A few months ago, an executive coach I’ve known since the early months of the pandemic asked me a question about the community health work I have been doing for the past several years.
“Tell me five things about working in the community that you think I should know.”
I have thought about the question and the answers I spontaneously gave him since, confident that one thing is certain: I don’t really know completely. And I know that I won’t ever completely know. So in that spirit of true humility, when asked I focused on what I was learning, and I gave it a try.
It is worth noting that I spent the first thirty of the forty years of my professional career in the U.S. Military, where everyone had a job, a house, education and access to free health care. It is clear to me now that military members are under greater stress from health related social needs than I realized while I was in uniform. Regardless, in the transition a decade ago from this successful, single-payer, government health system, the biggest wakeup call I experienced was coming face to face with the lack of the same social supports for the patients I now cared for.
For the past decade, I worked in population health as the payer systems evolved to include models of “value-based care.” Over time, it became clear that the greatest value we could provide would be to work with community partners to assure economic growth and stability, housing, transportation and food access as well as health education and seamless health care access for our patients. The individuals of the urban community where my wife and I have lived, worked and worshiped have vastly different life experiences than we do. We continue to learn from them.
Since stepping away from a hospital population health role eighteen months ago, my role has largely been in community health. Thus, my coach’s request. This is what I told him.
“Nothing about us without us.” This is the first lesson we all learn. It almost seems hackneyed except that we continue to pay less attention to it than we should. The phrase has Latin roots, “Nihil de nobis, sine nobis,” popularized in Europe as the standard for establishing foreign policy and legislation. It was made popular in the U.S. in the nineties by author James Charlton, who adopted the saying from South African disability activists. The idea has been applied to a range of community organizations and efforts working alongside historically marginalized individuals and groups.
The classic (unfortunately still common) example in university settings is a grant proposal designed by academics to study members of the community without any insight from the study population along with a request for endorsement from the academic department or center imagined to be working with “them” most closely. “They” should have been a part of the conversation from the beginning.
“Initiatives in communities of color should be led by leaders of color from the community.” It is more than just “optics.” It is a matter of better visual acuity: being able to see more clearly. There are too many things that quite simply cannot be learned or taught. These are the things that are experienced, and they are the exclusive possession of those who have lived them. That is what these leaders bring to the table, and why they should ideally have the seat at the head. No one really likes someone else’s great idea. This is especially true when the great idea is about you.
“The work may not be professionally rewarding.” In an academic setting, every lecture or seminar contributes towards promotion for junior faculty. But where on the CV do we record Sunday afternoons spent at community sites reinforcing asthma inhaler technique with children and their parents, or teaching community health providers about measuring blood pressure correctly? In terms of community research, you really can’t just study, write and publish whatever you want from the work you are doing. It’s not your data. And it’s not your story. However, in my experience, what is lacking in professional reward is more than accounted for by work that is personally rewarding.
“If you are not uncomfortable, you are probably not crossing cultural boundaries.” People from different backgrounds approach problems differently. And that can make us uncomfortable. We respond to these differences in a range of different ways. One of the ways is our response to leadership. If you’re not at least a little uncomfortable, you may not be following the community leaders. We like being in charge, especially as physicians. And whether we know it or not, we can sometimes assume and subtly communicate that we could do the job better. Or even worse, our bias leads us to unconsciously assume that a leader from a marginalized population is intrinsically less qualified to run a project than we we are. I used to wonder at times why some of my community-based peers often need to present their credentials when they enter a new public setting. Perhaps it is because of the inherent tendency of people like me to at least act like we assume they have none.
“It is a near vertical learning curve with no plateau.” I am not a rock climber, but I suspect that you can’t climb a vertical without help. Or at least you shouldn’t try. But that means we must also do the work and the preparation to make the climb. As the poet Maya Angelo said, “Do the best you can until you know better. And when you know better, do better.” In this work, we are continually learning. And the greatest risk is the assumption that we finally “understand.”
Perhaps to put it more succinctly, for those of us from outside the community, working alongside community partners for the community’s health is a lifelong journey. It is a near vertical climb where you never really arrive. You do not want to make the climb without someone who knows the mountain.
And you don’t want to make the climb alone.
Chuck Callahan Henry V 4.3 – Lead from the Front https://henryv43.com/
Henry V 4.3 