Micro or Macro?

More free time than usual and two 15 hour car rides led to a good amount of reading in the last week and a half. Two books stand out as reflective of a tension I often feel. Jeffrey Sachs' "The End of Poverty;" I finally finished Jonathan's copy of it, and "Finding Calcutta," a quick read about a woman's experience wtih Mother Teresa in Calcutta and what she learned about work and service while there (a Christmas gift from a friend). While the tension is personally relevant, I believe it is one that also inhibits much collaboration and potential for good work in the world.

Jeffrey Sachs is a macro, or big picture, kind of guy. He thinks and talks in terms of systems, structures, societies, markets, and global communities. Yes, he can identify value in one-on-one interactions and even talks about how it is important for policy makers to have face-to-face encounters with the people the policies are for. Still, his mindset is always one of "big picture" work, and clearly, he is pretty great at what he does. (side note- the book was great. Agreed with most of it, and looking forward to reading his next one...ie. Jonathan, hurry up and finish it).

Mother Teresa is very different. She is a micro person. She never (and made a point not to) involve herself in politics and policies, or social systems and structures. She is known for calling herself and her work "a drop in the ocean" or a "little pencil in the hand of a writing God." Momma T writes about herself that she "doesn't agree with the big way of doing things. To us what matters is an individual. To get to love the person we must come in close contact with him. If we wait until we get the numbers, then we will be lost in the numbers. And we will never be able to show that love and respect for the person. I believe in person to person; every person is Christ for me, and since there is only one Jesus, that person is only one person in the world for me at that moment."

Politically minded intellectuals often criticized Mother Teresa for not getting involved in the politics of poverty, for speaking out against abortion and for feeding the poor directly rather than "teaching them to fish." Her response was: "If there are people who feel God wants them to change the structures of society, that is something between them and God. We must serve Him in whatever way we are called. I am called to help the individual; to love each poor person. Not to deal with institutions. I am in no position to judge...All of us are but His instruments, who do our little bit and pass by."

I don't think Jeffrey Sachs and Mother Teresa are complete opposites. They are/were clearly gifted in their respective types of work. Jeffrey Sachs does see value in the individual and reminds his readers that the market/community is made of individual people and it is their interactions, in homes, shops, fields, and street corners, that reflect the effects of policy. Similarly, Mother Teresa certainly had an impact on many people she never met. While she didn't advize any policy or network organizations, her work is known world-wide- it is quoted in speeches and books, and inspires (though often cliched and skin deep) world leaders and common folk alike.

I am tempted to ask the question: which is better? Big picture or little picture thought and work. I can make cases, even biblical cases, for both, and in the end I do think both are necessary and it is unfair to rank them. I don't think the work of big picture policy people lacks emotion, heart, and genuine care for the people they are writing policy for (though this, of course, is not universally true). And I don't think that "little picture" work always makes you more aware of real issues and genuine in heart and care.

So which am I wired for? I am not as extreme as either Jeffrey Sachs or Mother Teresa. Do I have to pick? Can I do both? Am I allowed to want to do some kind of great work in the world?*

The tension between the two brings up a fear of mine. I am afraid of forgetting the personal, intimate, and unique person-to-person value when I think/work in a "big picture" setting. And I am afriad of not having any kind of sustainable or lasting impact through my work if I work for and serve only on a person-to-person level.

The first fear seems pretty legitimate; the second, untrusting of God and prideful. I have certainly seen how very small words or actions have made large impacts on people and even whole communities and I believe that God magifies our feeblest attempts at serving others. I'm comforted by the fact that we are saved by grace through faith, and not by works, and yet I easily become frustrated when I feel like what I do or say doesn't have any or a big enough impact.

Like with so many questions and tensions, I end up with a need for greater trust and humility. Wanting me/my work to be more than a "drop in the ocean" diminishes the size of the ocean. To do justice, to love kindness, and to walk humbly, that is the call.

It is a New Year, and so these verses from Psalm 7 come to mind as I think back on the year and as I think more about what it looks like to have humility as I ponder the tension between big picture and little picture. **

3O LORD my God, if I have done this, if there is wrong in my hands,4if I have repaid my friend with evil or plundered my enemy without cause,5let the enemy pursue my soul and overtake it, and let him trample my life to the ground and lay my glory in the dust.

6Arise, O LORD, in your anger; lift yourself up against the fury of my enemies; awake for me; you have appointed a judgment.7Let the assembly of the peoples be gathered about you; over it return on high.

8The LORD judges the peoples; judge me, O LORD, according to my righteousness and according to the integrity that is in me.9Oh, let the evil of the wicked come to an end, and may you establish the righteous—you who test the minds and hearts, O righteous God!10My shield is with God, who saves the upright in heart.11God is a righteous judge, and a God who feels indignation every day.

*sorry friends, no straighforward answers to these. I do think God works through people to do great things, but it seems rarely seems to be the people you would expect, and often the 'great work' isn't what you would expect either. We are saints, not saviors.

**by little picture, I don't mean "little" as inconsequential or un-important

Spreading the Safety Net- Obstacles to the Expansion of Community Health Centers

During the presidency of Bush, his administration's agenda of "compassionate conservatism" with its emphasis on market-based, rather than government-sponsered, approaches to health care services and income support, has been rejected by Democrats innumerable times. This philosophical conflict has resulted in stalemates on many health care issues, and the administration's proposed 2009 budget, which calls for reductions of 200.9$ billion in Medicare and Medicaid spending over the next 5 years, only deepens the political divide. Bush has remained resolute, though, in fulfilling one early campaign pledge that most Democrats enthusiastically embrace: doubling the number of community health centers (CHCs) over a 5 year period so that millions more people who lack insurance or have limited access to private medical care can be treated as publicaly funded facilities. Bush's commitmement persuaded more Republicans to support CHCs, and the result has been a politically effective bipartisanship on this front.

The CHC initiative was launched by Lyndon B. Johnson duirng the administration's War on Poverty and got its inspiration from a South African movement that had offstarted the creation of facilities where poor workers could receive both public healht services and medical care. The primary goals were combining these disparate models and removing financial barriers to access. These goals, along with an emphasis on empowering the community to participate in decision making for CHCs by requiring that the majority of their board members be patients, were build into the centers' operating principles.

Reflecting this "power to the people" philosophy, the funding mechanism for CHCs consists of federal grants that bypass state governments and flow directly to these nonprofit, community-based organiztions. CHCs now number 1200 nationally and operate in some 6000 urban and rural sites in every state and territory and served an estimated 16.3 million people this year. 40% of the patients are uninsured and 35% are covered through Medicaid, with the remainder on Medicare or private insurance. Patients who are uninsured pay according to a sliding scale based on their ability to pay [like Esperanza in North Philly].

2/3 of CHC patients are memebers of racial or ethnic minority groups and many lack proficiency in English. More than 2/3 live on incomes at or below the federal poverty level and more than 92% have incomes below 200% of this threshold. Because their population is relatively young and disproportianly made up of young women and children, there is a high demand for primary care services.

Still, the mix of private and public activities that make up the health care system presents the centers with major challenges. As more people have lost their employer-sponsored or Medicaid coverage and become uninsured, greater demands have been placed on CHCs. Other challenges include recruiting and retaining physicians, nurses, and allied professionals who can provide primary care; securing specialty referrals for uninsured and Medicaid patients; and functioning in the face of budget cutbacks in Medicaid and SCHIP.

The number of doctors providing charity care has dropped significantly over the past decade, increasing the burden on CHCs and ERs. Meanwhile, it is difficult to attract physicians to staff positions at CHCs because hospital medical groups can offer them higher salaries. It is difficult to find specialists willig to treat uninsured patients who have no source of payment.

CHC,s which participate in policy activities largely through the National Association of Community Health Centers (NACHC), are striving to attract more physicians through natoinal, state, and local levels. CHCs meet the definition of a 'medical home' as developed by primary care medical organizations, but we will not be able to reach expansionary goals if we cannot attract a greater number of clinicians to these centers and more federal support from Washington. Despite good intentions on both sides, it remains uncertain whether Congress or the new administration will see the continued expansion of CHCs as a vital step toward reforming the health care system. Clearly, I think it's a vital step.

healthcare, community, poverty, and policy

I just spent the last three hours listening to and talking with my new hero. Dr. Robert K. Ross, the president of the CA Endowment, whose goal is to expand access to affordable, quality health care for underserved individuals and communities, and to promote fundamental imporvements in the health status of all. I was so jittery and excited and at one point almost started crying because he seriously outlined exactly what I want to do with my life and gave me tons of crazy cool new ideas, and it is so strange and yet wonderful to be affirmed in those ideas by someone much older, well-known, and generally brilliant. Here is my response to some of what he said:

Health revolution #1: The late 70s/early 80s made communicable and infectious diseases the most importand health care issue. If you want to hear about the history of AIDS watch the movie "And the Band Played On."

Health revolution #2: In 1985/86 crack cocaine became the new street drug of choice. It went from 100$ per hit to 5$. It is highly addictive, causes pain to go away, releases people from depression, and only lasts about an hour. The effects of cocaine are so much greater in a community oriented framework. Since the advent of cheap crack cocaine, life expectancy in inner cities has decreased. In 1990 in Philadelphia, the average life expectancy was 48. In 1980 it was 60. The statistics are similar for Southern California. Women get addicted and how do they get their money? Prostitution. Men get addicted and how do they get their money? Stealing and dangerous street trade. The prostitution breeds STDs and unwanted pregnancy. Cocaine induces muscle contractions, so babies are born too early. Stealing and street violence produces gangs. All of the above produces unsafe streets and home environments, and there is an entire generation of young people who grew up in houses and neighborhoods where these effects were very present. What is society doing for these youths now? What is society doing for the 1980s coke addicts now? One might ask, can we really extrapolate all of these effects from one cause: cocaine? Mostly yes, but fully no. But we shouldn't be ignoring the fact that the answer really is 'mostly yes.' LA and San Diego were hit the first and the hardest with cocaine trafficking, but it clearly has become a national problem. Economics is key here. The fact that cocaine became more abundent and cheaper effected the drug market in huge ways, which in turn effected every other systemic structure of society these cocaine addicts came into contact with, from neighborhood housing, to education, to healthcare. 1 in 3 men of minority status is destined to be a part of the criminal justice system at some point in his life as of 1990. Clearly, no part of society is left untouched by these statistics...who, after all, is paying for the incarceration of these men?

The second healthcare revolution comes to a close in the early 21st century with chronic, rather than communicable, diseases being the most talked about issue. This is largely because health care organiztions and individuals gave up on trying to deal with the problems of drug dealer and prostitutes and changed their focus to the poor. The shift in healthcare brought a focus on the chronic problems of the poor: diabetes, obesity, malnutrition, hypertension, bad eyesite, some STDs, and even cancers [not an issue of the poor as much, but definitely chronic].

Heathcare revolution #3: The closer look at chronic conditions has caused healthcare organiztions and individuals to look more closely at the healthcare system at large. Chronic conditions, after all, don't go away and require long term care, so the issue becomes a systemic one rather than a 'fix-it-once' solution. If you look up the word system in the dictionary, in no way does it describe what we have in terms of healthcare. People are starting to realize that the US spends more on health care than any other country in the world, and by no means has the best health. This third revolution is focused, therefore, around bringing health. That should be a 'duh' isn't that what heathcare is for. But if you look throughout the history of healthcare in America, it really isn't. Healthcare has been structured around reaction to problems rather than action and prevention. Reactionary care is absolutely important, but it will always be incomplete. Preventative healthcare economics is predicted to be the new and revolutionary field in the 21st century.

Take a guess: how much of your life expectancy right now is determined by the quality of healthcare you receive? Between 10 and 25% depending upon your healthcare plan. That is ridiculous!! So, what else is determining your life expectancy? Race, class, social status, gender, genes, and the way these things affect the social structures you interact with. [this is all from a legit study nationally recognized].

So when I say that the new healthcare revolution is focused on health, I really mean that it is focused on extending life expectancy. This will require tackling these other seeminly non-health related issues.

How to act: it is all about neighborhoods and community. And really, it's not just because that's what I'm passioante about. This is what all studies in the last 4 years have shown. Healthcare workers who are fed up with trying to work within the confines of the system are opting out and creating neighborhood and community organiztions [some of which have grown state-wide and nationally!]. There's a guy in Harlem who picked 20 square blocks to dedicate himself to. He has fully reformed the way the kids in that neighborhood get healthcare, education, and housing/supervision at home. On his wall he has a map of his 20 blocks of Harlem, and another map of the US with pins in the different cities where these once-street kids are now going to college. This stuff works! [and it's making me cry to think about it working :)].

What about the argument: this is too small-scale? That is a valid argument [though let's not discout the fact that the small-scale efforts are working!]. Here is where the policy makers and economists come in. So far, the benefits of small scale community health care have yet to be scaled up to fit a larger national context. There are two options: Find a way to unite and scale up the several small community focused healthcare groups, or encourage lots more of them to form in as many communities as possible. I would argue that both need to happen at the same time and that they will strengthen each other. How do we create a national healthcare structure that has all of the intimacies of neighborhood healthcare? Our problem isn't that we don't know what a good healthcare structure looks like. We do know. The last 10 years have given us success story after success story of non profits, independent hospitals, and clinics which have drastically influence the health of a community. We have the structure, now we need to find a way to fit it to a larger model.

Behold, I will bring to it health and healing, and I will heal them and reveal to them abundance of prosperity and security...And this city shall be to me a name of joy, a priase and a glory before all the nations of the earth who shall hear of all the good that I do for them. -Jer 33:6,9

Life as a Wheel

I said I would expand on my theory stated in "The Great Depression" post that life was like a wheel with six spokes. Here's what I wrote before:

"Let's think life as a wheel with six spokes. The six spokes would be: economics, health, learning, environment [and what it provides for you...often a living], social/sociopolitical, and spiritual. Each of those spokes deserves it's own paragraph [that'll come in the next post]. I believe God cares about each of these spokes. This model would work...except the spiritual spoke is a part of all of the others."

The hub in the middle represents abject, unrelenting, bone-grinding poverty. These people have absolutely nothing. The outer rim of the wheel representes wholeness, adequacy, "enough." Notice I didn't say "wealth" or "riches" or even "abundance". Simply the condition of having one's actual needs met.

Spoke one is economics. If you don't have much money, your options are limited. In Haiti, the poorest nation in the Western Hemisphere, the average peasant family ears 140$ USD/year by trying to grow coffee or cotton. They would like a better life for their six, seven, or eight children...to send just one of them to school would cost 50$/year. So they take a deep breath, choose one child, and send him off to learn, tightening down the screws on life's other necessities even further. In daily life a lack of money translates into a lack of options, which is perhaps a more accurate definition of poverty. The world's poor look at a situation and cannot say, "Well, I could pursue choice A, B, or C. Which one makes the most sense? Which wuld turn out best for me and my family?" No, under the circumstances, there is only choice A. That is the reality of poverty.

The next spoke of the wheel is health. A big part of health maintenance of course is getting adequate nutrition. Some people think the earth can't keep up with the food needs of its population. That is not true. In fact, the UN Food and Agriculture Organization delcared at a World Food Summit in Rome that the planet could produce enough food for every one of us to have a daily diet of 2720 calories. So why is a third of our world battling obesity and spending large sums to burn off excess calories, while the other two-thirds yearn to get more of them? Poor health is a major component of poverty and not disconnected from the first spoke, economics.

The next spoke is called learning. Poverty is greatly aggravated by the absence of information and acquired skills. Without these, the big world swirls around you like a dust storm, bombarding you from all sides with surprises that you have no way to comprehend or process, let alone overcome. An example: One of the biggest killers in the world today is diarrhea. I didn't just say it was uncomfortable; i said it could take your life. How so? Because the message passed around villages is: obviously, too much water inside of you if it is all coming out. We need to stop drinking for a while and dry out. Then it'll be okay." And children go on dying of dehydration by the hundreds of thousands. The beautiful thing is, an educated child in the developing world becomes a multiplier of learning, creating a ripple effect.

The fourth spoke is called environment. This is no sideline issue. Ivoery Coast has cut down and exported so much timber that it competes in volume with Brazil, a country twenty times as large. Since 1975, Ivory Coast has suffered the highest deforestation rate in the world. The herds of elephants, lions, hippos, leopards, antelopes, and many other animals have ben decimated as a result, which has changed things for humans as well. Haiti too is in ecological disaster. The sun beats down on the bare, parched earth and radiates upward again. Rain clouds form over the land, are driven up by the head, and then pushed off toward the sea, there to drop their precous moisture where thirsty people cannot access it.

The fifth spoke is social/sociopolitical. Poverty is, among other things, a functio nof being powerles in the hall of governments and the social structures that administer our lives. If you are fairly sure your vote won't count and that whatever taxes you pay will only end up financing a war or maybe increasing the governor's personal fortune, it is very easy to get discouraged and become fatalistic. When jobs and infrastructure improvements go inevitably to the tribe or region of the party in power, while other sections of the population are ignored, resentment grows. Corruption bleeds the meager resources that average citizens can muster, making it harder and harder for them to get on their feet. Nothing saps teh peasant's initiative faster than a sense that the system is stacked against him.

The final spoke of the wheel is called spiritual. Religious bondage can suffocate the poor in excruciating ways. This is true for those who forgo the nutrients of a meal because they feel they must obey the witch doctor's directive to sacrifice it to ward off evil, or when neighbors decline to help one another because they feel it will interfere with their karma. The starving child in the street, they say, is working out some issue from a previou slifetime, and so that process must run its course.

Jesus asked one time, "what good will it be for a man if he gains the whole world yet forfeits his soul?" All the dollars adn euros and pesos and shillings and rupees in the world will not equal the peace that comes from knowing a God who loves you. He's not out to get you or destroy you. He is, in fact, on your side. In fact, far from being peripheral, the spiritual aspect is essential to the other five spokes of the wheel.

Does God get involved with econonics- absolutely- Proverbs 14:23- all hard world brings a profit, but mere talk leads only to poverty. Scripture is full of instruction about money and labor.

Does God care about health- absolutly.

Does God care about education- yes, his entire revelation to us comes in the form of a book, which he fully expects us to read and to help others read. Teaching is a gift of the spirit

Does God care about the environment- check out Psalm 8- it is his earth, after all, he made it in the first place. He put this planet together to serve the needs of his highest creation, human beings. When we interrupt or currupt the systems that should sustain us, he is not happy. He wants to see the created order restored to its highest and best uses.

Does God care about our sociopolitical world? Definitely. Poverty and injustice break the heart of God. He warns us in Proverbs 22:22-23: do not exploit the poor because they are poor and do not crush the needy in court, for the LORD will take up their case and will plunder those who plunder them.

If we are seroius about helping overcome poverty, about moving people from the dark hole in the center to the state of wholeness ath the perimeter, we must care about all areas of their lives. It is not enough to simply favor one spoke. It's what makes community so extremely and unswervingly important. No one can care about all of those spokes alone, and i don't think we're called to do that. We refelct the image of God individually when we care about the whole, but we reflect the image of God communally when we actively care for the whole.

The Great Depression

when you hear that phrase, The Great Depression, what do you think of?

some words that come to mind: crash, 1929, dust bowl, unemployment, poverty...etc.

I'm taking an English seminar this semester on The Great Depression. Authors write about it with such emotion and passion, exlaiming the terrors of those years and blessing the future with hope that such years will never be seen again. T.S. Eliot in his poems goes as far as to suggest that it might have been better if everyone had just started off poor and then they wouldn't have had to go through the pain of losing their possessions and livlihood during the Depression.

Well, guess what? Those years are here again. They have been here for many years. Though I guess that depends on how you define "here." There are people who have lived in their own "Great Depression" for years, for their whole life. Heck, there are countries that have lived that. Sure, there are lots of reasons that the American Great Depression was unique, and it deserves a place in history books. Older folks who think back to the depression still shudder when they think about the hardship endured then. Where are the poeple shuddering for the hardship going on in the inner cities now? In countries whose modern histories could be labeled "The Great Depression?"

"It's not the same," we say, "because that country isn't America or those people aren't really a part of America. They were never the great sophisticated and industrious country that we were so therefore their current situation isn't as much of a downfall. They're used to it. It's just another one of the differences between America and other places. They're supposed to be downtrodden and we're supposed to be a superpower. That's how the world works."

America had less than 30 years of 'depression' and we have a whole genre of literature to go along with it. We have classes and textbooks about it. What if those years of depression were multiplied by 10 and then 10 again, and again, until they took up the span of a country's post-colonial history. There are millions in America who have felt and lived the emotion and hardship of the Great Depression for their whole lives. They've been jobless, hit by unfortunate circumstances, forced to move around, and sure, sometimes they've made some bad choices. But haven't we all? Why don't my bad choices affect me the way the bad choices of minority groups or poor people's do?

Jesus tells us to love our neighbor, and the command stretches us to consider who our neighbor is, ultimatlely expanding our body of "easy neighbors." What would it look like if our country took on that challenge? We would be able to say then, that the Great Depression is "here" because it is with our neighbors, whom we love. Our Great Depression looks puny compared to what millions go through every day. That is not meant to minimize the American Depression, but rather to maximize all of the others. What would countries like Rwanda or Darfur give to be able to say they just had two decades of Depression but then pulled out of it. Not everyone has the luxury of being able to look back in history and pinpoint the beginning and end of the 'bad years.' Poverty, I think, comes from the inability to do that. From the inability to look back on your life and see clear turning points and change. In daily life a lack of money translates into a lack of options, which is perhaps a more accurate defintion of poverty. Without options, it's hard to have distinct change or turning points.

Let's think life as a wheel with six spokes. The outer rim of the wheel represents wholeness, adequacy, "enough." Simply the condition of having one's actual needs met. The six spokes would be: economics, health, learning, environment [and what it provides for you...often a living], social/sociopolitical, and spiritual. Each of those spokes deserves it's own paragraph [that'll come in the next post]. I believe God cares about each of these spokes. This model would work...except the spiritual spoke is a part of all of the others.

At its very core, poverty is a mind-set that goes far beyond the tragic circumstances. It is the cruel, destructive message that gets whispered into the ear of millions by the enemy Satan himself: "Give up! You don't matter. Nobody cares about you. Look around you: Things are terrible. Always have been, always will be. Think back. Your grandfather was a failure. Your parents couldn't protect or take care of you. Now it's your turn. You, too, wil fail. So just give up!"

"Unless there is an intervension of love and hope, these seeds of apathy lead inevitably downward to an even lowe rdeath sentence called fatalism The very word stinks of death. It is the bottom- aslow as a human being can sink. When the human spirit becomes truly fatalistic, it is almost impossible to retrieve. This is complete and utter poverty, the end of the road."
-Why doesn't Poverty just go away?

Too Small To Ignore

Too Small To Ignore- Why the Least of These Matters Most: Dr. Wess Stafford

"I learned in my childhood in Africa that a child may be born in poverty, but poverty is never born in a child. The worst aspects of poverty are not the deplorable outward conditions but rather the erosion and eventual destruction of hope and therefore dreams. When a child gives up hope, dreams are forever shattered. With lost dreams goes the potential and ultimate impact that a child might have had."

"The word community is more than just a gray sociological descriptor. It is a God term, designed by the Creator of children to water their souls and enhance their spirits as they grow. To ignore this is to sow seeds of dysfunction and future trauma. To welcome the young into the center of our lives is to enrich not only them but ourselves as well."

"Americans spend more for garbage bags each year than 90 of the world's 210 countries spend for everything!"

"God's kingdom deserves excellence. It just doesn't need the conquest of anyone except Satan...competition should be our servant, a mere tool to drive us toward excellence."

"An even greater challenge is to receive graciously, especially from the hands of the poor. The Scriptures teach that it is more blessed to give than to receive. In my experience, it is also easier to give than to receive. We in the developed world are generally very awkward about it. If there is one great pearl I have witnessed in my years of ministry among the poor, it is their ability to be truly and joyfully grateful."

"Any response to the needs of the poor certainly involves money somewhere along the line. But it is not the cure-all by any means. Billions have been spent by governments and nonprofit organizations alike to relieve poverty. At the time my family and I just returned to America, President Lyndon Johnson was aggressively pushing a national "War on Poverty." It did some good, but it certainly didn't solve the problem forever. Today, forty years later, one of every six American children still lives below the poverty line.
Worldwide, it is more like one out of overy two. Think about that for a minute. This gobe, with all its resources and efforts at getting organized to meet the need, still fails to provide adequately for almost half of its precious little ones. On the test of caring for the next generations, we're scoring a lowly 54 percent, which wil get you an F at any school."

"Unless there is an intervention of love and hope, these seeds of apathy lead inevitably downward to an eve nlower death sentence called fatalism. The very word stinks of death. It is the bottom- as low as a human being can sink. When the human spirit becomes truly fatalistic, it is almost impossible to retrieve. This is complete and utter poverty, the end of the road."