Health, Leadership, & Systems Change: A Conversation with Organizer Marshall Ganz
Health is everyone’s business. It’s time to invest in the first mile of health: where we live, learn, work, and play. This interview series is part of First Mile Health, a collaboration between IDEO, Robert Wood Johnson Foundation, and Building H to imagine how we might design health into everyday life.
Our current health crisis is a leadership crisis. In a system as complex as health, where many communities, sectors, and industries, intersect, it’s hard to see where change could start — or who might lead the change. What does it look like to lead — to empower, heal, and support others — through today’s multilayered health crises?
In this interview, Steve Downs (Co-Founder of Building H) and I are speaking with community organizer-turned-teacher Marshall Ganz to learn about a form of leadership rooted in organizing and how leading with hands, head, and heart is the first step to systems change.
Joanne: It’s hard to be healthy in America for many different reasons, and it has been increasingly hard in the last few decades. So far, most solutions for making people healthier have been to ask people to work harder, but that doesn’t change the system. How could we align the choices we make around health with the structures that shape our everyday lives?
Marshall: It seems like a question of agency structure. In other words, there’s the domain of me choosing, but then there’s the conditions under which I choose. How do those two interact in a dynamic way? Neither one is static. Structure itself is always changing, but at a different pace. The dimension of agency becomes crucial.
We need to think in terms of virtuous institutions, not just virtuous people.
How do we create a context in which we can be our better selves? We need structures that enhance our capacity. We’re human beings, and we need that help.
Grounding choices in value
Steve: I wonder if we need more of an environmental change to make being healthy easier to do. What are some ways to make healthy choices easier?
Marshall:
One of the things I’ve noticed in organizing is that people tend to commit not because something is easy, but because it’s valuable.
And we confuse the two. As we try to make it seem easier, we trivialize it. If I’m convinced something is efficacious, I’m much more likely to commit to it. All this focus on the cost and difficulty misses the benefit, in a way.
It also seems like people need to be involved in changing the environment, not just changing themselves. And I think we’re seeing an example of this play out right now across the country with the protests against police brutality. Some people think it’s just one bad-apple cop and treat it as an individual problem, but really it’s an institutional one. It often takes people engaged in changing institutions for them to actually own it.
We’re in the midst of a very interesting experiment on making choices with respect to health. This dramatic shift that we’ve made since February has been unimaginable. Urgency became real, and we’ve undergone some drastic changes with not that much resistance. We radically altered our daily lives — our family life, our work life, everything — hugely. Everything that we thought was a given suddenly wasn’t. Everything that we thought could never be changed suddenly could. It opened up a whole opportunity for creativity and adaptation.
And I think it’s related to what’s happening right now with racial justice. It has created a context in which things we thought were impossible become possible. We’re experiencing this intense moment of possibility.
Story of self, story of us, story of now
Joanne: The pandemic is exposing deep injustices in the system. There is tremendous possibility but the complexity and the weight of it all can also feel daunting. Where do we start?
Marshall: We’ve learned to approach these types of challenges as a leadership challenge. The ground for our understanding of leadership was three questions posed by Rabbi Hillel, first century Jerusalem scholar: the first one, if I am not for myself, who will be for me? It’s not meant to be selfish but meant to be self regarding. In other words, if you presume to exercise leadership, then you’re very clear about what you bring to it. And the second question, if I am for myself alone, what am I? The implication being to be a human being is to recognize that everything we do is in relationship with others, our capacity to realize our objectives are inextricably relational. And finally, he says ask yourself, if not now, when? This is to avoid falling into what Jane Addams described as the snare of preparation, you know, that we’re going to have the perfect plan, then we’re going to launch, and the world will totally conform to our expectations. It never does. And it can’t, because the future is unknown.
In order to learn to do what we want to do, well, we have to begin to do it. So we have to build in learning in doing and not treat them as sequential, but treat them as simultaneous.
Leading with hands, head, and heart
Joanne: The type of leadership you’re describing is very different from leadership defined by hierarchy. It seems less predictable and more emergent. In what contexts do you see this type of leadership coming into play?
Marshall:
Leadership becomes highly relevant in dealing with challenges and contradictions.
Usually when people say, where’s the leadership or who’s in charge, it’s because there’s trouble. If you think of the domain of leadership as being dealing with that, there never is going to be this place of control. When you have a functioning system, it’s all routine and you don’t need the adaptive and creative dimension. When everything’s working, what do you need leadership for?
It’s time to articulate a notion of leadership that’s quite specific. Ask yourself questions like: Do I have the skills I will need? There’s new things requiring skills and we take that as a challenge to the hands. Can I use my resources in new ways to deal with this? That’s a strategic challenge, a challenge to the head. And there’s where do I get the courage and where do I get the hope, and how do I inspire the courage in others? That’s a challenge to the heart.
The practice of leadership
Joanne: These are important and tough questions! I imagine they can’t be answered in the abstract. What’s your process for building the culture and practice of leadership?
Marshall: We’ve focused on five practices that we anchor our work in: relationship-building, storytelling, strategy, structure, and action. I call them practices because they involve a skill, concepts, and values.
The first one is relationship building, to accept and understand the core texture within which this stuff happens is relational and how you do that with intentionality. Organizing is a particular form of leadership that starts by asking, Who are my people? In other words, with whom am I engaging to work, to accomplish whatever I’m trying to accomplish? Then the second question is, What is the change they want or need in terms of their lived experience? And what could help? And then thirdly, How can I help enable them to turn their resources into the power that they need to make the change? So it’s working with folks not like clients, not like customers, but as a constituency. The next question I would ask is, Who cares? For whom is this vital enough, urgent enough, that they would fight for it?
Then storytelling — the heart part. Stories are a way in which we learn to mobilize the emotional resources embedded in our values, to turn threats from which we flee in fear to challenges which we can approach with hope. In other words, it is creating the emotional conditions for the exercise of agency.
The third practice is strategy: how to turn what you have into what you need to get what you want. In other words, how you turn the resources you have into the power you need to get what you want.
The next is structure. In other words, how do we organize ourselves in order to do this? What are the commitments we make to one another? How are we going to work together? How are we going to handle authority resources?
And then in the end is action, which is how to actually make things happen on the ground. If you can’t count it, it didn’t happen. It’s a commitment to actual outcome and creating the kind of metrics so that you can learn as you’re doing.
Joanne: These practices probably aren’t linear, but rather as you said earlier, simultaneous. There seems to be a tension between the energy that can mobilize a movement and the stability needed to structure and organize ourselves.
Marshall: There’s a tension between change and continuity.
Organizations tend to be a whole lot about continuity and campaigns are really about change.
It’s a different rhythm. And so how do you balance the rhythm between change and continuity? It’s the university classic challenge Robert Michels writes about the iron law of oligarchy. You have your movement, your movement succeeds and you make it a successful organization. Guess what, sustaining the organization supplants the goals of the movement. And so then you don’t want to take risks. And eventually you become obsolete. Stephen Jay Gould talked about that in his book Time’s Arrow, Time’s Cycle. That’s kind of what a campaign is. It’s time as an arrow. It has a beginning and an end. It’s an intensely focused stream of activity that builds capacity in the course of what it’s trying to achieve.
Turning moment into movement
Steve: If you analogize the gradual, but steadily increasing prevalence of chronic diseases to the moment we’re in with racial justice, you could argue that it has been a growing problem — or a terrible problem that simply hasn’t gotten better — that’s punctuated by moments of acute visibility and outrage.
Marshall: And the question now is about turning the moment into movement. In other words, it’s whether those moments galvanize, whether people confront those moments with the capacity to use them, to turn them into something that goes beyond the moment.
I’ve been interested in how people take these moments and turn them into an opportunity to actually make structural change. It’s hard to plan these things. It’s like the problem with the climate change movement: the important is decoupled from the urgent. We will always respond to urgency, and urgency is an expression of extreme priority. There is a real, visceral understanding of urgency.
The other thing that we often talk about is anger. And by anger, I don’t mean rage — I mean outrage over a contradiction between world as it is and world as it ought to be. That moral dissonance, which is really important for generating courage, is not enough by itself. And that’s where the second set of emotions come in: hope, solidarity, and a sense of self-worth to balance the fear, isolation, and self-doubt.
In our own lives, we often learn what we care about through experiences of hurt. But we also have experiences of hope.
If we didn’t have the hurt, we wouldn’t think the world needed fixing. If we didn’t have the hope, we wouldn’t think we could.
In this context, how do you make it real enough that it shakes you out of the ordinary? And how do you make it hopeful enough that you actually think you could do something about it? These are important questions for movements to consider.
Shifting power with a critical eye and hopeful hearts
Joanne: Emotions like anger, hurt, and hope are human to human-level expressions. How do institutions and systems fit into this?
Marshall: Well, if you think about it, there are values in the interests of institutions. If you think in terms of values, individuals have values of hurt and hope and so forth, so do communities, so does a family. They take shape in the kinds of norms that we establish or the rituals that we may have. I mean, that’s what religion is: a way of experiencing challenge and hope. In other words, yes, there is that individual level of experience, but it can be embedded in community and it can be embedded in institutions.
I think of interests as specific objectives that are rooted in your values. That’s where power comes in. In organizing, there are things you can do through collaboration. For example, you can build capacity by supporting one another, but you bump up against the reality that there are others whose resources you may need. You can try to convert them to join you, but that’s difficult if they have different interests. And so then the question is, How do we make it more costly for them to not do what we want them to do than to do it? Or you can think of it positively: How will it be more beneficial than costly? That’s the power calculus.
Joanne: Once you have your organizational narrative, does that change how you conceive of your own narrative? It seems like there are two different kinds of power coming from different places.
Marshall: Power’s really interesting. There’s this notion about three faces of power. There’s the obvious — for example, when somebody gets arrested and goes to jail. But then there’s a second face of power, which is: Who authorized that? And then there’s a third question: Who set up the conditions under which those people could be making those decisions? It takes you then from an individual to a structural level.
As an example, let’s look at Rosa Parks protesting bus segregation. The city council and the bus company made the decisions to segregate buses, but those decisions stemmed from a larger system of segregation. And that system, it turns out, stemmed from institutionalized racism.
[Sitting in the back of] the bus was a grievance, a daily grievance. The protestors had the resources called feet; by walking to work, they could deny the bus company bus fare. And if everybody did it, it was substantial. That is one answer to the question, How do you turn moral resources into economic and political resources? That’s often what’s involved in a movement. It’s a calculus of sacrifice: giving up certain things in order to create the capacity to actually change something much bigger.
Joanne: People who experience the most hurt tend to also bear the greatest burden. When we look at the changes that need to happen for us all to be healthy together, who do you think could shift the power and drive structural change?
Marshall: I think the practitioners — the people who are called to healing — are really important. Medical professionals have a really important role to play. Young people, also.
Young people come of age with a critical eye but also, almost as a necessity, hopeful hearts. That is such a valuable, critical social resource. So it could be a real movement. It really could.
And we need one. This whole virus experience has helped reveal all the radical dysfunction not just in our health system, but in everything — we are seeing how the most vulnerable are the most screwed. It’s just so visible now, and we can’t let it just go away. There’s huge potential to make this country healthy, to give children more of a future.
