Soma Stout, MD, MS is the Executive External Lead for Health Improvement for the Institute for Healthcare Improvement and serves as Executive Lead of 100 Million Healthier Lives, which brings together hundreds of partners across communities to support 100 million people globally to live healthier lives by 2020. She also directs the Innovation Fellows Program at the Harvard Medical School Center for Primary Care and is Lead Transformation Adviser at the Cambridge Health Alliance (CHA).
Dr. Stout is deeply committed to improving the health and wellbeing of underserved people and communities and has worked as a primary care doctor in the safety net for over 15 years. Previously, she served as Vice President for Patient Centered Medical Home Development at CHA, where she led a whole system transformation that garnered numerous national awards for achieving breakthrough results in the Triple Aim. In 2012, she was awarded the Robert Wood Johnson Foundation Young Leader Award for her contributions to improving the health of the nation.
Interview by Gary Gunderson.
Stakeholder: Let’s start with a little bit about your background.
Stout: I began on this journey to figure out what it takes to support well-being and people in less fortunate communities when I was a kid growing up in India in a family that made about ten dollars a month. My mom had an amazing ability to see the gifts that people have and to build on strengths and to develop a sense of service. In India every night I would see from the veranda people on the streets or living in shantytowns with no electricity. I didn’t see them when I first came to the U.S., but when I got to Harvard for my undergrad, I suddenly saw them again and I didn’t understand. I understood why they were there in India. Poor people had moved from the villages often together as families and you put people in relationship with one another. You didn’t think there was something wrong with them because they were poor.
Whereas in the U.S. when I began talking with the homeless men and women of Harvard Square and hearing their stories it became clear that poverty in the U.S. is very different. It was a poverty of social isolation, stigma, and mental health issues. Also, it seemed like something was fundamentally missing in a system in the wealthiest country, outside the wealthiest university in the world. A simple technology like housing hadn’t been equitably distributed. I loved molecular biology and could imagine making wonderful contributions developing new therapies but I couldn’t be confident that those technologies would be equitably distributed either. So I became interested in understanding what decisions lead to communities that are thriving, especially in places that have historically not had a great deal.
I ended up getting my public health background in the UC-Berkeley/UCSF joint medical program. Along with my medical degree, I was in Guyana learning from the second poorest country in the Western Hemisphere with a non-governmental organization that had only a little health background and an enormous amount of knowledge gained from the community’s approaches to social and economic development. They saw that the purpose of development was to unlock the capacity within those communities to create health and well-being for themselves. These communities didn’t have a lot materially but they had a deep and coherent sense of what it meant to be a community. They understood that health wasn’t something that somebody else delivered to them but rather something that they needed to create for one another.
All the rest of my career has been applying those core principles that understood people and communities as noble, as having enormous gifts and trapped and untapped potential that could be released through effective processes. And that you didn’t have to know the answers at the beginning, you just have to have a humble spirit of learning and improvement and a willingness to change to do what was needed.
I came back to the Boston area for my residency. In my first job out of residency, I was asked to start a new community health center in one of the Harvard Health System’s Cambridge Health Alliances and within six months was asked to also take over the hospital of service. I didn’t know that you were not supposed to do that in partnership with communities, so from the very beginning we worked with our local health departments and community-based organizations to address things in the community. Within a couple of years applying the methods that I had learned in Guyana we created what became a national model.
I was elected the president of the medical staff when Massachusetts’ healthcare reform financing shifts happened, and our system had to figure out how to survive them. In that moment of survival, instead of focusing only on what was going wrong, we decided to create a vision of what we wanted to be in 2015. We applied those skills from Guyana and it took us on a journey to think about — as a public health system, working with two hospitals and twelve community health departments — what it meant to improve the well-being of a population that had historically had poor health outcomes because of the social drivers of health.
I quickly realized that it was the social and behavioral drivers of health that were creating the poor health outcomes. What was crazy was how easy it was to get to outcomes, both within the community of Revere and Everett and across the entire 130,000 people we served. We were able to take 10 percent of costs out and improve health and well-being outcomes substantially. You know, mostly because we created changes from the population up rather than from our own theory about what it took to create change and again applying those principles that I had learned in Guyana.
It was really that same journey — once I realized that it was those determinants — it became clear that that’s not how most people were thinking about health care reform. So I began to wonder what it would be like as we saw people having that same “ah-ha” moment across places. What would it be like to be a community of people working together to learn what it looks like to improve health and well-being in our country and scale? That was what brought me to 100 Million Healthier Lives, which I now serve as executive over at IHI.
Stakeholder: One of the hallmarks of the 100 Million Healthier Lives effort has been an explicit respect for the potential of the younger leaders, the ones who still think of themselves as students. Would you share what you learned about transformation from the 3,000 students who were part of your experience in Guyana?
Stout: I was a student when I got to Guyana, and they used me as a person coming in from the outside who could give a different point of view. I was convinced that I would have no value to them and that it would just be me learning — and I still maintain that it was 90 percent me gaining value and 10 percent them gaining value. What was remarkable was seeing that my insights could be useful. I could notice that if the program depended on people coming in from the outside, and if the capacity of people to take over the program wasn’t developed, that it wouldn’t be sustainable. I could notice that they had only up to a fifth-grade education and that meant teachers went up only to the fifth grade and then went back to teach the kids. This system of trickle-down education over the generations didn’t necessarily lead to great health outcomes. So there were contributions that I could make as a student.
Similarly, there were community health workers, villagers, and teachers with no more than a fifth-grade education who had brilliant ideas about how to improve health. When those community members took over the development process that you began to see things like malaria rates decrease by 90 percent while eliminating malnutrition among widows. They figured out how to remove — absolutely eliminate — acquired developmental delay. I realized that it wasn’t the experts who figured out how to do that, it was the people who came to it with a different perspective, who actually weren’t burdened by too much of an idea of what the solutions were. They actually looked at what was going on and created the local solutions. I came to value those fresh perspectives of people who didn’t have the traditional view because, frankly, if the traditional view could have solved it, it probably would already be solved.
So at the Cambridge Health Alliance, we had students — from engineering students to art students to college students to high school students — from all over the greater Boston area who came in and shadowed patients and worked with them to create plans. This was a phenomenal way to showcase a rich resource in the greater Boston area, that actually that all communities have. And those students made dramatic improvements. So when we got into 100 Million Healthier Lives it was important to have students play that role of being curious and being young enough to not be afraid to ask the hard questions or just a different question and wonder what a different answer might be.
Stakeholder: 100 Million has been careful with vocabulary and language. What’s striking is the increased sharpness, which is aspirational. And the shift from determinants of health to drivers of health is indicative of that. Can you unpack what that means?
Stout: We shifted from determinants to drivers because we place a high value on bringing in people with lived experience. Say you’re working on homelessness. A person who has been homeless has a much better understanding of the systems that support homelessness than any professional in any one of the agencies. When you value the expertise that people with lived experience have, you suddenly see language differently. So if you’re saying something is a determinant that means there’s no choice, that something has been determined for people. I know that we use the word determinant as a way of saying “let’s not blame the individual,” and we have tried to shift to language that is generative and that creates space and potential for people to grow. The shift to driver is very much about that. It communicates that this is driving an outcome — it’s sort of like trying to go up on a down escalator — it’s driving but people still have a way of addressing it. And maybe if we’re able to change the system we can get it to go up instead of down.
Stakeholder: Can you tell us about the goal of 100 million people living healthier lives by 2020?
Stout: For us it was a way of creating a goal that was so large that we couldn’t continue business as usual. No one organization could achieve it alone, which meant that we had to learn how to work together, because that was one of the gaps that we saw. Everyone was trying to create health but in their own silo, and lots of people were falling through the cracks of our various silos. The real goal with 100 Million was to change our mindset, to change the way we think and act to improve health, wellness, and equity. Most people don’t think their way to a new way of thinking; they actually act their way to a new way of thinking.
So, the other piece was to create a goal that would inspire and incite a critical mass of people in our country to think differently and acting differently. So while there’s action — what could you do that would help 100 million people live healthier lives by 2020 — but in doing that action, there are a whole set of new behaviors and ways of thinking, whether it’s about social drivers or about how you partner with people with lived experience or co-designing and valuing what people, like community health workers or school kids might have to contribute to creating solutions.
Stakeholder: You use the metaphor of “escape velocity.” Can you tell us what that means in this context?
Stout: We spent a year talking with people about what it would mean for us to have a shift in the country. We looked at where have people done this before and found a helpful example in the space program where John F. Kennedy set a goal of landing a man on the moon and bringing him back home safely within a decade. We spoke with Jim Hester, who had been an early sort of intern in the space program, an actual rocket scientist. He told us when they set that goal, they set it as an audacious goal. They didn’t have the technology worked out. They didn’t even have NASA, but by setting that goal, it inspired them to create NASA. It brought together scientists and people who were working in a huge number of fields to put their pieces together, to try things, see what happened, and then try again. So it helped them break out of gravity. And the first stage of that was to achieve escape velocity, to escape the forces of gravity that would move you from the earth at least into orbit around the earth.
That felt important, because people have been thinking about how to improve health for decades. Hundreds of groups working in the U.S. alone are thinking about that. But we weren’t working together effectively, nor did we have that kind of goal. So that idea of working together to break free of gravity was the idea behind escape velocity.
Stakeholder: 100 Million Lives meetings are full of extraordinary, aspirational thinking. It’s catching and you see people behaving differently towards each other. But it’s striking that this is happening during the most polarized, mean-spirited public discourse in history.
Stout: Every action creates an equal and opposite reaction. That’s a law of physics, right? We need a different narrative. We are at a place where extreme wealth and poverty, where changes in social class and their implications in social class on health and well-being have reached a critical point. Discourses of anger and loss and zero-sum game begin with some people winning and some people losing.
You counteract that discourse not by arguing against it but by creating a different model, to see ourselves as abundant. We recently spent four days in Oklahoma City with 100 people from all walks of life — from librarians and teachers and health system innovators to businesses — thinking together about equity. We grounded ourselves in what we know about the discourse and equity but then created a vision that equity isn’t the goal, the goal is the interconnectedness of the human consciousness.
What does it look like to move from a discourse about pathology to a vision of interconnectedness, of the possibility that can be released? The bright spot stories created hope and belief in something. It was amazing. And by the end of the session we watched person after person reframe their thinking to be about human interconnectedness. What we’re building the foundation for is that interconnected human consciousness and it was amazing to watch how it created a much more whole discourse on equity that wasn’t about anger about a black and white conversation nor was it about a historic anger and injustice, though those were acknowledged up-front, nor was it about white privilege only and leading to white guilt and shame, but rather a call for all of us to become conscious together and create a solution that didn’t require us to keep thinking in black and white as we move toward that solution.
Stakeholder: What I experienced at 100 Million Healthier Lives was the embrace of the possibility of being a sharply defined alternative view of what’s possible without bringing with it, sort of a conflict or even some of the pride of difference that you commonly see in other groups. So there’s the non-conflicting but very clear alternative voice that’s actually very compelling and very invitational.
Stout: We celebrate diversity as we would celebrate flowers in a garden that have many different colors — it makes the garden more beautiful. It’s not that we want everything to be one color. We invite the diversity of thought, the approaches of people and their cultures — we had an impromptu Native American ceremony on the last day — people brought their whole selves and felt welcome to do that, but it was founded in this understanding of our common humanity. Our job is to create the narrative of what it means to be united in our diversity, what it means to recognize interconnectedness and create a whole different way of thinking.
Stakeholder: 100 Million talks about co-design. Where do the fields of co-design and improving the health of the public intersect? And why is it important?
Stout: Plenty of efforts by people to improve health for those who don’t have it have failed globally. We have tons of evidence that that doesn’t work. There’s no reason to replicate that experiment and think we will get to a different outcome — that’s the definition of insanity. So we begin with the understanding that if we’re going to have any hope of getting a different outcome, it has to be informed by people who are living in that. That’s one of the five core principles of 100 Million, partnering with people with lived experience.
An example of how we do that is leading from within, which is our inner work of leadership leading together, which is really what it means to see and understand where each other is and to collaborate toward common, shared goals together, leveraging each other’s assets, leading for outcomes and equity. In leading for outcomes we say the three buckets of skills are the skills of design and co-design, the skills of improvement science, and the skills of implementation or knowing how to make the path easier.
For design and co-design, we teach skills and practices where people begin by grounding themselves in what’s actually happening. This is something we did, for instance, in Oklahoma City. Instead of sitting in a boardroom and thinking about a how to solve a problem, you actually look at the data to understand who is thriving and who isn’t within the same population. And you actually go out, walking people’s footsteps and understanding what’s happening.
You hear stories. We listened to the story of someone who had been in and out of prison for 20 years as part of a school-to-prison pipeline in Chicago and used that story to understand the system that was producing that result. We just listened deeply to the story and then broke it down to understand people from across perspectives. There were people who had lived that experience alongside people who might be a mayor or a health system leader or a community leader sitting at the table together. They were using things like silent idea generation so that one voice doesn’t dominate.
And within an hour they created one of the most coherent maps you could imagine of what the system looked like, what the different interacting systems were, where the barriers were, where the opportunities for interruption might be, where there were assets that might be leveraged, what critical strategic partnerships might help to interrupt the system, and where there were bright spots and evidence of where people might have figured out how to interrupt part of the cycle.
Start first with what’s happening with real people in real neighborhoods. Actually look at seven example lives, people who have agreed to share. Ninety percent of the data and the insight probably lies right there. Generate solutions from a wide range of voices and through methods that allow people to come up with unlikely solutions. Where we are stuck and not moving further, we usually need the unlikely things. And you just can’t get unlikely thinking with the usual people with the usual powers.
Stakeholder: When you are talking about 100 million people, with so many bright spots, how do give them all a sense of cohesion?
Stout: First, we’re inviting people to put that in a Bright Spot Library using iMap. Everyone has bright spots, they’re just all scattered in different publications and what we would love is to have those put in one place.
Second, bright spots don’t usually spread in the absence of relationships, so we’re also helping people find generative centers for learning as they need them. Our idea of Hubs is to help people find an area where they want to learn, they can connect with others who may have developed bright spots in that area.
The third thing, as people have said what they’re doing — for instance, around addressing opioid overdose or incarceration — we’re creating maps of the system we’re tying in what bright spots exist to interrupt a particular part of the system alongside it with links to those particular programs.
Art: Creative Commons, Farbfeld-Marerei. Gmhofmann