By Heather Wood Ion
A number of us have focused for some years on the Leading Causes of Life (LCL). Its language inspires, clarifies and enables. As we reflect on this language as a tool for social change, we see that it can bring about a shift in definition, in behavior, in engagement, in policy. And it can maintain gains made, even despite opposition. Although most of the public measures of our economic models are not relevant to its focuses—connection, coherence, agency, generativity and hope—the language of life reinforces that we find both healing and wholeness in relationship with each other.
The Supporters of Health program, out of Wake Forest Baptist Health in Winston-Salem, is based on a clear identification of the target needs or clients, on a broad comprehension of the factors influencing the ecology of care, on the application of practices that influence and/or change how those factors work together, and on a purposive sense that actions taken and lessons learned will change the communities as well as the lives lived in those communities.
The program is sacred work, dedicated to creating more Life for those who are outliers to our communities and for those who serve them.
Initially, I was asked to “shadow” the Supporters of Health in an attempt to understand the ‘art’ of what they are doing. The premises of this program are expressed as a strategic statement: “The hospital must be smarter about the flow of charity dollars because proactive mercy is cheaper than reactive charity.” And a tactical statement: “By reducing the readmission rates among our most costly outlier cases at the hospital, we can save money, and do a better job of case management in the community.” The early data being analyzed by Dr. Teresa Cutts shows that the Supporters are achieving remarkable results regarding this tactic, both by reducing readmission rates, and by the numbers of people being enrolled in insurance.
Compassion, seeing and building paths
The art of the Supporters is a combination of deep compassion for those they reach, astute and thoughtful observation on the dynamic circumstances faced by those with chronic problems, and a profound passion to build a path forward with new steps on the life journeys away from desperation. The Supporters point out that most of the vulnerable people they serve have had little or no education about available resources, and that most of the church service providers, or community agencies, have had little or no education regarding the resources provided by others.
The Supporters proceed on the assumption that they can open the necessary doors, and bridge the gaps in knowledge for those they serve and for those within their sponsoring institution. They are creating a dynamic body of knowledge that can lead to careful evaluation as well as a catalogue of responsive contacts. To do this work, they must be brilliant and perceptive reporters on what in fact works to help Life find a way. They must also be relentless in their determination to see each task through to its conclusion, whether that is the five hours necessary to getting the electricity turned on for a patient discharged into an apartment without lights or heat, or finding the appropriate food to keep a multi-generational family at least subsisting if not thriving.
Connection
In terms of the Leading Causes of Life, on the surface the Supporters program looks to be dedicated to building Connection and bringing Hope to those who have every reason to despair. Much of their time is spent on building connection—they are coordinating community resources, and must continuously build trust with the gatekeepers of those resources. Connection means more than identifying an asset, it means diligently building reputation through visibility, through transparent dignity, and through responsible and comprehensive understanding of the limits and definitions each asset claims. In practical terms this means repeatedly waiting in line, filling in forms, and answering queries again, again and yet again, to meet the requirements for each resource. Not only do the Supporters actually wait, but they are willing to wait again and again in the service of Life.
Connection in this context must include evaluation: Is this bond worth building? What does this engagement cost? Does this connection truly contribute to health and vitality?
Hope
Several of the clients we visited commented that the Supporters brought them Hope. I am sure that in establishing this program, as with the Congregational Health Network in Memphis, one of the assumptions was that the presence of the community coordinators would itself bring a sense of hope to the vulnerable, as well as to those serving the marginalized population. What the supporters bring is ‘Informed Hope,” as they teach people to ask for help and how to use existing resources. Many of those they serve live isolated lives: isolated because of physical, environmental and economic conditions, but also isolated because of ignorance, social prejudices and emotional withdrawal.
Agency
We also see in the program that the Supporters advocate as well as exemplify Agency. Annika Archie, the leader of the Supporters, constantly advocates self-reliance with her clients. She is sometimes fierce on the phone with callers who ask for additional help, but it is a ferocity geared to evoking a sense of possibility as well as a sense of responsibility. Agency is a particularly important aspect of health when we think of the passivity inculcated by most of our medical systems. When the Supporters brought a winter coat to an elderly lady, their first question to her was where was she going to go, now that she could go out? They did not want her merely to be grateful for their gift, they wanted her enabled to take action because of it.
Coherence
Most striking when you spend time with the Supporters is the Coherence of their work, and the coherence they bring to lives that feel chaotic. Many of those being served by the Supporters are accustomed to the arbitrary policies of systems and institutions, and their own marginalization from any ‘sense’ within those systems. The Supporters reassure them that they share a sense of meaning and purpose. One recent amputee whom we visited spoke of his fears of the future. Annika Archie said to him: “Every morning you have to set your mind right. You have to be optimistic every day because this is Life.” The Supporters are articulate regarding the absence of Coherence and how necessary it is for them to talk about both meaning and perceptions.
Intergenerativity
We know that people in poverty must live in terms of acute, immediate needs, and that this can lead to a poverty of time. That is, the scarcity of this moment makes the future harder to reach, and harder to imagine. Each of the Supporters speaks of the future, of the ongoing journey, even if only to say “until next time” or “I’ll see you Friday” when leaving. Many frail grandparents are raising their grandchildren, or the grandchild is the caregiver to grandparents with chronic issues, so the traditional views of generosity and connections to past and future are confused. However, the Supporters speak of these relationships as a continuous whole, and they are agents of Intergenerativity even as they teach their clients how to adapt to their changing lives. It was also striking, despite the limits on time with the clients, how often the Supporters refer to the importance of each person’s story. It is, they say, a Blessing, to share those stories.
In seeking to learn what we know about the leading causes of life, we must be alert to the ways others enable transformation, and whether their practices can reflect the five causes. For instance, in the San Joachim valley there is a chain of clinics that serves migrant agricultural workers. There each patient is engaged in a contractual relationship by which they commit to becoming literate, and to serving other patients and their clinic in return for services. When you enter one of these clinics you cannot leave without visiting all of the components—medical, dental, financial, housing, labor, mental health, social services, education. And each time you visit, you make a further commitment to serve others. While the clinics are a teaching venue for primary care, they are not merely that: they are engaging a population in the work of building a community based upon coherence, connection, agency, hope and generativity. They do not use the words, but they do the deeds. If they had the words and the lens, their work would be further clarified and elevated.
Currently Nicholas Christakis and James Fowler are investigating, with the support of The Templeton Foundation, the social contagion of generosity. They believe that generosity is a key predicate for forming and operating social networks. Generosity is also a predicate for both the Supporters of Health and for the Leading Causes of Life. As we begin to understand the neuroscience behind our abilities to adapt and build relationships that sustain health and vitality, I believe that we will become aware that where humans thrive, and where healthy communities exist, the Leading Causes of Life are evident.
Language of life
The language of life is clarifying since it helps us ask ourselves what our efforts are for, and enabling because it focuses our attention on what we can do with and for each other. This lens is profoundly pragmatic, for it invites us to see our lives in a new way, to reframe our experiences from an enriched perspective, and to discover new tools within our capacities. The moral dimension of this is that it creates a sacred or sanctuary space for both the making of sense and the work of living. This is the language of transformation that reminds us that the seeds of joy are hidden in the struggles of everyday life, and those seeds are made visible when we change our perspectives.
Transformation is a process without an end-point, and our Leading Causes of Life language can be a catalyst of transformation. That means that we must be wary that we are looking at the dynamics of change, not at measures of transaction. For the sake of an institution, we must measure the transactions and the effectiveness of our programs, but for the sake of our mission, we must look for the indicators of transformation and the efficacy of our language. These are distinct and necessarily separate tasks.
What are the consequences of the use of this language? In programs like the Supporters of Health which bring LCL to challenged neighborhoods, what changes over time, and what bonds become resilient? Richard Gunderman wrote in his We Make a Life by What We Give that philanthropy “invites us to look beyond the distinctions of giver and receiver, and to see one another as sharers, parts cooperating for the benefit of a larger whole.” If we are to become smarter regarding the flow of charity dollars and charitable actions, how can we keep this perspective before us as we work?
The power of language
We know that language can change societies: Churchill sent the English language into war, Gandhi and Martin Luther King gave us a summons to the language of peace, FDR taught us that we have nothing to fear but fear itself. I believe we must now find a way to use our language to lead us toward health in all its meanings and to the wholeness of Life. Jonas Salk repeatedly asked us to ask ourselves “Are we being good ancestors?” Part of the responsibility we feel is surely the use of the clear and igniting language of Life.
This language and perspective transcends the limits and failures of reductionist medicine and public health approaches and can inform our communities in emphasizing possibility, mutuality and our convergent capacities. We script these goals, objectives and calls to action in order to begin the quest, not to provide prescribed solutions or predictable outcomes. We anticipate that the shared adventure of exploration is part of the healing process. We all know we must be better stewards of all of our resources, and perhaps that can begin with celebration of what each of us can contribute to another’s Life by responsibly, and responsively, clarifying the way we practice, within our diverse and varied contexts, connection, coherence, agency, generativity and hope.
Painting: Libba Davis.
