Community

by Peter Block

  It is a polarized conversation, with low trust and each side attached to its story. Developers bemoan the social services concentrated in poorer neighborhoods. Activists know that without a strong voice, the poor will be sent to warehouses under the interstate highway.

  Reconciliation will occur through a new conversation in which the developers talk about the compassion they hold for those on the margin. The new conversation for the social activists is to acknowledge that without some wealth coming into their neighborhoods, they will continue to depopulate and deteriorate. The way into a different future is to build relatedness between these groups. Beneath their positions is a common concern for the well-being of the city. A perpetually wounded city serves no one. There are many examples of these groups coming together. It is all possible when people decide to work something out rather than trying to win and be right. It is the shift in conversation and a care for the whole that make the difference.

  The other monster issue facing the country and community is the development of a local economy. Small businesses are the growth engine that is kind to community. Each neighborhood has a microeconomy that needs to be healthy. A place where people live, work, and shop. Most of the visible models are for well-off, resurgent neighborhoods. The emergent possibility is to create neighborhoods that are vital and friendly to the middle class. This is also the way out for those on the margin. For example, a strong local African American economy does more to create racial justice than minority hiring regulations and diversity workshops.

  Jim Clingman, an active citizen of Cincinnati, has given voice to this issue for years. He calls it Blackonomics. Find his books and read them. He argues that the civil rights movement created political freedom for blacks to live, vote, and shop according to their wants, but this occurred at the expense of the economic well-being of African American small-business owners. This becomes the new conversation: how to marry capital with all the educational opportunities for creating business plans and incubator agencies that are intended to expand the pool of entrepreneurs. The answer for those on the margin is to become economically self-sufficient. Working at minimum-wage service jobs or becoming acculturated to work for mainstream large businesses leaves too many people outside the living-wage economy.

  One more point. We need to educate people about the politics of the dollar. When they shop at the big-box stores, searching for the lowest cost, they do this at the expense of the community and local economy. For every dollar they save at the big boxes, they spend a dollar-fifty in taxes, high-interest loans for credit cards, overpriced staples at convenience stores, and get-me-through-the-night loan operations. Supporting small businesses, buying from those people who are a reflection of who you are, circulates money among businesses that will be ultimately sustaining. If we do not become conscious of the political and economic power of a single dollar, the class divide will only widen.

  Family Well-Being and Human Services

  In the human services world, we intend to approach families as whole systems; we talk about integrating service, but are so broken into disciplines and accreditations that it is mostly lip service. Even if we did organize services around the family, we are still deficiency oriented.

  To fully explore this subject is beyond our purpose here, but a couple of headlines will make the point. The shift in framing is that people and families are a pool of gifts and capacities, not a series of needs and deficiencies. Their suffering is an effect of their isolation and their being labeled. The struggle in their life is to find a way to use their gifts. In the way we traditionally deliver service, by raising money for and valuing their deficiencies, we reflect and reinforce the cause of some of their troubles.

  We still call citizens who seek help “cases.” People who serve them are called “case workers.” What does it mean when someone is labeled a “case”? By naming people cases, lawyers, social workers, human service workers in general dehumanize those they are committed to serve.

  Human services also relate to citizens through diagnostic categories. We are interested only in their needs and deficiencies. We call people “homeless,” “single mom,” “poor,” “ex-offender.” If a family or person has no pressing needs and deficiencies, nothing that can be categorized, nothing that can be funded, we have no interest in that family or person. Perhaps we should develop diagnostic categories for people’s gifts. Right now we have only crude positive labels: high school graduate, economic status, size of family, job experience. Suppose we named people in categories, using terms such as connector, knows everyone in the neighborhood, street-level entrepreneur, fashion plate, compassion for those in need, lights up a room when they enter, creative speech, practical intelligence, risk taker, cook.

  The shift is to focus on gifts and capacities. Again, McKnight has led the way in this thinking.

  Example: Cynthia Smith

  Cynthia Smith was an assistant director of client services at the Hamilton County Department of Job and Family Services. They still “service” about thirty thousand citizens through the front door per month. Cynthia decided to work at shifting the thinking of her division from the needs of people to the gifts of people. She got interested in something called Appreciative Inquiry, which is a way of helping institutions build a future on what is positive about their past and present. It is designed to use appreciation as a form of leadership and organization development. According to some, this is a radical path for human services.

  Cynthia also had the consciousness that the employees of Job and Family Services (JFS) reflect in their own lives the same struggles and heartaches of the general population that JFS is chartered to serve. This means that if we want to transform the context and thinking of those we are here to serve, then we must begin with ourselves. The internal culture of a human services system must value the gifts and capacities of its own employees before those employees can bring that mind-set to the community. People inside systems need to operate with compassion and appreciation toward each other. How can we be hospitable to the community if we are not hospitable to each other?

  Another important step Cynthia took was to invite members of the community at large to be part of the internal conversations she initiated. She valued the capacity of the larger village to care for the success of JFS, an idea that is radical and healing in itself. Most government agencies think they have to defend and justify themselves to the community; Cynthia welcomed the community in, to help create an alternative and more restorative future. She believes that it does take a village to raise a child and was acting on it. Now, since this happened a while ago, some may ask, “Did it work?” “Was it cost effective?” “What evidence do we have about it?” Wrong questions. It for sure created for a moment in time an alternative culture and world. Proof enough.

  Health Care

  Health care ranks high on centralized control, private sector domination, and dependency on expert intervention. We thought that mergers and restructuring health care would help. We moved to managed care and brought 60 percent of the physicians under that umbrella. We privatized, with all the bottom-line efficiency that promised. We have invested heavily in research and dramatized the heroism of the professional. We market it on TV and billboards and with stories of the miracles of cure and science.

  Health care also ranks high on every dimension for the conventional wisdom about how transformation occurs: strong leadership, noble vision, clear outcomes, predictable and regulated practices, tight measures, high-influence expertise, major investment in training.

  So how is it going?

  Not great. The United States spends 40 percent more on health care than the next highest spending nation, Switzerland. Yet the average rank in quality of care and health of citizens in the United States doesn’t quite make it into the top ten.

  What is paradoxical is that all who work in health care are committed, well-intentioned human beings. What is poignant is that most who work in the system, these committed, caring people, agree that the sys
tem is not working. Some call it broken.

  For anything fundamental to change, the context needs to change. The current context is a conversation about better management, cost control, and universal access, called affordable care. This conversation is about minor improvements, making what is not working cheaper and more available. These conversations will not create an alternative future. To oversimplify, we are asking the wrong questions.

  For example, the current conversation about controlling costs is not changing the nature of the system. A beginning conversation would be about who is responsible for our health.

  Another example: We have only begun to shift to a focus on health versus disease. Slowly. The profession is very tentative about taking seriously nonchemical, nonsurgical forms of healing (which the profession would name as nonexpert intervention). In fact, any approach that focuses on anything other than system care, professional knowing, and chemical treatment is called alternative medicine. As if we would never turn to it first, only as an alternative. It is as if the conversation about prevention, widely available curatives, healthy eating, positive lifestyle habits, and ancient and traditional healing were not medicine but a second cousin. As if we had to choose between alternatives. Pick one or the other. And if you want your insurance company to pay for your getting healthy, you know which one gets the nod.

  There are signs of a shift in context for health care. There is increasing evidence that if people are connected to their community and have people in their lives who care about their well-being—in other words, who experience a sense of belonging—they are healthier and live longer. These are encouraging indicators, although still outside the dominant conversation about the cost of professional services and who pays. Who is to say how this will eventually play out.

  As for every other big question, there are small, local solutions occurring. Wherever you are, you can find examples of the future that you might seek. Someone, probably not too far away, is changing the world, though you will never see it in the news. Here are two examples of a major change in context in the realm of health care. These are two stories of individuals taking a stand for a possibility. They have organized their practice as an example of a future, and done so at significant personal cost, with the belief that local action, committed to over a long period of time, is what changes the world. And they do this in an industry where most feel helpless about anything really changing. Not these two.

  Example: Paul Uhlig

  A thoracic heart surgeon named Paul Uhlig is opening new possibilities for health care. In many ways, he is creating an alternative future for his calling. He has been very innovative in the realm of collaborative care and the value of collaborative rounds. Collaborative rounds, in Paul’s practice, are times when the physician, nurse, social worker, and other support people working with a patient literally stand in a circle with the patient and his or her family and talk together about the patient’s condition and path of action. This means that decisions will be based on more than just the progress of the disease; they will include the viewpoints of the whole team, patient and family included. This is in sharp contrast to the common practice of placing the decisions about care in the hands of the single expert—the physician—or a team of experts. The idea that the patient, family, social workers, and nurses have a voice about care, expressed in front of all others, is a serious inversion of thinking. A shift from physician as the cause of care to the patient and care community. If you do not realize how radical this is, get thee to a hospital.

  Collaborative care has been around for some time and was not invented by Paul and his team, but they have moved it forward with their advocacy. They have accumulated hard evidence of the impact of this kind of collaborative care, with data on the improvement in patient safety, length of stay in the hospital, patient and family satisfaction, and professional satisfaction. With the collaborative methodology, all these measures improve, at little increase in cost. If a drug were developed that produced even half of the outcomes that this innovation has produced, it would be used in every system in the country.

  In the face of this, Paul has been treated by his industry as an interesting anomaly in the system. As a surgeon, he is near the top of the food chain. Still, wherever he goes, he both draws interest and catalyzes resistance.

  The problem is that Paul’s innovation confronts the dominance of the expert model in the extreme. And it delivers no large profits to the institution.

  Paul believes that a community of care is what will make the difference in our health. Among his heart surgery patients, 95 percent will return to the lifestyle that broke their heart, after the professional supports, which are very expensive, have disappeared. The 5 percent who do change their lives hold on to this commitment by working with others to do the same.

  What Paul is paying attention to gives an indication of the shift in conversation that might lead to real transformation in the health care industry. The new conversation he is initiating is one of ownership. What is our individual and community contribution to the problems we are facing? What commitment am I as a citizen willing to make toward my own health? What is the possibility of creating wellness in the world rather than fighting disease? What is the refusal I am willing to make to the expert and professional control of the conventional solutions? Collaborative rounds is a means for creating a new conversation that places the doctor, the family, the supporting professionals, and the patient all at the center of the planning and decision-making process.

  Making these questions central would shift the nature of the health care debate. This conversation would change the context from disease to health, from romance with technology and drugs to actions on the part of the citizen, from discussions of cost control and dependence on the professional to engaging the community. Paul has finally written a book about his work. Read it and join his network.

  Example: Dorothy Shaffer

  Here’s one more example of how transformation happens small, quietly, in rooms designed for humans and based on relatedness. Dorothy Shaffer is a Cincinnati physician in internal medicine. I first noticed she was up to something before I met her. Most mornings I took the kids to school and drove through a neighborhood somewhat on the edge. I noticed on the corner of Reading and Clinton Springs the renovation of an old house that was taking forever. What were they doing there? Why was it taking so long? Strange neighborhood to make that kind of investment . . . Then I forgot about it.

  Two years later, I am shopping for a new physician. A friend recommends Dr. Shaffer, who I find out was the one who renovated that building I had been watching. When I go there, I realize she has taken the care to create a version of the possibility of health care. Here is a taste of the future, on the corner of Reading and Clinton Springs.

  I call for an appointment, and a human being answers the phone. I ask for an appointment, and she apologizes that I will have to wait three weeks, since I am a new patient. She asks why I want to see the doctor. Tells me that if I become a patient, there will be an annual fee. I agree to this. This is to enable Dr. Shaffer to keep her patient load down to give the service she wants to give. For those who cannot afford the fee, she waives it or figures out what will be possible for that patient.

  I show up for my appointment and walk into a living room. It’s like staying at a W Hotel, where they redesigned the lobby as a living room. I go to the desk, and on the counter there are raisins, not candy and not nothing. Brenda, the receptionist, who knows me when I call, gives me forms to complete, and when I am done, she says the doctor will be right with me. I sit down and see there are books with some intellectual content: poetry, the environment, nontraditional cures. I have to search hard for People and Time magazines, both of which are entertaining and content-free. There is no TV on the wall suggesting new treatments.

  In four minutes, I am escorted right away to the examining room. The nurse takes my vital signs and weighs me without my shoes on. Scale is a little inaccurate on the heavy side, but no
t to be picky.

  Doctor comes in without a clinical coat. Dressed casually in street clothes. We talk, she does the exam, is not anxious about the time. Is interested in my way of eating, my lifestyle, and the stress in my life (takes a while). She knows about vitamin supplements and explains why some are better than others. She thinks part of her job is to educate me.

  She is more interested in the person than disease. Most of her focus is on keeping me healthy. Exercise and diet are major focuses for her. Everyone’s body resists certain foods, and she suggests we find out about mine. Her office offers acupuncture, massage, and other healing arts, all in the same building. She has organized her service around the patient. I now have one physician who sees the whole picture, one place that treats the whole person.

  Dr. Shaffer has eliminated the distinction between conventional and alternative medicine. She has put the patient at the center of the service. She has transformed health care.

  If there are people like Paul Uhlig and Dotty Shaffer in one community, then we know there are others like them in all communities. All we have to do is recognize them, support them, and declare them to be mainstream.

  I give these two examples for two reasons. First because they embody the idea that communal transformation begins at a small scale, takes a long time, and does not require large funding or a driving concern for efficiency. This means that each of us can join in moving things forward. If we seek large-scale change, we will create it by aggregating a large number of very local efforts like these and finding a way, conceptually, to thread them together under an inclusive umbrella. When a myriad of small efforts to heal the planet got named and woven into an environmental movement, something more impactful was unleashed. Same with the civil rights movement. Decades of local struggles were finally ignited by a few people sitting at a lunch counter and a woman sitting at the front of a bus.