This is the final working paper for an article that appeared in the Oct-Dec 1992 issue of Nursing Forum:
"On Being an Advocate"
by Tim Size
"A museum with no opportunity to touch
is a vacant lot for patrons who happen to be blind."
"The civil right's and women's movements teach us
that we impoverish ourselves when we impoverish others."
"Medicare's view of wages has been based
on a simplistic and erroneous model of a labor market,
isolated mesas of high wages abruptly dropping to lower wage rural plains."
"Costs can be driven down by a health care czar simply limiting
what people are allowed to spend,
but quality and efficiency can only be achieved by
committed and empowered local organizations and individuals."
Advocacy is acting out a belief that your vision can be brought to life.
Some of my most vivid growing up memories of the late 1950's are the endless kitchen arguments with my devout Baptist mother on the theory of evolution-hardly the stuff my own teenagers bring to the table. Her particular tenacity on this issue may be traced to her childhood memories of her guardian's friend, William Jennings Bryan, the famed attorney on the then winning side of the "Scopes Monkey Trial." Like many women of her generation raised in the shadow of the old south, she had a finely tuned nature of smiling and cajoling while not giving an inch. On the way to the rest of my life, I finally offered a compromise, never accepted, that the Biblical account and Darwin's theory could be seen as quite compatible. What we did have in common was never stated: a passion for defending and promoting a vision, however abstract, however distant.
Thirty years later, I find myself an advocate and to a lesser extent, a lobbyist. Lobbying and advocacy are roles that depending on the person and the situation, may or may not be overlapping. Personally I don't respond well to being labeled a lobbyist, particularly when State oversight leads to the tedious task of recording every moment spent or preparing to spend communicating with any State official or employee. The critical problem of influence peddling aside, our democracy is well served by lobbyists representing various voices to the polity. I'm comfortable with the image of a lobbyist with a client (or in my case an employer), the right contacts, good information, and a quick mouth and pen. I'm uncomfortable with the common implication that vision and passion are not required. For the lobbyist money may be an end, for the advocate it is more of a necessary means. The principle object of a lobbyist's attention is, by definition, public officials. In contrast or addition, advocates challenge their own people as much as they try to affect the government. Passion can be a liability for the lobbyist, particularly to those with an eclectic taste in clients, but it is unavoidable for the advocate.
The lobbyist helps to define the compromise; the advocate stretches the limits of the debate, developing credibility for new alternatives. As a member of the Board of the National Rural Health Association I have frequently had the opportunity to be an advocate in Washington for more equitable reimbursement to rural health care providers. Not being part of the inside the belt-way crowd, I have not been involved in the details and deal making of the lobbyist. However in Wisconsin, position and proximity have led me in some instances to be both an advocate and lobbyist for rural health, involved with both idea generation and compromise.
A lobbyist selects his or her clients and issues; an advocate can choose not to act but probably has little choice in the visions that capture his or her passion. At work, a vision that has captured me for the last ten years is that of a coordinated but decentralized healthcare system in Wisconsin -- organizations and communities coming out of isolation, working together collaboratively rather than under a hierarchical private or public order. If my own experience is indicative, the advocate has or develops a nature that is willing to or may even enjoy challenging conventional wisdom and authority. For better or worse, the habits of advocacy tend not to be left at the office. Occasional problems related to two of our four kids with special needs have created a number of opportunities to bring my "work" home: a camp with horses totally off-limits to an active Girl Scout who happens to be blind, a museum without items to touch, a school tortuously slow to adopt this generation's Braille writer, talking computers and a teacher seeming to miss the point by saying "she can't force kids to like each other."
Are my visions rational choices or the result of a being dropped as a child on to a green linoleum floor one time too many? Within healthcare would I be less of an iconoclast on behalf of rural health if the current system did not put rural health at risk, if there was not a Goliath to slay? Did we choose to adopt children in order to challenge convention or was this option simply consistent with our vision of family? Is occasionally having fun as a gadfly consistent with encouraging system reform or pursuing a serious vision?
To all these questions I say yes, true. Being an advocate is being driven by mind and heart, past and present. While I was frequently reminded about getting too big for my britches did Darwin's nemesis know she was raising an advocate? My guess is that she did.