In a post 9/11 world, we have come to see more clearly how interconnected we all are, whether globally or locally: if others do not feel safe, we are not safe. We could add, if others are struggling, we experience the consequences, and if others are poor, no matter how wealthy we are, we experience the consequences of their impoverishment. In the world of public health, we would say, if others are unhealthy, we are all affected.
To live in this world, we need to learn to think differently, by actually seeing the systems we are participating in: to look at rather than simply through the lens that shapes what we perceive as the world. We need to become systems thinkers, to think together as things that are part of the same living organism. For that we need a whole set of skills that we never learned in school. These are the skills of Dialogue.
MAPP
While MAPP is defined as a strategic planning tool, it is, more fundamentally, a new approach to public health that attempts to be community-driven, by genuinely engaging the entire local public health system. MAPP represents a new way of doing the business of public health, that requires the engagement of all the stakeholders in a skillful way that will produce results that are comprehensive, inclusive, and locally owned. MAPP, in other words, reflects our growing awareness of interconnectedness and its implications for how we live together; in this case, how we do public health together.
Dialogue
Dialogue is "thinking together": it is the development of shared understanding by simply holding differences together in a way that is open, empathic, and equal. Daniel Yankelovich, the well-known social commentator, has said that as our world grows in complexity, the tendency, already rampant, to misunderstand each other, will increase, and ordinary conversation or discussion will not be enough to prevent this tendency from hurting us. Today's headlines reflect the consequences of such misunderstanding.
Discussion and debate, while they may sound similar, and are often used interchangeably, are not the same as Dialogue. Discussion is about reduction and analysis, while debate is about defeating and winning. Dialogue comes from Greek words dia (through) and logos (meaning), and suggests a kind of participation in the unfolding of meaning. When we bring our differences together in a certain way, new meaning emerges out of their marriage.
Dialogue consists of three things: intention, attitudes, and skills. The intention of Dialogue is to participate in the emergence of a (new) creative resolution: it involves presence-showing up; listening at many levels-paying attention; speaking one's truth without blame or judgment; and staying open to outcomes that may be unexpected. The attitudes that allow Dialogue to happen are openness, empathy, and equality. Openness means one is willing to learn: open to being influenced. Empathy suggests a willingness to walk a mile in another's shoes, while equality says that every perspective is valid, no matter how unsophisticated or unscientific. Finally, the skills of Dialogue are many, but essentially include connecting, sharing, exploring, holding, harvesting, and closing. Fundamental capacities that underpin these skills are listening, balancing inquiry and advocacy, and thinking and acting as a "we." Table 1 gives a sense of what is a very comprehensive process.
In a world where results alone count, Dialogue can be the forgotten piece; nonetheless, it remains the glue of interaction, without which relationships and process founder and sustainable results are nor realized.
Dialogue and MAPP
Cross River Connections has been working with the MAPP program almost since its inception 6 to 7 years ago. It has done this in two ways: (1) it has consulted to the working group that produced the MAPP tool and (2) it has provided Dialogue training to a number of counties as a way of creating a more fertile soil for the planting of MAPP. The intention has been to offer what we consider to be the underpinning capacity that allows the tool to be used to its fullness. Dialogue is what allows MAPP to realize what it intends-to be community-driven, to engage all the stakeholders-and to do public health in a new way.
Thus, Dialogue has offered a way to enrich all the stages of the MAPP tool: for example, Dialogue's ability to connect people around a shared vision makes Organizing for Success and Partnership Development (Stage 1) a more complete foundation for MAPP. Similarly, Dialogue's emphasis on listening ensures that the Four MAPP Assessments are comprehensive, while Dialogue's focus on building shared understanding assists a group in the work of Identifying Strategic Issues and Formulating Goals and Strategies. Finally, Dialogue's skills of thinking together assist in the final stage of Planning, Implementing, and Evaluating.
Dialogue and MAPP in Action
Dialogue training was offered in three states-Georgia, California, and New Jersey-when MAPP was in its initial stage of development, so there was little opportunity to see it in action. More recent work in the state of Tennessee, however, has offered a more robust picture. In Nashville and in the Eastern Tennessee Health Region, basic Dialogue training was offered to quite a larger number of public health personnel (around 100 in 2003, and another 150 in 2004). This was followed by a train-the-trainers program that provided deeper knowledge and increased capacity to a number of people (18). The intention was to build the capacity of the system by initiating a momentum and then providing the resources for furthering the process on site. Both of these regions are, in fact, test sites that participate in the MAPP Work Group, and, in both places, Dialogue has been a deliberate part of their MAPP process. It is our sense that there has been a marked difference in results in both places compared with the other test sites. Both claim fuller involvement by stakeholders, more comprehensive data, better shared agreement on strategic issues and goals, and a richer sense of local ownership by the community.
Judy Dias, MAPP Coordinator in Nashville, Tennessee:
"Nashville, Tennessee realized the value of Dialogue training as a companion and adjunct to MAPP implementation and made Dialogue training available to numerous staff and community partners. Dialogue was central to determining assessment information, recommended by MAPP. The dialogues also provided the opportunity for community voices to discuss and prioritize potential events or threats that could impact the health of Nashville if they occurred."
Stephanie Welch, MAPP Coordinator for Eastern Tennessee Health Region:
"Dialogue has really created a foundational philosophy upon which we've moved forward with MAPP. I would like to highlight how we used it in our Community Health Status Assessment in one of our counties. As we know, compiling data mostly consists of gathering numbers, but data in this form is unhelpful until you bring meaning to it. So, we created a series of community meetings with our various partners, in a Dialogue format, which helped the community react to and explore the meaning of the data we had gathered from them. The impact was clear in terms of engagement and their sense of ownership. In fact, I would say, if we are to do public health in a way that engages the community, our approach will require that Dialogue be its foundation."
Dialogue as the Capacity to Do Public Health Differently
Feedback on MAPP at this stage is less about revisions to the tool itself (the what) and more concerned with the MAPP process (the how). The skills of Dialogue speak to this how. Dialogue was offered as an optional extra at the MAPP trainings that were held throughout 2002 to 2003. Usually, about 30 percent of the participants would wait behind to participate. Without fail, a large percentage of these volunteers would comment that they would have been better able to appreciate the MAPP training had the Dialogue piece been offered at the beginning. I think this is because Dialogue addresses the challenges of community engagement and effective partnering. Skills in this area are necessary to genuinely do public health differently, since they require public health practitioners from all parts of the department and the community to move well beyond their traditional roles, and to creatively partner with those who may know nothing of epidemiology or immunizations, and to still effectively bring traditional public health values and strengths to that conversation. It might be suggested that this applies to public health in general.
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