From the 1960s to the 1970s, many efforts to improve health, education, and community efforts were successful. Since 1980 the successes have been limited. The US soil appears to be unable to sustain the necessary growth and development to help make interventions in health, education, nutrition, and other areas more effective.

In many ways the progress of recent decades has been about lasting impact from the previous decades. A generation with greater investment will benefit and will also benefit the next generation. The past investments have run their course.

War on poverty, the creation and increased funding of Medicaid and Medicare, support for the National Health Service Corps, Community Health Centers, and other investments have been followed by decades of cost cutting and austerity focus. Funding for humans has been diverted to other areas and the moonshot focus continues. Once it appeared that numerous interventions worked. Even the medical education efforts seemed to work for primary care and rural practice. But national changes in investment have resulted in changes in outcomes.

It is really difficult to see how health policy designers think that primary care can be made better when the dollars are too few to support the teams to deliver the care and the new designs make teams less productive, more distracted, fewer, and more burned out. Technology fixes all clearly has limitations, especially in basic child development, basic education, and basic health care where progress remains about people investing in people.

Governments, foundations, and communities are always hoping to facilitate more efficient and effective services. The Robert Wood Johnson Foundation has asked again and again - How do we give kids the building blocks for physical, cognitive, social, and emotional health? Other foundations measure progress and the results do not look good.

It has taken far too long to understand that it takes more than prenatal care and clinical interventions to address infant mortality and maternal mortality. Many "experts" have had a field day blaming religious leaders, women's health terminations, or states such as Texas for infant, maternal, Medicaid, or other outcomes. The factors that influence these outcomes are more about social fabric than other areas and the United States overall has allowed the social fabric soil to deteriorate.

This makes it difficult for any number of investments to work as well - until the soil is improved. The likely area most closely related to soil improvements is child well being. By any number of measures we are not doing well.

Health outcomes are shaped by behaviors, environments, situations, and social determinants.

Quality is in the matrix of relationships (Deming)

Outcomes orientation should teach the value of these relationships. Instead we have quality efforts that focus on measures, technologies, and other areas that actually compromise the ability of education and health care teams to address their important societal tasks. Measures and technologies and their advocates take on a life of their own while infrastructures fall further behind.

The Status of Physical, Spiritual, and Human Infrastructure

Physical Infrastructure in the United States is also not doing well. For decades the United States worked at all levels to help make transportation, utilities, and other areas more efficient and effective. Now such investments are avoided as are the maintenance costs. Paying more later because of tragic neglect is far too common and should continue for some time.

The Spiritual Infrastructure in the United States seems to be at an all time low. It its difficult to get the American people regarding what the nation should do in many important areas. Congress is a reflection of this impasse. Spiritual infrastructure can have impact far beyond religion but also can be far less. Nationalism can also be a double-edged sword to unify or to divide US.

The Human Infrastructure in the United States most impacts education and health care. Nurses, teachers, public servants, public health, and other humans serve people directly in important health, education, public security, and other areas.

Few would argue that these representatives of human infrastructure are facing greater challenges from more directions, more regulations and standards, increasingly complex interactions, greater scrutiny, and increased burnout as more is required with same or less support.

With decent Spiritual Infrastructure, Physical Infrastructure, and investments in improving the social fabric/soil of living, the human infrastructure tasks are more reasonable, more efficient, and more effective. For example some states can invest far less in education for same or better outcomes. Some places can spend multiple times as much for worse outcomes.

Exceptional Circumstances and Exceptional Challenges

When a nurse, police officer, or teacher is working with a person who believes in future for themselves or others, there is some hope of needed behavioral or other changes. When there is not such belief, the outcomes of encounters become more unpredictable - and often dangerous for all involved. Mistakes are going to be made when people are unable or unwilling to invest the time and effort in addressing each other's needs.

Media Distractions

It is a great sadness of our time that our media and social media are about blame and shame rather than context, reflection, awareness, and problem solving.

Edward R. Murrow is a good source of reflection from past to present or from a time when the media worked to inform and educate as compared to media focused upon marketing, advertising revenue, and profits:

But during the daily peak viewing periods, television in the main insulates us from the realities of the world in which we live. If this state of affairs continues, we may alter an advertising slogan to read: LOOK NOW, AND PAY LATER.

Lip Service to People Factors But Not Investment in People to Impact Care

It is a great sadness of our time that our education and health care designers cannot see that outcomes are about people factors, behaviors, situations, environments, investments in each other, social fabric. If they had seen this they would have understood

The futility of measurement worship with numbers additional costs and compromise of the social fabric
The discrimination of Pay for Performance as schools, practices, and hospitals serving those with less resources and greater challenges get even less funding or are closed.
The futility of health insurance expansion with payments too low to support basic services (cost of delivery higher than payments). Greater investments in the team members to deliver the care allows small hospitals and practices to address the needs of insured and uninsured patients - doing what the current insurance expansion cannot do.
Other nations succeed in health and education where we fail because they invest far more in children age 0 - 6 (2% of their GDP) while we spend less than 0.5%. A move to 2% of our GDP invested in the earliest months and years of life could do much to reduce health spending from 17% to 12% or less. Nations such as the US and the UK have insufficient outcomes in health and education and both share bottom of the pack rankings for developed nations. (both from UNICEF)

The route to become a local teaching or health professional should begin, continue, and end locally. There is no longer a need to send children to distant colleges or professional schools when there are classrooms and practices without walls with great needs to address using local community resources - starting age 14 or sooner.

It is quite ridiculous to paying more and more to send a teacher or health professional to serve a population that will be difficult for them to relate to for two to three times the length of any loan repayment.

It is interesting that tele education and tele health are considered solutions for deficits of services when the internet can actually result in education and health care most specific to local needs and least distorted by those with other agendas. Murrow was right. The lights in the box distract, but fall short of the full potential.

Mutual Interdependency

The fact of the matter is that we are mutually interdependent. Physical, spiritual, and human infrastructure are also mutually interdependent. Compromises must be made so that we can move forward with needed investments specific to children, future generations, health care, education, and other areas.

We seem to forget the most important lessons all around - such as civil wars or our own civil war. These are of course places where the social fabric has been devastated with consequences for decades as we still see across Appalachia and parts of the South. New areas left behind are seeded by the old problems as yet unresolved.

Where we improve is about where we all invest. Outcomes are the result of preparing the soil to improve environments, situations, relationships, behaviors, social determinants, and outcomes in health, education, economics, and more.

The investments required rarely look efficient or effective when considering one outcome, but dozens of important outcomes can be shaped by these investments.

Some Can Learn the Most Important Lessons But Not Others

Sidney Kark went to South Africa to "fix trauma" care - to bring western triage and technology to bear. To his credit he did not leave or try to make claims of benefits in trauma care. He saw a greater need. What he discovered was that basic public health, sanitation, nutrition, and other people factors were more important and Community Oriented Primary Care was born. Eva Salber MD was a disciple and helped in the US in Boston, did early research exposing the harm of teen smoking, and facilitated lay nursing health care efforts in eastern North Carolina via black churches. There were other community health activities via her efforts and those of her husband.

Community Health Centers can also vary in outcomes. Many are found in areas that have greatly improved in health and in health outcomes. One of the two original CHCs begun in 1965 was started in Bolivar County MS and there have been few changes in Bolivar County across 50 years. Investments in Appalachia have been many in type and amount, but the major improvements have been where superhighways, urban areas, and federal jobs impacted the area.

Working to Restore Social Fabric, Health, Education, Community

There is some element of Community Oriented Care rediscovered about every 20 or 30 years or when the usual clinical interventions are exposed as inappropriate, too costly, and lacking in the ability to change health outcomes, especially where people most need better outcomes.

This community idea does not need proving - it needs support and replication.

Essential is that people work together to address community needs as deemed necessary by the community aligning local assets.

What is tragic is that these lessons are lost or mistakes are made that should have been prevented by review of the previous works.

Social Fabric Experiences in Health Care

It is difficult to grasp the important concepts involving education, health, and societal outcomes. I consider it a great blessing to have family and job experiences that have taught me much about these areas.

Solo rural practice learning from the people in Nowata OK was most important. Few understand just how much more important the first years of practice are for learning in many dimensions as compared to the short formal years of training.

The State of Tennessee invested in me and in a rural FM fellowship development.

HHS through HRSA invested in me in the rural minifellowship. The minifellows were as much teachers and mentors as learners. The right fabric can accomplish much. During the minifellowship activities it was great to meet Eva Salber and learn from her - one of the disciples of Kark.

At the time I did not realize it, but later I began to comprehend the value of my particular family medicine training at Waco. This training was the result of local community efforts to extend health access (a reason why the Mega CHC effort funded from above is so misguided).

Asset based improvements have helped many communities.

Gerald Doeksen was influential regarding the importance of economic activity to rural and small places spanning the 1980s and continuing to recent years. Studies that dismiss the consequences of losses of rural physicians, practices, and hospitals are quite appalling in their assertions.

Theresa Hilton was one of the most influential people I ever met and it was a great honor to send her students for her to mentor in Columbus NE as she constantly pushed health, public health, health access, and care where needed. It is indeed unfortunate that the National Health Service Corps would award programs that matched students to mentors in this program and through HPDP at Community Health Centers, and then take the funding away - or have it taken by a Congress that appears to understand less about people, outcomes, and future generations.

I give my thanks for all of the above and for supportive wife, her teaching experiences, and for children to illustrate much of what is essential in life.

Sowers, Seeds, and Outcomes

It only takes a few seeds to fall in fertile ground - but our nation suppresses the seeds and fails to prepare the groundwork. Half enough for primary care, public health, basic legal assistance, housing, nutrition, jobs, child development results in barren ground - making it harder for any seeds to survive, much less replicate.

Matthew 13 New International Version (NIV) The Parable of the Sower

That same day Jesus went out of the house and sat by the lake. ²Such large crowds gathered around him that he got into a boat and sat in it, while all the people stood on the shore. ³Then he told them many things in parables, saying: “A farmer went out to sow his seed. ⁴As he was scattering the seed, some fell along the path, and the birds came and ate it up. ⁵Some fell on rocky places, where it did not have much soil. It sprang up quickly, because the soil was shallow. ⁶But when the sun came up, the plants were scorched, and they withered because they had no root. ⁷Other seed fell among thorns, which grew up and choked the plants. ⁸Still other seed fell on good soil, where it produced a crop—a hundred, sixty or thirty times what was sown. ⁹Whoever has ears, let them hear.”