Ari Johnson: More Than Enough
When their study began in 2008, 1 in 7 children died before they could celebrate their fifth birthday in Mali. Seven years later, child deaths had become rare—only 1 in 142 children. Read the results of Muso’s methods, here.
Kate Bowler: Can we change the world? According to everyone’s graduation speech, yes absolutely, probably today. But really, can we? I think it’s an incredibly interesting question right now in this political and social climate where there’s tremendous fear. And with fear often comes fatalism. What can we really change anyway? I’d love to introduce you to someone who is often praised as a world changer, which makes him deeply uncomfortable. He’s the Co-founder and CEO of an organization called Muso, which works in the African country of Mali. Muso provides care for 350,000 patients and supports the Malian Government’s national effort to connect more than 18 million people with healthcare. The work they do is really incredible. Mali used to have the sixth highest rate of child mortality in the world, and in the area in which Muso works, the chances of a child under five dying drop significantly. I’d love him to tell you more about it. Incredible. Ari is the person I go to, to talk about what we can change. How much can we change in the world, in our lives? And here with me in the studio, or rather I’m out here with him in San Francisco because this is where he also practices medicine and works as a professor at the University of California, San Francisco. Hello my friend.
Ari Johnson: Hi Kate.
K.B.: I’m really grateful you let me come out here and do this.
A.J.: I’m grateful to be here.
K.B.: I feel like it’s worth starting this conversation with the fact that you could have just been a fancy doctor. Like, you went to Harvard medical school. Your life could have taken a very different turn. So, can you tell me how your organization got started?
A.J.: Sure. Muso began as the common work of a group of Malians and Americans, and I was one of them. And we were concerned together with injustices of health inequity, the way in which poverty enacts itself on the lives of the poor. And it got started with one particularly important act. We decided to move in with the communities that we sought to serve in the shadows of Mali’s capitol.
K.B.: Were you just friends and you just had an idea?
A.J.: There were several of us, um, young Malian and American professionals who shared a common determination, common concern about the injustices of health as they’re bound up in poverty.
A.J.: And that led us to decide to move into these communities in the shadows of Bamako, right?
A.J.: And not long after we moved in, one of our neighbors came to find us and she said, “Will you come see my grandson”? We heard an urgency in her voice, and so we rushed with her through some winding alleyways to her house and we saw her grandson, we met her grandson and he was soaked through in sweat from a fever and a high fever, and he was struggling to breathe. So, we rushed him to the nearest hospital, but we were too late. So, the next day we were sitting at his funeral, reliving what it was like to watch a one-year-old baby die in front of us. To watch our neighbor die in front of us. To watch his grandparents watch him die. And that experience really changed me, changed the course of my life, changed all of us. But just as we are trying to absorb how, why this had happened, a few days later, something very similar happened again. Then it happened again. Then it happened again and again and again.
We were being called upon by our neighbors, first a few, then a few dozen, then a few hundred. It got to the point where we would wake up at dawn, open our door, and we’d have neighbors waiting outside of our door. And they were struggling and failing to access healthcare in a system that was designed to exclude them because they were poor. And their expectation of us was simple, they were struggling and they asked, “Will you struggle with us”? Of course we did. And as we accompanied our neighbors and their struggles through the health system, and as we heard their stories and saw their experience walking beside them, we came to understand that so much depended on time. So much depended on when someone got care.
A.J.: We noticed that when one of our neighbors found us early, we could connect someone with care in the first day or two. Just a few dollars worth of pills to cure a kid from malaria or from a pneumonia infection. A few dollars worth of care, a little bit of effort was enough to completely turn their life around. That little bit of effort, and you see this Lazarus-like effect, and I was part of that once and I just got hooked. I never wanted to do anything else with my time, I just wanted to be part of that again and again and again for the rest of my life. But most patients didn’t find us early.
A.J.: Most patients found us after a long, long struggle. Most patients found us late. And those are the patients where no matter how much we put of ourselves, no matter how much resources we mobilized, it often wasn’t enough. Those were the patients whose funerals we went to, and it got to the point where we were attending the funeral of a child or a young mom about every week.
A.J.: And out of that experience we asked ourselves a question. “What would it look like if we could reimagine healthcare delivery and redesign it to reach every patient early with the care they need? What if we could cure delay?” And that question became the foundation of what became Muso, a conviction that healthcare delayed is justice denied.
K.B.: I think that was one of the first things I ever heard you say about the violence of delay. And as someone who’d had a stage four diagnosis instead of a stage one, I was so grateful that you were looking at the system as a whole and saying, “Despite people’s best intentions”, which is how people usually want to frame problems, that there is still an evil that can persist and that we can think differently about how we step into the void when too many people are the victims of delay.
A.J.: Nobody should die waiting for health care.
A.J.: Nobody should die waiting for healthcare.
K.B.: So, what exactly did Muso do?
A.J.: The first thing we did was actually to redefine the responsibility of the health system. The moment that the health system is responsible. Typically, I’m a doctor, I got to train at some fancy places and I learned that my responsibility to the patient begins when they walk through the door of the clinic or a hospital where I’m at and seek care from me.
A.J.: And what patients taught us is that that kind of passive approach to healthcare delivery is failing patients and particularly the most vulnerable patient, because way too many patients never even make it to the door.
A.J.: Or they make did the door far too late. Patients face so many barriers along the path to care. Our patients told us about fees they couldn’t afford to pay. Money they didn’t have in their pockets. Distance they couldn’t travel. Providers without the infrastructure, the equipment or the knowledge they needed to make the diagnosis to provide the care, right?
A.J.: So, based on what our patients taught us, we came to understand that if we were going to reach every patient quickly, we would need to really overcome walls that they had to climb over on their path to care. And so, Muso deploys community health workers, paid professionals who are predominantly women from the communities that they serve, who spend hours every day going door to door making house calls, searching for patients who need care.
A.J.: And they sit with people in their homes and each community health worker is also equipped and trained and rigorously supervised to provide a package of evidence-based diagnostics and medicine in the home. They also identify the patients who are too sick to get care in the home, for whom they need to call an ambulance to come out and evacuate them to a strengthened government primary care clinic. And Muso partners with those clinics, improving their infrastructure, their staffing, the training, the equipment and removing all of the copays, all the deductibles, no point-of-care fees. Because those fees are the number one barrier that patients told us about on their path to care.
K.B.: It’s probably easier to just blame patients for not getting the care they need. I have had my own limited experience with blame. Colon cancer is always the favorite target of, “It must’ve been something you ate”. But when patients don’t get what they need, I’m sure it’s much easier just to blame them.
A.J.: I hear that all the time. “Oh, they came to care late because they didn’t understand the importance of healthcare. They didn’t understand how bad their sickness was or they never went to school, so they were uneducated and ignorant”. So, these are the kinds of prejudices that our patients face and it makes me so angry. It makes me so angry because our patients are accessing care late not because they don’t realize that they are sick, they know they’re sick.
A.J.: They know the stakes better than anyone. And they are working to tenaciously to figure out how to get themselves and their loved ones care. They are exercising the full force of their resources and will to try to make it happen. But we have together designed healthcare systems that exclude the poor, maybe not intentionally. So that’s why I said it began by actually redefining the moral mandate of a health system. Our responsibility, the health system’s responsibility, begins the moment someone needs our care and it’s our responsibility to find them, to meet patients where they are.
K.B.: I was wondering if you could paint a picture of like, you have your professor at a university life and the one I’m kind of seeing around me, and then you’ve got this life in Mali. Can you help us know the two versions of your life? How does it look for people who’ve never been to Mali?
A.J.: So I have the immense privilege of getting to live part of my year in Mali with the communities that we serve and partner with and some part of my year out here in the Bay area in San Francisco. And when I’m in Mali, I still live in the same place I’ve lived since 2006, so for over a decade together, with a family of five generations of amazing women aged three to we believe about 99. Yeah. Mali has an extremely outgoing, ecumenical, warm culture. Mali’s a 90 plus percent Muslim country, but what you’ll find is that the Muslims of all sects and the Christians, the Catholics, the Protestants and a couple of Jews that are in country, we all bless each other in the same language.
K.B.: Stop it.
K.B.: What kind of stuff?
A.J.: It’s in every single interaction. So, on a given day, it’s more likely than not that you’ll give and receive more than a hundred blessings.
K.B.: Oh my gosh.
A.J.: And that’s with your mom when you wake up in the morning, that’s with your kids, that’s with the stranger you pass on the street, with the lady who sells you your tomatoes. The lady who sells you your tomatoes will bless you to have a day of overflowing peace, that you may have a long and healthy life. She’ll bless you that your children should have nourishment, that you achieve what you’re seeking. She’ll bless you that at the time of your death, you will look back and be fulfilled in what life you have lived.
K.B.: Oh my gosh.
A.J.: And that is a person who just sold you a tomato.
K.B.: That is comprehensive.
K.B.: I love it.
K.B.: That is a mode of speech we don’t have. I mean we have positive affirmations, “I am healthy, I am blessed,” but we don’t openly bless each other.
A.J.: Yeah, it’s in almost every interaction.
K.B.: That’s amazing.
A.J.: Yeah, it is amazing and perhaps that gives you a little bit of a sense of the kind of culture that you’re just wrapped in there. It’s a pious culture. People do pray a lot in their different religions and practices, and it’s a very warm, friendly, welcoming culture. If you’re eating and someone passes outside your house, you’re expected to call to the person on the street-
A.J.: “Come eat with me”.
K.B.: Oh my gosh.
A.J.: It’s rude if you continue eating without calling to the passer-by to come eat with you. So,-
K.B.: Now I’m feeling guilty of all the barbecues I’ve had which I was like, “Keep going neighbors, I’ve got friends over”.
A.J.: When you greet someone in the beginning of every conversation you don’t just ask, “How are you”? You ask, “How are your parents doing? How are your little brothers and older siblings? How’s that friend I met with you three years ago”?
A.J.: “How are your kids, and how are you really”? And only after you do all of that, do you maybe engage in whatever substance of conversation like, “Can I buy that newspaper”? I tried this once in New York, it really didn’t work.
K.B.: Your organization has had tremendous success in lowering the number of children under five who die from a variety of diseases. So, can you tell me just a little, a few of the stats on that?
A.J.: Sure. Muso has partnered with the Ministry of Health of Mali, the Government of Mali, for more than a decade to design and build and test approaches to reaching every patient quickly, new healthcare systems. And last year Muso together with the Malian Government and researchers at UCSF, Tulane, the University of Bamako and some other institutions, published a study with some remarkable results. In that study, in the British Medical Journal of Global Health, the co-authors documented what happened to the rate of child death before and after the rollout of Muso’s proactive approach to early health care delivery. And here’s what we found: we found that at baseline the rate of child death was 154 per thousand live births. So 15% of kids at baseline were dying before they could reach kindergarten.
A.J.: That was one of the highest rates of child death in the world. Then we found essentially that after the launch of this proactive healthcare approach, the rate of child deaths plummeted. The areas served by this approach sustained and achieved a rate of child death lower than any country in sub-Saharan Africa for five years running, at or below 28 per 1,000. Those communities by the end of the study had achieved a rate of child death of 7 per 1,000 live births. That’s roughly on par with the rate of child death in the United States.
K.B.: That’s amazing.
A.J.: You know, it is an extraordinary result, but it shouldn’t be. It shouldn’t be extraordinary at all. Death of a child should be rare everywhere.
A.J.: We’ve known how to cure the leading causes of child deaths for decades. We’ve had the tools, and we have collectively failed to deliver them on time to the kids who need them. And so, for us it has been an amazing privilege to be part of this journey and to witness what the communities we serve have achieved. They have achieved something extraordinary, and I think it is our common commitment to make it so that those results don’t stay extraordinary. To make that kind of transformation normal. So the death of a child can be rare everywhere.
K.B.: One of the things that really surprised me about the work you do is that I think maybe just because my geography was off.I mean I understand Canada’s large, but sometimes I forget the scope of other countries. But this transformation happened amidst a lot of obstacles. I mean the geography itself is enormous. You had an insane number of things happen when you were trying to make this work.
A.J.: So, that study was a seven year study. And over the course of the seven years in which this transformation occurred, there was a coup d’etat, an Al Qaeda occupation of Mali’s north. There was massive refugee and internally displaced persons crisis that came out of that as people fled the Al Qaeda occupied areas and many of whom landed in the areas where we serve seeking refuge. There was an Ebola outbreak.
K.B.: Okay, now you’re just making stuff up. That was insane. Oh my gosh.
A.J.: So, if this kind of transformation is possible in the midst of a coup d’etat, an Al Qaeda occupation, a refugee and an IDP crisis, and an Ebola outbreak…we’re all out of excuses.
A.J.: This kind of change is possible. We collectively have the power to make this happen for everyone.
K.B.: It gets to one of the things that you and I have a lot of feelings about which is what is under our control, what we can actually change.
K.B.: Because one of the things that struck me is that you a deep impatience, I think a holy one, with people’s passivity around what can change because you watch the impact of neglect and you speak about that so beautifully. It’s just a little funny because on the surface we have opposite languages, right? So I go around and I tell everybody that, “Not anything is possible and simmer down and it’s cruel and that we shouldn’t always think of ourselves as like boot strappers who can do anything”. And on the surface it feels like we have a serious disagreement.
A.J.: It does right?
K.B.: Because you’re, “No seriously, we can do anything. Now would be a good time. Also now, maybe 10 years ago”. I really like that.
K.B.: But I think too, part of what I hear you describing though is that, “Yes, everybody is called to action”, but that we… I think we both share a deep frustration with people who are lucky who don’t know they’re lucky. And that there is a… right, a burden placed on all of us to know what our act of service should be. And that sometimes we’re talking to people who feel like they’re self-made, and you’re describing a situation in which nobody gets to be self-made. Everybody belongs to each other because their lives depend on it.
A.J.: Which I believe to be true. I believe that we vastly, and you teach this, you preach this better than anyone I know. We vastly overestimate our own control over our own lives. We are not in control of our own lives. We can not control the outcome. I also believe that we vastly underestimate our power. We vastly underestimate our power. I believe we even hide from our power, because our own power is terrifying. We are terrified of how powerful we are, particularly our power in the lives of others.
A.J.: Our power to cause harm. Our power to cause harm and to hurt those around us.
A.J.: And our power to heal. Both of those are terrifying.
A.J.: The resonance of our actions both to hurt and to heal are so much bigger than we see and so much bigger than when we estimate, and it is terrifying for us to look at that because if we look at it… it takes so much courage to look at that because once we look at it, once we embrace how powerful we are, then we are responsible.
A.J.: And there’s no letting ourselves off the hook. We have to take action. There’s no other way.
K.B.: The second I was really, really sick, then all of a sudden it felt like I could see, it sounds a little overly pious, but I felt like I could see everybody’s pain. And that gave me a window into reality, the world as it really is. That was unbelievably clarifying. The problem is, is it’s way easier to let that go because it’s too painful.
A.J.: I think that love is not a finite resource.
A.J.: Love is not a finite resource, it is something we grow and cultivate. Our ability to love, our ability to love ourselves, those close to us. Our ability to love people we’ve never met before. We can do that.
A.J.: We have the ability and this is an incredible thing.
K.B.: Yeah, you’re right.
A.J.: When this happened to me for the first time it knocked me out of my chair. We have the ability to love people we have never met.
A.J.: Isn’t that incredible?
A.J.: And that is a wellspring. When we love people, we feel a part of their lives and we also feel a part of their own suffering.
A.J.: Their suffering becomes a part of us too, and yes, that hurts. But it’s worth it. I mean, that is the work of life.
K.B.: Yeah. I was giving a talk recently and the interviewer said something like, “You know, it’s been a while since your diagnosis. When are you going to get back to normal?”, kind of thing. And I felt immediately kind of horrified by the idea that I would ever want to go back to whatever it was before. I mean, health sure, health is great.
K.B.: But like back before I knew that the work is just supposed to be love, right?
K.B.: Like seeing… I love your account of the more than enoughness of it. Like love is like a muscle you can build up and you can get better and better with a bigger and bigger capacity to do it.
A.J.: Yes. Yes. We also know that we are far more connected to each other than appearances would suggest. That in a world where I might wake up in the morning and drink coffee grown in Ghana out of a cup made in India wearing a ring with gold in it pulled from the ground by miners in Mali…that we’re all neighbors, right? We’re all so close to each other, so much closer to each other than we tend to estimate.
K.B.: I know you’re also a person of deep faith and I think that’s part of our shared hope, that this doesn’t begin and end with our ability to be better, be good, be good people. Like that’s… it doesn’t sound like that’s what you want to rest this on.
A.J.: So, I’m a practicing Jew and we’re called to love God. We’re called to love our neighbors, yes? As we love ourselves. We are called to love strangers, people we’ve never met. We’re called to love and care for our enemies. We’re called above all, we’re called to love those who are oppressed, who are struggling with oppression. And to do that, we are called to relive every day, our history. To relive our experience of being slaves, the Jewish experience of slavery in Egypt and relive the struggle for liberation. And that is something that every Jew is supposed to relive every day of their lives, so that you can know the souls of the oppressed, of those who face oppression today. Those who are struggling today. That in taking that history and making it present for us every day, and making a daily practice, we make common cause with those who struggle.
K.B.: Yeah, you find kindreds.
A.J.: Yeah, and we open ourselves to loving other people.
K.B.: Yeah. It’s kind of why I friendship stalked you though Ari. You have this very wide open heart, and even though my stuff was specific to me and you do big global work, I’m always grateful when we can find brothers and sisters in just the experience of wanting to still have gifts to give even when you kind of come to the end of what you know how to do. And I know your work is not easy. You come to the end of yourself a lot, and I’m so grateful to hear your pitch for being in a world of love. And I want us all to kind of be with you in it.
A.J.: I think we are in it together.
K.B.: I didn’t just sell you tomatoes, but I will say bless you. It’s so nice to spend time with you.
A.J.: Bless you too Kate. Thank you.
K.B.: I used to absolutely nail the genre of graduation speech and now as a professor, I’ve sat through a zillion more and it’s always something like this, “Get out there. The world is your oyster. Live the life you’ve always imagined. There are far greater things ahead. Don’t underestimate the power of your dreams”. Totally. Totally. Sometimes everything is possible and sometimes nothing is possible, but when do you know the difference? We’re not always in control of what happens to us, but we can be aware of our power to harm and our power to heal. Ari and the work of Muso reminds me that agency rests on a sliding scale. Yes, you can help and now is a good time. Or no, you’re tired and fragile and you need a nap. Instead of resting on the lore of individualism and the goal of personal happiness, Ari makes me believe that we can really belong to each other. That our happiness is intrinsically tied. That my flourishing cannot exist apart from yours. That your pain is also mine.
When Ari said something about how we can love people we’ve never met, you should’ve seen his face. It just lit up. He has gotten insanely good at loving people, but it really started when he told himself that he had to start today, because if you’ve ever been in love, you know it just can’t wait.
This episode was made possible because of the generosity of the John Templeton Foundation, the Issachar fund, the Lilly Endowment, North Carolina public radio WUNC, Faith and Leadership: An online learning resource, and Duke Divinity School. Not to mention my team, Beverly Abel, Jessica Richie, and Be the Change Revolutions. Let’s be friends. You can find me online @KateCBowler, or at katebowler.com. And it would mean so much if you left a review on Apple podcasts. This is, Everything Happens With Me, Kate Bowler.