have asked and accepted the responsibility of serving in a governance role with not-for-profit health care institutions from all over the country. It’s so striking to me that you and I have worked, and long before you knew me, your work on the front edge of fundamental transformation of health systems and the work of caring for the poor, and doing it with amazing success that’s well documented.
When we meet with board members, raising the subject of population health, most board members are still at a very primitive stage in even understanding that this is a subject that’s relevant to the work of a board member of a not-for-profit health system. The question is, obviously, we’re not at a primitive stage because there’s not been decades of amazing work done. Why are we at a primitive stage?
Stout: I divide that into soul and role. From a soul perspective, it’s actually people believing that real change is possible, to things like structural inequity or and racism, to social determinants, quote/unquote, which are everything from housing and transportation to education to income, which all may feel beyond what a healthcare system might possibly be able to take on, or more importantly, what anyone might be able to actually solve. Until we can begin to shift from a sense of scarcity into abundance or a sense of pathology, where we just talk a lot about all of those problems without talking a lot about what the solutions are, it’s difficult for people to believe in their soul that even taking on these challenges is possible.
On the role side, hospitals and health systems have been designed to be reactive to people dropping dead on the streets from infection and then from heart disease. They are designed to be repair shops, they’re not designed for prevention, and most of our efforts and our funding has gone toward the repair function and not very much to re-envisioning what the role of the health system is, or supporting the fuller role of what a health and well-being system can be as people not just survive acute illness but actually live with chronic illnesses like cancer or evolving diabetes, or where we are only beginning to understand the interrelationship between social illness and physical illness.
Gunderson: I was going to say to a board member, but pretty much to any grownup today, and you say, “Abundance, abundance, abundance, you’ve got to believe in abundance.” And they look at you like you’re from Planet Zobar, so tell a little bit about what your mom taught about abundance, and why you can see these systems like you do.
Stout: Yeah. What my mom taught me about abundance is that, you know, as we were growing up in a family that only made about 10 dollars a month at the time in Calcutta, which even in Indian standards was not …
Gunderson:Even in India, that’s not a lot.
Stout: What she would say, as we lost electricity every night and spent time on the veranda, was to look out at the world around me and see all the people who had so much less than we did, and just to really look at the gifts we had, the everything we had, and to think about how we could use what we had to transform the world around us. It was the same thing that I learned in Guyana, in the second-poorest region in the second-poorest country in the Western Hemisphere when, as I asked people with a fifth-grade education what their vision of health was, they said it was complete mental, physical, social and spiritual well-being, and was a human right for everyone. When I asked what it meant to … how that was created, they said, “Well, it’s our responsibility as a community to provide that for one another.
It’s what Parker Palmer says about what abundance is, that it’s not from any one soul hero, or secured stockpiles of goods or resources or love. It comes when we choose to put together our shared assets into a common store, and recognize and believe that we can achieve more together than we could achieve alone.
I think for me, having spent my life actually watching examples of that happening in the poorest-paid health care system in Massachusetts at Cambridge Health Alliance, whereby thinking differently about looking at our assets and saying, “How might we use what we have and partner with others who have other things, what could we do of what really needs to be done to improve the health and well-being of the poor?” Or in 100 Million Lives as I’m watching barbershops and beauty salon owners become promoters of health and well-being in a way that …
Gunderson: Tell me a little bit more about that. I find your work with SCALE communities to be so inspiring.
Stout: Oh, gosh. I would have to say, well, that the work with barbershop and beauty salon owners is Freddie Spry, and began between Freddie Spry and Steven Thomas, a pair in New Jersey … sorry, in Maryland … where Freddie was a youth who was in the school-to-prison pipeline. In fact, he was incarcerated, and he got out and he taught himself to cut hair. And as he formed his … accreted his business, he knew he wasn’t … he couldn’t go back to prison. He began creating a very simple measure of what it meant for him to create well-being in the community. If you ask him at any time, he’ll be able to tell you. The last time, he said, “It’s 18, Soma,” and that measures the number of people who were in that pipeline who aren’t anymore, because they have jobs cutting hair with him.
When Freddie, who sees himself as a contributor to his community, was then asked by Steven Thomas, who was working at the University of Maryland and knew that we couldn’t reach black communities with the traditional health methods, not just because they didn’t trust health systems but because frankly, people get their hair cut much more often and with a real relationship with their barber, as they do much more often than they might see their primary care doctor, once or twice a year… and asked Freddie if he would consider that.
They tried that out, and what they and other barbers and beauty shop owners all around the country have demonstrated is that actually 75 percent of these, the studies, that show real improvements in outcomes with simple interventions that support local people who have the power to change the health behaviors, the health education, of their peers.
What the skilled communities have demonstrated is they’ve sort of taken that knowledge and put it on steroids by growing the capability of youth, by growing the capability of community residents to create a path where they not only believe in their capability but can create their own aims and drivers for change, and where system leaders actually support the leadership of community residents to create the change that’s needed in their lives.
Which has led to efforts that used to be traditional public health efforts that failed on food insecurity to be active community transformation processes with hundreds of community residents leading, people’s lives being transformed, youth emerging as leaders, with the number of jobs, the amount of community wealth, the number of business partnerships all being created and counted as measures of health, along with people’s report of their own well-being and the well-being of their community as the kinds of indicators that they care about.
Gunderson: Besides being an extraordinarily inspiring speaker, you know all about tools. You’re vice-president of IHI, which is renowned for its extraordinary toolset, and much of those tools have been developed and aimed at and employed by thousands and thousands of professionals, who are already professionals. You’re describing the identical sort of equipping of change makers who are at radically different social positions in society. Tell me what that feels like, to transfer those tools, and tell me a little bit more about how smart that is. Go ahead.
Stout: To me, that is our fundamental strategy to unlock the trapped and untapped potential that’s needed to really create abundance in this process. Because you see, it’s not just that we have created the tools and transferred it to them. It’s that we’ve been in a collective process together of finding the tools that really lead to breakthroughs. They’ve been contributed as much by them as by us.
Over those last two years, by trusting in their leadership, rather than having four leadership academies a year that we could hold at the national level—we still do those as a train-the-trainer—these communities have held 54 leadership academies on the ground that have engaged and trained over 800 people as change makers in their communities. Those are 800 people that are regularly engaged in integrating community thriving, in addition to the hundreds of other people who are regularly involved in their community change process.
Gunderson: Where are they?
Stout: They’re all across the country, in 21 states. Now, 17 additional states have actually signed on at the state level to become States of Solutions. These are in 18 regions of solutions across places from Maricopa to Downtown Los Angeles to Laramie County, Wyoming, to Proviso Township outside of Chicago, to North and South Carolina. They’re rural and urban and suburban, they’re in every part of the political spectrum. And what’s amazing is while they still lean on us some as a support system, they lean on each other.
Gunderson: Yeah, tell me more a little bit about that, because I think what I hear in this work is the collective intelligence and the sharing of energy and the peer relationships that are shockingly not dependent on those of us in highly-privileged, educated roles.
Stout: Yeah. We planned scale at 100 Million from the perspective of generative sustainability, which means you can’t leave it dependent or even begin with the idea of it being dependent, on a small number of people who are, quote/unquote, experts who are going to teach others. You have to truly trust the capacity that’s there within residents in communities.
As someone who has watched people with a fifth-grade education who are community health workers in Guyana create some of the most transformative health outcomes in the world, I knew for certain—I have watched medical assistants and receptionists create some of the most extraordinary changes in the world—I knew without a doubt that barbershop and beauty salon owners and community residents would do the same, especially if they were supported by system leaders who didn’t see that their jobs was to create the solutions, it was to enable the solutions that were needed.
We built 100 Million in SCALE on that core idea of the wisdom in the community, both in individual communities who are then supporting the communities around them, who know much more about their context, and where it doesn’t become grant-dependent. Because they’re a sustainable resource to catalyze the transformation in communities, but also across one another.
We believe that, while we might have a few useful things to add—as the group that was working in Guyana did, as our team did at Cambridge Health Alliance— that people who are local to the problem would have many more solutions and wisdom to offer about what each other needed. By creating that network of trust with one another, I think they looked at how many changes they’d adopted from one another. Not only could 100 percent talk about things that they’d adopted, that communities had on average taken three or more things from one another.
Gunderson: Oh, really? That’s beautiful.
Gunderson: My logic would be that… what I’m hearing in all this is not just beating down the walls that protect pathology, but you’re working with the very forces of life and you see that…This is what you’d expect to see if you expect life to find a way.
Stout: Yeah. In fact, we use the Fibonacci spiral as a way of describing how a community-of-solutions process works, that you trust that even something starting small in such places grows and continues to evolve, that it is part of the law of life, that when you build things on a foundation of trust and love and abundance, of seeing what’s possible together and doing what’s right and connectedness, that you have an accelerating spiral of transformation.
Gunderson: I always enjoy talking to you, because you can flip from deep data sets to the most spiritual of language. Tell me a little bit about your own spiritual formation and your current work as Baha’i.
Stout: Sure. That’s a big question, Gary.
Gunderson: Yeah. It’s like an hour and a half answer, but if you could… Pick either question and work on that.
Stout: My ways of creating change are pretty deeply informed by being a Baha’i because Baha’is truly believe that people and communities are the protagonists of their own change, that people and communities are noble and interconnected, and that it’s actually our understanding of our interdependence, our understanding of what it means to truly believe that every people holds a part of the puzzle, a piece of the puzzle that’s needed for the healing of the world, that this work on equity isn’t about those who have much giving to those who have less, or rich versus poor. It’s actually recognizing the nobility and untapped and trapped potential of those whose voices and pieces of the puzzle haven’t been able to find their contribution to the solution we collectively need. So that pathway of walking alongside is always a pathway of mutual generativity and mutual abundance. One of the biggest things to actually stymie such a pathway is to create false dependence. This model of love, mutual learning and accompaniment is… and models for how education can be owned by people locally, under mango trees in villages, all the way to boards of directors such as here.
What it means to create the system and the system principle in your design from the beginning for that to be possible, so that those initial 18 communities could train over a hundred in the last two years, and that hundreds of others, youth from all over who bring in their own pieces of the puzzles that align to some principles and can teach others. That’s fundamental to the design of I think anything I’ve worked on. I think that some of what’s needed in the world requires smart thinking.
Some of it requires all of us to spiritually reframe who we are, how we relate to one another, and how we relate to those who are most affected by inequity. It challenges us to reframe who has the answers and what it means to be part of unleashing the solutions, and what our obligation is, if we have privilege and power, to be part of that.
Then at some fundamental level, it means that those of us who are predisposed to be the saviors need to step back and instead trust that people have not only the solutions that are needed for their own salvation, guided by all of us, all of us as children of God who have access to the world of the Spirit, but also that perhaps actually it’s others who might save us, too.
Gunderson: I was thinking of another question, and you flipped me into reflection on my own desire to be one of the ones who save, so I almost lost the track of the conversation.
Stout: This is not where I thought we would go.
Gunderson: Good preaching, Reverend.
Stout: We don’t sit or have clergy.
Gunderson: Maybe the last question would be… This is such a deeply compelling line of language and thought and practice. We’re in a time that seems so just deeply hostile, almost mocking, of the very values and the practices that your life has laid out. How do you hold those two in contrast? You know enough about the meme that you know what to hope for. How do you keep hoping?
Stout: I suppose I keep hoping because I have the best job in the world. On any given week— and I will include this one— I’ll hear from youth all around the world with their ideas, not only about what they will do, but also what they need me to do to help them. Girls from The Gambia who are transforming things, along with girls from outside of Chicago who are going to educate communities in North Carolina about a radically simple way of seeing profound change that then changes my practice.
I think I feel hopeful because I think this is a head game. I think that what’s needed is actually a reconnection just to heart and spirit. What I’ve seen is system leaders, when this isn’t approached as a head issue for the most part… There’s some head that’s needed. People need a path. They need to see that what you’re talking about actually leads to real meaning and outcomes, but people are parched for things that feel meaningful and real. Exposing them to something, to life itself, is the most effective and rejuvenating thing I know. I don’t have to convince people of things. People just have to experience that reconnection to soul and role and to admit to their core mission.
I think things like pathways to population health, on the one hand they may seem like head things, but really what they do is create pathways of people to be able to see and acknowledge reality together, and recommit in ways that are utterly accessible to them, if they have the courage to act and the agency to choose to do so, to what their core mission was that’s about why they went into health and health care in the first place.
I think seeing so many groups choose to have the courage and agency to act, to reclaim soul and role and being part of a community of change makers that go from youth to heads of federal agencies, that are choosing not to create change separately but to create change together as part of 100 Million Lives and all the other networks it is in and out of, I think that begins to create hope for me.
Gunderson: Your language is so precise. It makes me grateful that we transcribe these podcasts and don’t just listen to them audibly. The words are so perfect. I’m looking forward to reading them. You talked about the inspiration you get from watching girls around the world. I hope your mom understands who her little girl is and what she means in so many lives. Thank you for this conversation.
Stout: It was a privilege, as it always is.