As the Executive Director of Kokua Kalihi Valley, an organization that has wrestled with what it means to be a community health organization for the past 44 years, I will share a few thoughts in response to the question, “How do we reconceive and describe health as something plural, culture-specific, and not professionally-provided?”, which was posed in the Creating Health Collaborative’s recent report, Eleven Principles for Creating Health.
Who is this “we” that is spoken of? Is it the “we” of us as professional health practitioners, seeking to maintain our professional prerogatives through the language of the “new”? Or is it an intentional movement towards becoming a “we” with our communities? If the latter, then answering this means coming to terms with the reality that many communities already cherish a much broader conception of health, one that is already “plural, culture-specific, and not professionally-provided.” The question then becomes, how do we as health practitioners move in their direction?
At Kokua Kalihi Valley it has taken 40 years of carefully listening to the stories that our patients, families and communities tell, of trying to let go of our arrogant assumption that we hold the answers, of asking careful questions, of always knowing that deeper questions lie beneath the ones we ask, and of then shaping our work to be true to what we have learned. This work is always iterative and prone to missteps. We are asked to do our best at any given moment and cannot afford analysis-paralysis. But we strive to begin from a place of deep modesty, knowing that what we know is only a tiny portion of what there is to know, that more stories are always waiting to unfold and lead us deeper into relationship with our community, and that what we can dream of at any moment is only a tiny part of what might actually transpire if only we create the space for what Nomvula Dlamini calls the “becoming of healthy community.”
Could I, as a general practitioner (primary care physician) starting out 27 years ago serving a Polynesian and Asian community in urban Honolulu, have known that one day we would be caring for 100 acres of upland forest and gardens in partnership with as many of 5,000 members of our community each year—and in turn “recovering” health? Not a chance. But it was enough to hear in our patients’ stories a profound longing for that connection to land and place that so many of them had lost when forces of colonization had either brought them to Hawaii or severed their connection to ancestral lands. In response, we began to ask ourselves and our community: what could we begin to do about it?
When we ask our community members to describe a time in their lives when they felt whole and healthy they often tell stories of remembered places — of towns, neighborhoods and landscapes of light, soil, and ocean; of connections to family, extended family, neighbors, and mentors who paused long enough to care; and especially, either directly or indirectly, of their aspirations for themselves, their children and their grandchildren.
So often – if we are prepared to listen carefully – these stories of the deeper meaning of health emerge in the clinical context. I vividly remember counseling a Samoan elder with poorly controlled diabetes about the potentially disastrous consequences of her medical non-adherence. She waited patiently, then opened her purse to show me photos of her youngest grandson, a high school junior, who was doing well in school and looking forward to going to college. At the time I was not quite ready to see that her shifting the conversation was not some form of denial; nor was I ready to understand that her grandson’s thriving was an important part of her health.
Traditional components of health such as these — connections to place and to others, connections to the past and to one’s better self — are not our domain to reconceive as health professionals. We can and must participate in these discussions, as fully vested partners in community, but our proper domain is somewhat different.
What then are the proper questions for our domain? Here are some suggestions:
- How can we foster a health industry culture and practice of listening and co-creation with community?
- How can we rightfully participate with our community in a process of resurfacing and clarifying health?
- Among communities that are successfully recovering health, are there recurrent principles and practices that can inform our policies, work and industry, without eliding the important differences among communities and the need for each community to undertake its own journey of health?
Health, as Wendell Berry reminds us, “is not just the sense of completeness in ourselves but also is the sense of belonging to others and to our place; it is an unconscious awareness of community, of having in common. It may be that this double sense of singular integrity and of communal belonging is our personal standard of health for as long as we live.” It is this more vulnerable, personal and devoted sense of our place in health that seems to me an essential—perhaps the essential—starting point for “[co-]creating health.”
- David Derauf
David D. Derauf, MD, MPH has been with Kokua Kalihi Valley Comprehensive Family Services (KKV), an Federally Qualified Health Center in Honolulu, for the last 27 years. He has been recognized for his leadership in helping to move the work of a Federally Qualified Health Center upstream including such programs as: the the KKV Elder Program, which provides comprehensive community supports to 700 Kalihi Elders; a youth earn-a-bike program (K-VIBE); chronic disease self-management groups; and Seams Wonderful, a microenterprise sewing program. By sustaining projects that are based on community self-determination, cultural identity and justice, KKV is able to work far beyond the exam room to address the root causes of health inequity. Through strong relationships that honor culture, KKV works to support not only medical definitions of health but social, spiritual and indigenous expressions of a healthy, interdependent and just community. He is married, the father of two boys, and tries to get out in the surf from time to time.