interviews
An Introduction to Care | Part Two
by Dr. Kali Cyrus
February 13, 2020
Dr. Kali Cyrus is our February co-editor. This is part two of our conversation.
There is a lot of off the clock work happening, and out of pocket spending. So much of the care falls on staff after hours.
I would call it the out of pocket / out of office hours commitment. In terms of the costs to me, if I happen to be a doctor who gets bothered, a doctor who works in the public system, what ends up happening is most of my time is not actually spent treating the person's mental and physical health. It's mostly spent trying to figure out case management issues.
If we know this person doesn't have any food at home and they need to be taking their meds with food, or this person doesn't actually have a primary care doctor and they're smoking half as many cigarettes, which is usually the case, or their blood pressure is 200 over 120, or they keep getting hospitalized for medical reasons, if they're in a house dealing with trapping every night, they can't get sleep, it worsens their depression, and they're in a crisis and calling the cops, I can't do my job.
It isn’t really monetary, but as a team, we spend most of our time trying to figure out how can we get this person food when they may not be eligible to get free food from the state district, how can we actually try to get this drug dealer to forgive a debt – which is like, how can we do that?
What we end up doing instead of focusing on what kind of medications can I give you, or how can I meet with you on a weekly basis and talk through what you need to change, what is a path to recovery, is trying to manage the social stressors. It more so impacts social workers or people who've gone to school who want to be therapists, they end up being case workers. They end up doing these kinds of things, you can talk to them and use your therapeutic knowledge in that way, but it's a very different job that requires a lot more patience because you're dealing with systems that are so non functioning.
It's like going to the post office every day and getting in line for eight hours.
It's essentially what that part of the job has become. I think the other end of it, if you think about teachers who end up spending their money to buy supplies, that type of stuff, I don't necessarily end up in that position because I'm the physician. That's something a lot of us have very strict boundaries about. If I have a patient asking me for food, I'm at a clinic or I'm at their house, I'm not going to. No one would expect me to go run to the grocery store. That's going to fall on my staff. If my staff goes to see them three times a week, they're the ones who are going to get asked for money three times a week.
Think about people who work in group homes, where you have mental health patients with people who have other physical or mental disabilities, staffed by people who are not necessarily nurses. One, you're not making a lot of money and you're supposed to be in house with them all day, those are the clients saying, "I need a cigarette, I need a cigarette" when they've already used up all their cigarette money. But if they're going to flip, they're going to punch you in the face because they have a psychotic illness and they don't have the insight into knowing that you can't just give them cigarettes, cigarettes, cigarettes – they'll go buy them cigarettes if that's the thing that's going to keep calm.
Thinking through the costs in that way, is something I've learned from, and the way I've tried to help my staff out is however I can apply to services for them. I have some people in D.C., once I find out that they're at an age where they could potentially qualify from a home health aid, I apply to everything. I try to get them meals on wheels. I try to get them this thing, that thing. Many of them have been denied in the past, maybe they haven't really tried, or maybe they aren't eligible, but the main way is to try to get them as many services as possible, which then leads to complicating the treatment because you have four or five different agencies involved, and you're trying to figure out who's doing what, which is a different problem, but a better problem to have.
For the most part, the out of the pocket comes from my case workers. You end up spending a lot of money to help the system function to help your patient.
What needs to happen for these systems to work more cohesively?
I think about it as large group solutions and smaller more immediate solutions. In terms of the large overall solutions, I think crisis, I think crisis settings. I really believe in the urgent care system. If you're having a crisis right now people come to the ER and there's no beds to send them to. No long term hospital spaces. Not everybody needs to be in the hospital for seven days a week, 24/7 to be monitored.
We can move them to this middle unit where they can be kept safe for a little while. Some of them just need to get through the weekend. Observation units that aren't hooked up to all the expensive hospital bays are really great places, and then a lot of people can go home after that. They might not need the five days, they just need a couple of days. And I've found that that's a good workaround of not having inpatient beds.
I've also found that outpatient urgent care settings are good. It's a nine to five clinic, with staff, social workers, usually one physician, some peers. You can walk in off the street. It's an outpatient model, imagine how much money you save in that.
You can deal with the multitude of crises by having some place where you know you can go that's not waiting in the ER for eight hours.
In terms of the large system, it's groups. If you're not going to magically be able to reimburse every psychiatrist or every outpatient, why don't you have more groups of people, who once they leave the hospital just need something from six to nine. Think about AA in terms of mental health treatment, they need other people who are going through the same things they are that are staffed by social workers or staffed by psychiatrists who can provide ongoing care for them, in a model that's in a community center somewhere. That's not expensive and something the state can pay for.
Imagine the quality of what you could have at that time. It's not one reimbursable, so it's not there. Obviously the other individual level solution, you need a meals on wheels program or functioning transportation to help people get to appointments. You could even put a psychiatrist or psychologist in primary care offices.
My simple answer is how do you incorporate mental health players in these spaces? Making sure you at least know there are places that you can go. That takes investing in social services not just mental health centers. It's investing in the community itself.
interviews
How Change Happens
by Duncan Green
September 25, 2018
Duncan Green is Senior Strategic Adviser at Oxfam GB and author of How Change Happens and From Poverty to Power: How Active Citizens and Effective States can Change the World. He also authors the From Poverty to Power blog.
frank: I want to talk to you about what you've written about a lot, which is how to be an effective activist.
Duncan: Malcolm Gladwell wrote some really interesting stuff off the back of the Arab Spring a few years ago. He was saying, look, the people who really bring about change have deep bonds of trust. They go into scary situations together and face them. Those bonds tend to be built face-to-face, having gone to school with people or having been in organizations with people. More than the quite thin bond you create on Instagram. One thing is that you need to build up that personal network of people you trust, and who you're willing to work with and occasionally take risks with. And that means getting out of the house.
frank: Once you establish that sort of personal connection, how do you scale from there?
Duncan: The book talks a lot about the idea of power. How do you understand power? I find it really helpful when I look at that sort of process that you just described to think, "well, there's a process of power within." People feeling effective, thinking that they have rights, a light bulb moment's come on in the heads of people who are often quite downtrodden, when they suddenly stand up and say,
Where they're going to scale is to unify, to find people who have similar views to yours, or are in similar situations to yours, and learn to work with them, which is not easy. But what you get by working together is irreplaceable.
frank: Do you think there's a way to cross over from NGO work to policy and government?
Duncan: A couple of points on that. The book argues that activism is not just about being a protestor on the streets. It includes that, but it's actually anybody who's trying to bring about change in their context, in the institution they work in, in the situation they find themselves in. That's because I started to find repeat patterns in terms of how people bring about change.
If you're trying to change the world through a private company, through an NGO, through a mass organization, you're actually looking at similar rhythms, similar tactics, you're asking yourself the same questions about, "Who are my allies? Who are my opponents? What tactics might help strengthen the allies, weaken the opponents?" It's the same.
frank: You mention activists need to become reflectivists. Can you explain that term?
Duncan: This is part autobiography [laughter]. I started off as an angry activist. Lots of things to be angry about. When I was starting, it was what was going on in Central America, it was the U.S. funding a really nasty war in Nicaragua. A lot of the activism was about protest! It was about saying, "this is wrong." And, in a way, that's cathartic, and it might make a difference, but I never really thought about how this protest was likely or unlikely to bring about any kind of change. It was much more of an expression of outrage. Over time, I got more impatient.
When you're trying to do more insider influencing, you tend to work in different ways. It's not all about numbers on the street. It's about contacts, and language, and ways of doing things. People try and change the system from the inside, and from the outside.
Outsiders will be numbers on the street. Protest movements in civil society is a big part of the work I've looked at. I've worked with a lot of those organizations, I've been in those organizations. Then there's an insider track of people who are trying to get meetings with ministers, or trying to get meetings with officials, trying to come up with the kind of evidence that might persuade them doing pieces of research. There's an uneasy relationship between the insiders and the outsiders. If you're an insider, if you're trying to get a company to worry more about the labor standards in its supply chain, in the factories that produce its goods, it's great to have protests. It's great to have outsiders putting pressure on the company, so the company talks to you.
My rule of thumb is that insiders, if they're sensible, love outsiders. Outsiders have a much more ambivalent attitude to insiders, because if you're an outsider, and you're doing a protest, and you want to keep things clear, you don't want to have all these people messing up, coming up with compromises, making things halfway okay. That really messes with your campaign. The outsiders are sometimes more hostile to insiders. Insiders are usually quite happy about the outsiders. It's kind of asymmetric.
frank: Do you think it's a mistake for outsiders to be hostile towards insiders?
Duncan: It depends what your purpose is. If your purpose is to bring about change, I would say yes it is a mistake, because that combination of insider and outsider is ultimately very effective. If your actual purpose is to mobilize as many people, and make them really angry and get them to join your party, or whatever it is you're trying to do, then it does mess things up. So it's a sign, really, of what's actually motivating people.
There is also a political difference, sometimes, which is that the outsiders are kind of maximalists. They want really transformational, big change. They want to get rid of capitalism. If you've got an insider who is making capitalism a bit nicer, that actually makes it harder to get a big change. So, there are political reasons for the differences, as well as motivational ones.
frank: Are there any movements at the moment that you think are really successful, that are doing a good job at not only provoking more thought, but also enacting real change?
Duncan: There's loads. But, I'll talk about one which is really close to home, which is an organization in London, in the U.K. called Citizen's U.K. I love it because it's really different from Oxfam, and the kind of NGOs that were. It is a community-based organization based on the same principles that Obama applied when he was learning his trade in Chicago all those years ago. It's got the same kind of intellectual gurus. And, they work. They basically go around to poor communities working in particular with faith institutions (mosques, churches, synagogues), and with schools. And, they ask people what their problems are. You know, "What's pissing you off?"
But, the reason I know about this is partly because my son works for them, so...
frank: Amazing!
Duncan: Just full disclosure there. He's set up something in one part of London, and they were working with local groups to clean up parks, and to get changes in planning, and to get social housing, and all sorts of things. I love that approach because it's so different from online activism, and it respects the institutions that poor people trust, which is faith organizations and things that matter to them as families, like schools, and starts from there, and I think that's really interesting.
frank: Community based that goes macro from the micro, it seems.
Would you expand more on the kinds of power you define in your work?
Duncan: When people talk about power, they often mean the formal political power who is actually in the government, or who has got the guns and runs the army. That leads you to think that power is a bad thing. I think far too many people go with that line that power corrupts...Absolute power corrupts absolutely.
In order to actually change anything, you need power. That's why the book argues that we need to be a bit more nuanced and thoughtful about power. One way of thinking about it is there is formal power. The people who are sitting in the government making decisions. Then, there's hidden power, which is old boy networks, the backrooms, the lobbyists, the people you don't see who sort of seem to influence events. Then there's invisible power, which is actually the power in people's heads, it's close to that "power within" idea. Why do some people think that they're entitled to run the country, and, loads of us, think, "Oh, no, what do we know?" And that kind of thing.
You need to confront those less obvious forms of power if you're actually going to create change. There's lots of different ways of looking at power, but overall I've found, say to people, "Look, power is like this force field, which permeates society. And, most processes of change involve a change in that force field whereby some people get more power, some people get less." The nature of power shifts, so if you're going to become serious about change, you have to make power visible and then try and act upon it.
I think there's lots of different tools for making power visible, and that invisible-hidden-visible is one way.
frank: We're at a particular moment now where more and more people feel an urge towards activism. How do you push people who have no history of activism to participate beyond a march, beyond a like...?
Duncan: There's really interesting studies over centuries about social movements. How do these movements come? They suddenly spike, and then they disappear again. We've got one of those at the moment. We've got the #MeToo, Black Lives Matter. There's a lot of these big, upsurging movements. All of them, when you look at them, they're made up of little grains. They're not amorphous blobs, they've got structure.
Those grains are actually more long-lasting groups of people. It's faith groups, churches, mosques. It's trade unions, it's sports clubs, all sorts of things! Suddenly, they all come together and they make a big noise, and you think, "Oh where did that come from?" When it settles down again, they go back to their grains.
I think one answer to your question is...I am getting to an answer to your question...one answer to your question is, look at your own life and see where are you in a grain? Where are you in a sports club, or a cultural group? Where have you got social capital? Because that might be a place where you should become active.
If you're a parent to your kids at school, and if you're in a faith organization, if you're a believer in some religion, whatever it is, any of those could become big, whereby you're not alone. I'd say my advice would be think about doing that, not just doing the online petition.
frank: Is there anything at the moment you feel really urgent about? Anything you think people need to be taking into consideration but aren't?
Duncan: It comes back to that point you picked up earlier, we need to be activists and reflectivists. I think one of the aspects of reflection, which I think we need to get much better at, is spotting where things are working in our environment.
If you're concerned about the environment, getting better at seeing where people are doing the right thing for the environment, and then trying to ask, "Why?" There's a whole field of work called positive deviance, which looks at where things are unexpectedly good. I think especially now, we should be consciously looking for these positive outliers, these unexpectedly good results on any given issue, and seeing what we can learn from those.
The reason I like that is because it shows some respect for the people and systems who generate solutions. They're not always waiting for the great, white savior to come in and solve it. It might well be my next book, this positive deviance aspect, because I think it's got fantastic potential as a way of reading about change.