In the workshop’s final session, George Flores of The California Endowment asked the roundtable members and the workshop’s other participants to think about what they had heard over the course of the day and to consider the implications of those observations. Flores began the session by repeating an adage he uses in presentations—“Nothing about us without us”—to reiterate the point made throughout the day that communities are intent on making sure that if they are going to be studied or be involved in an initiative, their members should be at the table with shared power, respect, and the capacity and tools to be full participants in the partnership.
He also commented on an important lesson from the recent national elections, which is the importance of thinking more carefully about who has and has not been left out of the conversation, perhaps because it has not been convenient to bring them to the table because their point of view is so different and they come from a different part of the country. It is incredibly important to connect to all sectors in society and with people who have different belief systems, Flores said. It is not sufficient to associate merely with people who support one’s point of view, he said.
Another lesson that Flores said he learned from the day was the need to be deliberate in forming partnerships while remembering that there is no one way to form a partnership, no one-size-fits-all approach to community building. Flores also said that he heard about how much hard work it takes to build successful partnerships in communities. “We cannot rush in and expect people to fall in line and for change to happen
immediately,” he said. “Even if you have the most wonderful idea in the world, you cannot expect that pushing it on others is going to result in change right away.”
Flores said that the adage “Go slow to go fast” applies to working in communities. Sometimes, he said, it takes years to gain the trust, participation, and common understanding to build a common vision needed to get a particular task accomplished. He reflected on his work with Building Healthy Communities and how frustrating it can be to wait year after year for work focused on a disease prevention outcome to bear fruit. Going into a community with money and instructions does not produce results if the goal is building community to achieve community change, he said. “It is about giving up that right of making decisions for others and handing it over to the community members to decide for themselves once they have the capacity to do so,” Flores said. “Once they have gone slow to build up that capacity and make decisions, they all want that change to happen. They all want a better life for themselves, and once they have the tools and the resources to do that, they will move quickly to make life better for themselves and make the necessary change for improved population health.”
Matt Stiefel from the Kaiser Permanente Care Management Institute and 100 Million Healthier Lives said that the day’s discussion pointed to the importance of making measurements to serve local communities and of making them meaningful to the people in those communities. While saying that he agrees completely with that idea, he noted it is also important to learn from other places. There is great power, he said, in not having to invent everything locally, and one way to do that is to have a common framework for measurement from which others can learn. “If everything is measured and invented locally, it makes it very hard to aggregate stories, and while stories are powerful, they need to be accompanied by measurement,” he said.
His second observation referred to the question that Marthe Gold of The New York Academy of Medicine had asked earlier about whether health is the right way to frame these improvement efforts. He said that he has had discussions with people in the population health field about changing the slogan from “Health in all policies” to “Well-being in all policies,” but after today, he said, he wondered if the goal should be to improve communities.
Karen Ben-Moshe of the California Health in All Policies Task Force remarked that Shelton McElroy’s comments on the harm of labeling communities as disadvantaged communities are important to remember. “How do we do right by communities without retraumatizing them through the way that we talk about them?” she asked.
Thomas Kottke from HealthPartners spoke about some relevant lessons learned from studies using functional magnetic resonance imag-
ing to identify five qualities of social interaction that can enable the brain’s reward response: status, constancy, autonomy, relationships, and fairness (SCARF). Going into a community and telling the community what to do to solve their problems lowers their status and their autonomy. Taking that approach does not foster relationships, and it leaves people feeling that they are being treated unfairly. It should be no surprise then, he said, that people’s brains freeze up. “So if we use that acronym SCARF to think about how we approach people,” Kottke said, “we give them status by asking them how they would like to approach a problem. We do not make too many changes. We give them autonomy. We create relationships, and we treat people fairly.”
Mary Lou Goeke from United Way of Santa Cruz County (California) remarked how hopeful she was after hearing the inspirational stories from all types and sizes of communities from around the country. She also recounted something that Alexis de Tocqueville wrote in his book Democracy in America some 200 years ago, which was that Americans are really curious in that they love to help each other out, and not just in their village or among people of their own origin. Today, she said, she has witnessed that same phenomenon, with people sharing with each other a great deal of skill and commitment and knowledge, which fills her with hope about what community partnerships can achieve together.
Soma Stout of the Institute for Healthcare Improvement also said she was inspired by the stories from these communities and wondered how much more would be gained by letting go of privilege and not needing to be the saviors of communities and instead trusting communities to be able to create their own healing with the support of programs such as the ones discussed during the day. “I wonder what if, instead of funding communities to do the things that we think are needed to create change, if we funded communities to make progress on their journey of transformation for growing their own capacity, and for learning what it takes, wherever they are at, to be making progress on that journey,” she said.
Stout then noted that she and her colleagues at the Institute for Health Improvement have been looking at data on organizations that are trying to make changes. The difference between the ones that are performing and achieving outcomes and savings and those that are not, she said, is that the ones that are achieving outcomes chose to do it because they thought it was the right thing to do. “I think that there is an important lesson to be learned in that,” she said. “I think there is enormous inefficiency to believing we know what is right and to let the money be the driver of sustainability. I wonder what it looks like to let our belief in community and the abundance that community has within it be the driver for doing what we do and what the implications would be for us as funders if we were to be able to invest in that.”
Gold remarked that the day’s discussions had inspired her at a time when she needed some inspiration. However, she said, the idea of bringing everyone into a room and finding common ground does not always work for her when thinking about engaging people who have points of view that are not just and not fair. She has seen tension in discussions about how broad a canvas one draws so that everybody comes under the umbrella versus having to argue, fight, and prevail when others think so differently. “I think there is great work to be done for people who want to work together to achieve good things with justice and fairness, but I think there are many people who do not think that way, and we have to be careful not to be too Pollyannaish about this issue,” she said.
Dory Escobar of Escobar & Associates said that she was thinking the same thing as Gold but was leaning toward a different conclusion. “I believe that if we put more focus on shared values and the principles around which we are willing to work together, then that to me makes it clearer about who is going to be in the room and the sector they represent,” she said. “If people do not want to work together, they are not going to show up.” She recounted experiences in which there were significant disagreements about goals, strategies, or tactics and discussions had to stop to call out the disrespect being shown for someone’s values before agreeing to disagree and moving on. “That requires first building human relationships and being explicitly in agreement that we have the will to do that,” Escobar said. “If not, then people self-select or they are invited not to participate.”
Pete Knox reflected on several things he heard during the day. “This is about empowering communities to dream and realize those dreams, and about empowering the many to have a stronger voice,” he said. Too often in too many communities, he said, the voices of the few dominate the voices of the many, but as the stories shared over the course of the day showed, creating the collective voice of the community to speak about what the community wants to achieve can produce meaningful change that benefits all.
Knox also remarked that there are lessons to learn from why there are so many failures, and he said he believes that studying those failures could produce a roadmap or a set of common features that could provide guides to success in creating momentum going forward. “I think there is a common set of principles, concepts, and building blocks that can be put into that roadmap,” he said. “I do not think as we move into the future that we can continue to tell our stories in all different languages. I think that at some point we have to develop common language and be able to tell common stories.”
Bobby Milstein from ReThink Health took Knox’s idea one step further. “I think the examples that we have seen here today are very inspir-
ing, but they are not the norm,” he said. “I am wondering whether the synthesis of the practice that we are seeing here ought not [to] develop into defining new standards for the field about what is expected when you are in a situation of trying to orchestrate change at this level with so many stakeholders and processes that need to get fulfilled.” He said that he does not see any inconsistency in saying on the one hand that there is not a dogma and a formula for success but on the other hand that there are standards of excellence for doing this work. “I think we have seen some examples of that here, and I do not think we are all that far away from being able to summarize some of those,” he said. “I would love to see the field go in that direction.”
Anne De Biasi wondered if agency, gained through community engagement as a strategy, can have a positive impact on the community by empowering it. “This could be a new way of thinking about community engagement for public health,” she said, “and I am interested in working to develop policies on how to move that forward.” She explained that this idea is something that came up when the Trust for America’s Health held focus groups with the NAACP and Salud America! to explore why obesity prevention programs in African-American and Latino communities were not producing the expected results.
Gillian Holey, an independent consultant, said that one thing she has learned from managing complex change in Fortune 500 companies is that it is important to look at the world through someone else’s eyes and to step into that person’s shoes to build understanding as a starting point for change. Trying to push change through someone who is resisting will often lead to that person undermining the change process. Talking about why that person is resisting change and understanding those reasons can make the ultimate solution better and more successful, she said.
Mary Pittman commented that she also felt hopeful after hearing the workshop’s presentations, but she cautioned that the room was full of shared values. “I am concerned that we are facing a big tsunami of change that is going to come that is not based on the shared values of the community work we talked about today.” Pittman noted that the speakers presented some good ideas on how to frame this community’s work in a way that can be open and accepting of others, but she said she is fearful that she does not have the tools to be able to address some of the challenges ahead to keep this great work in communities going forward. “I am hoping that we can continue this dialog in a learning mode and activist mode to make sure that we do not lose sight of these values that have really driven all of this wonderful work that we have talked about today.”
Shelton McElroy reminded the workshop that the work this community does is often a matter of life and death. “We are talking about 9-year differences [in life expectancy] from one zip code to another zip code,
so we have to have a sense of urgency and determination in spite of the obstacles we face.”
José Montero from the Centers for Disease Control and Prevention commented that the only way to identify the real needs of the nation is through community work. “Community work is what will keep us on track and allow [us] to know toward what end we are moving,” he said. It will be important going forward to figure out how to moderate the factors about which Pittman and Gold expressed concern, he said. “If we are unified and believe we are going in the right direction, we will get there, but we need to be systematic in the way that we define the goals, in the way that we assess them, in the way that we provide the results, and the way that we interact with organizations.” Montero also agreed with Knox’s earlier comment that there are important lessons to learn from what did not work if for no other reason than that it may prevent other groups from wasting time and resources and perhaps losing the opportunity to achieve meaningful change.
George Isham from HealthPartners reflected on the comments Flores made at the start of the workshop about power and racism and other -isms and wondered how the events of the recent national election will affect how those issues play out at the community level. He also noted Gold’s question about the role of health relative to other framing with regard to the work being done in communities. “I think about education, economics, and race and wonder about those relationships and how they should be framed versus wellness,” he said.
Another item he mentioned was the recent spate of news stories about falling life expectancy in the United States, and he noted that increasing life expectancy and quality of life, along with addressing disparities across the population, are central to the purpose of the roundtable. The challenge, Isham said, “is thinking about the complexity of the different levels at which these various questions arise and trying to get clear about what messages we should be thinking about in terms of that complexity so that we can convey messages to people that want to take action, whether they are in communities, organizations, or local, state or federal governments.” He noted, too, that the tremendous examples of activism and inspiring leadership at the local level presented at the workshop seem to occur irrespective of what is going on at the national level, and that is something to tap into. “Quite frankly,” he said, “it is a strength that we need to admire, be part of, and be inspired by.”
Isham pointed to the importance of McElroy’s statements about framing and language and the need to truly see one another, and he thanked him for bringing those ideas to the table. Isham then commented on the tension Stiefel discussed between the need for both national metrics and standards and those developed by the community, and he said that it is
possible to do both. In his home state of Minnesota, for example, there is a strong commitment to measuring things by national standards but also a strong commitment to measuring things by Minnesota standards. “They are not in conflict with one another,” he said.
Sanne Magnan said that the day’s discussions brought to mind a paper she and a number of individuals at the workshop wrote nearly a decade ago in which they proposed a vision of a community-based reinforcing loop in which health care would save money, some of which could be reinvested into communities to make them stronger. The paper was rejected by one journal after another, and, as she recalled, one physician said, “Why would anyone ever give up their margins to put it back into the community?” Given that experience, she said it was almost unbelievable to hear that Algoma and Bellin Health are actually making that vision a reality. “It just reminded me,” she said, “about the importance of vision and of having an idea whose time is not quite right, yet you hold on to that idea and keep working at it, thinking about it, and promoting it.”
Concluding her comments, Magnan said that the roundtable’s vision of building a strong, healthful, and productive society that cultivates human capital and equal opportunity was evident in all of the stories recounted over the course of the day. To her, the common theme among these stories was deep listening and the importance of being heard in the midst of conflict. “That is the first step toward any resolution, and that resolution is possible if we believe it.” On that note, Isham thanked all the speakers for their presentations and adjourned the workshop.
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