Dr. Risa Lavizzo-Mourey, President/CEO, Robert Wood Johnson Foundation: Philanthropy in the Service of a Healthier America
Created by Robert Wood Johnson II, the son and nephew of the co-founders of medical products giant Johnson & Johnson, the Robert Wood Johnson Foundation was launched in 1936 as the Johnson New Brunswick (NJ) Foundation, a locally oriented philanthropy with an interest in helping the poor and indigent. Over the next thirty years, the foundation, which assumed its current name in 1952, began to reshape its priorities, devoting more of its grant dollars to hospitals and health care, scholarships, and community-service programs, mostly in the New Brunswick area.
When Johnson died in 1968, he bequeathed his stock in J&J — more than ten million shares valued at roughly $300 million — to the foundation. Although it took three years to probate his estate, when the foundation finally received the proceeds from the bequest in 1971 it immediately became the nation's second-largest philanthropy, with more than $1 billion in assets and an ambitious agenda "to contribute to the advancement of health care in the United States."Today, the Robert Wood Johnson Foundation has almost $8 billion in assets and awards grants and contracts totaling more than $300 million annually in support of programs and projects to improve health and health care in the United States.
Recently, Philanthropy News Digest spoke with Risa Lavizzo-Mourey, president and CEO of the foundation, about what it's like to run the nation's largest healthcare philanthropy, the foundation's approach to grantmaking and some of the things it has done over the last few years to enhance the impact of its grantmaking, and the critical role of organized philanthropy in strengthening the healthcare system for all Americans.
Dr. Lavizzo-Mourey is the fourth president and chief executive officer of the Robert Wood Johnson Foundation, a position she assumed in January 2003 after having served for eighteen months as senior vice president and director of the foundation's Health Care Group. Prior to coming to the foundation, Lavizzo-Mourey was the Sylvan Eisman Professor of Medicine and Health Care Systems at the University of Pennsylvania and director of its Institute on Aging. Dr. Lavizzo-Mourey earned her medical degree at Harvard Medical School and an MBA at the University of Pennsylvania's Wharton School. [Ed note: The first woman and African American to head the foundation, Lavizzo-Mourey stepped down from that position in 2017.]
Philanthropy News Digest: Tell us about your background and how you became interested in health philanthropy and the philanthropic sector in general?
Risa Lavizzo-Mourey: Sure. I grew up in Seattle, the daughter of two physicians, one of whom was a surgeon and the other a pediatrician. They inspired me from an early age to pursue a career in medicine and to think of myself as being the kind of person who wanted to help patients, one patient at a time. That was the vision I had for myself throughout my childhood and adolescence. In college, I met a legendary figure in public health, a man named Jack Geiger, and he became one of the people that illustrated the connection for me between the broader fields of public health and the kind of health care and quality of life that people experience on a day-to-day basis, which really led to a major shift in my thinking. By that I mean it helped me to see the importance of being able to look at patient populations rather than only looking at the patient in front of me, although I've certainly derived great joy from taking care of individual patients.
As I was finishing up medical school, I learned about the Robert Wood Johnson Clinical Scholars Program and was taken with the notion that one could learn a different discipline, whether it was education or medicine, and apply that new lens to being a change agent in the field of health care. That was also my first introduction to the Robert Wood Johnson Foundation and the field of philanthropy. And throughout the next part of my career I held on to that lens and applied it to my clinical work as a geriatrician.Ultimately, however, you could say I was bitten by the philanthropy bug and the idea that philanthropy has the opportunity and the means to transform whole communities and groups of people in a way that you can't caring for one patient at a time. And I'd say that realization really led me to the Robert Wood Johnson Foundation. What continues to energize me is the opportunity to address big problems in the area of health and health care, to make a difference on a large scale, and to touch people directly and change their lives. In some ways, I can't imagine anything else being more rewarding.
PND: You joined the foundation in 2001 and were named to succeed Steven Schroeder as president and CEO about a year later.
Lavizzo-Mourey: That's right. I took office about six months after that.
PND: Were you daunted by the prospect of taking the helm at the country's largest health philanthropy? And did you receive any advice that served you well in your first year or so as CEO of the foundation?
Lavizzo-Mourey: Daunted? No. Captured by and driven by the mission? Absolutely. That was foremost in my mind when I learned that I had been selected to succeed Steve. I'd already been at the foundation for a little over a year as senior vice president of the health care group, so I had a good understanding of the organization and its many strengths, as well as some of the potential opportunities. And that familiarity, both with the programs and with the foundation's incredibly passionate and dedicated staff and grantees, really made the transition for me easier than it might have been for someone joining the foundation from the outside. When you walk through the corridors of this place, one of the things that strikes you almost immediately is the spirit of the staff and their passion for their work. That sense that we really can make a difference in the lives of people is infectious, and as a physician it really captivated me and reaffirmed what I already knew, which is that I had been given an extraordinary opportunity.
Of course, I did benefit from the counsel of many wise people, including Steve Schroeder, who advised me to always stay true to the mission. That is outstanding advice for anyone who leads a philanthropy or not-for-profit institution. I also had the good fortune of working during that time with our then-chairman, Bob Campbell, who has since stepped down as chair but still serves on the board. His advice was to be explicit about not only our mission but our values, and to really push to have a measurable impact on the areas we choose to enter. And both those things have been important drivers for how we do our work. One of the things we've developed in the last few years is a document that explicitly lays out our guiding principles and the values at the core of the institution. They're things like being good stewards of the private resources we've been privileged to manage and using them for the public good. It's recognizing that we have to work as partners with others to achieve our mission, and having explicit guidelines that inform our interactions with our partners, guidelines that emphasize the concepts of fairness, transparency, and open communication about the results our work. It's understanding the importance of staff and highlighting their ethical and professional standards, as well as our commitment to improving ourselves continuously and to advancing our mission.
PND: One of your first actions as president and CEO was to organize a reexamination of the foundation's work — an examination, as I understand it, that led to a new framework for the foundation's grantmaking. Can you tell us about that process and its outcome?
Lavizzo-Mourey: Our board had been challenging the staff to think about how we could structure our grantmaking to have greater impact on the health and healthcare fields. We've always been focused on measuring what we do and having an impact on important health-related issues. So, in that spirit, as I prepared to move into my new role, I asked our grantees as well as experts in the field to send me a short essay, something I could literally read in a minute, about our work. What I learned from that exercise was that the foundation's grantmaking and the way we do our work was quite diverse and spoke to a variety of needs. And after many months and much discussion, we created a framework that recognized the variety of approaches already incorporated into our work and also organized our grantmaking in a way that enabled us to realize synergies across the areas we funded, while getting the most impact from each area.Let me explain. One of the first things we did was to arrange our work into four portfolios, three of which have a very long time horizon and that we're in for the long haul. The Human Capital Portfolio promotes the kind of diverse workforce and leaders needed to continually improve health and health care in this country and includes a number of programs like the Robert Wood Johnson Clinical Scholars Program that have become signature initiatives for the foundation. They tend to be long-term investments where we don't expect to reap the benefits for years to come, and they require certain skill sets, in terms of staff and grantees, to harness the best from them.
Advancing health and health care requires acknowledging that factors such as poverty, violence, inadequate housing or education contribute to poor health. Through the Vulnerable Populations Portfolio, the foundation supports promising new ideas that address health and health care problems that intersect with social factors like poverty, race, education and housing and affect society's most vulnerable people.
Now, we've always invested in programs that were innovative and cutting-edge and sometimes high-risk, but with our asset base having been basically flat over the prior three or four years, we decided it made sense to fund that kind of work in a more disciplined way, so we created a third group, which we call our Pioneer Portfolio, specifically for new and pioneering investments.The idea behind the fourth, and largest, major area, which we call our Targeted Portfolio, is that to have a measurable impact as a leading health and healthcare philanthropy, we needed to choose a manageable number of areas where we felt we could make a difference in a more defined period of time. So, after carefully considering the big challenges facing the field, we decided to focus on an area that we had, since our inception as a national foundation in 1972, been deeply involved with, which is healthcare coverage — in part because we felt it had the potential to affect and benefit much of our other work. We also chose seven other areas: addiction prevention and treatment, childhood obesity, reducing and eliminating healthcare disparities for racial and ethnic groups, reducing the shortage in nurse staffing, strengthening our public health infrastructure, improving the overall quality of health care, and reducing tobacco use and exposure. Then, in each of those areas, we set out to define a set of measurable objectives, a specific timeframe in which to address those objectives, the amount of resources we wanted to invest over that period of time, and a tactical action plan for achieving our objectives. That approach has allowed us to be both tactical and strategic in positioning our work. It has helped us, for example, to think critically about and prioritize the fields we think we're best placed to address. And it has allowed us, at the same time, to calculate a life cycle for the areas in which we're already investing.
That's really important for those of us who work in philanthropy. We all spend a lot of time thinking about new approaches and reasons for going into new areas, but we don't spend nearly as much time thinking about the full life cycle of a program or initiative, or what needs to be done to actually create impact or effective follow-through. As we began to lay these strategic areas out, however, it became clear to us that the money we invest is only one part of what it takes to get the job done. It's an extremely important part, and we are fortunate to have the resources to make long-term financial commitments in these areas. But we're also very mindful of the fact that we have to have a coordinated, strategic communications approach if we are going to have a meaningful, measurable impact on a problem as complex as, say, childhood obesity. We have to create, and people have to be able to see, the connections between and among grants and outcomes. Not only evaluating whether a given program achieved its goal or didn't, but integrating all our programs that drive toward a specific objective, understanding how to get to the objective, and the lessons that can be taken from it.
PND: RWJF is, in fact, the largest foundation dedicated to health and health care in the United States, which gives you and your colleagues a unique perspective on the nation's healthcare system. Earlier in your career you were a member of the White House Task Force on Healthcare Reform chaired by Hillary Clinton. Have the problems that served as the catalyst for that effort improved or gotten worse in the dozen or so years since that effort ran aground?
Lavizzo-Mourey: Well, actually, I went to Washington to work in the administration of George H.W. Bush as the deputy director of the Agency for Healthcare Policy and Research, now the Agency for Healthcare Research and Quality. And through that experience I gained a perspective on health policy and the problems of our healthcare system that has been invaluable. But to answer your question, I think the issues we faced during that period, the late 1980s and early 1990s, and the issues we face today really do dramatize the extent to which our healthcare system is broken. We have a growing number of people in this country without health insurance. In 1993, it was almost forty million people; today it's forty-five million people, almost eight million of whom are children, despite the fact we have a major program, the State Children's Health Insurance Program (SCHIP), to insure children. With numbers like that, you could call it an epidemic of uninsurance.
Beyond that, there continue to be deficiencies in the quality of the health care people receive, as well as racial and ethnic disparities in the system with respect to access and quality of care. It's not as if solutions to the problem of the uninsured haven't been offered. The real question is why our political leaders can't seem to find common ground and compromise as a first step, rather than as a last resort, in an effort to solve the problems of the system, or can't seem to act to address what is a growing crisis.
PND: We're facing a situation in which Medicare and Medicaid costs are rising at an alarming rate, even before the bulk of the baby boom generation begins to retire. If those costs continue to increase at the current rate, do you think Medicare and Medicaid will still be around when the last boomer retires?
Lavizzo-Mourey: I think the issues here transcend what is or isn't going to happen with baby boomers. Businesses in this country increasingly are finding it far too expensive to provide health care coverage to their employees. People who purchase their insurance on the private market are finding it increasingly difficult to pay for a policy that, for a family of four, can cost up to $10,000 a year. And polls showing that the majority of Americans want government to do something about it are just a reflection of the serious problems we have across the board with respect to healthcare costs and quality, which is part of the reason we have included both in our Targeted Portfolio.
PND: Are the problems of healthcare cost, quality, and access amenable to quick fixes? And if not, does organized philanthropy have a sufficiently long-term view of those problems to contribute to their lasting resolution?
Lavizzo-Mourey: Quick fixes and short-term fixes won't do the trick. That's where the philanthropic sector has a unique advantage and contribution to make. Philanthropy has the ability to take a long-range view of a problem and really stick with it until a solution becomes clear and progress toward solving the problem is evident. But what's maybe more important to me is that we also set some short-term goals to stay motivated and accountable, and that we remember to communicate and celebrate our achievements along the way.
Take an issue like childhood obesity. We've set ourselves a goal to help end the rise in the incidence of childhood obesity by 2015, ten years from now. And we're aware that there's an incredible amount of work to be done if we hope to accomplish that goal. But what's going to be really important along the way is our ability to measure our progress along certain trajectories, so that we can see whether we're making progress toward our goal and, at the same time, evaluate whether there are other programs out there that are more innovative and have the potential to have greater impact on the problem. We need to measure things like how much physical activity kids are actually getting and whether that amount is moving closer to the recommended sixty minutes a day. It's only through those kinds of indicators that we'll know whether we are moving in the right direction toward the longer-term goal.
PND: Can you give us an example of a public health problem that we've actually made some progress on solving over the last ten or fifteen years?
Lavizzo-Mourey: The one that comes immediately to mind is tobacco. If you look back twenty, thirty years, you would have found it absolutely the norm to travel in a smoke-filled airplane, or to eat in a restaurant enveloped in a haze of blue smoke; today, in contrast, virtually every domestic air flight and many international flights are smoke-free. Back then, the prevalence of tobacco use among adults and underage high school students was approaching 50 percent and 30 percent, respectively; today, for high school students, the number is somewhere in the teens. Over the last few years there have been eight states and many, many cities and municipalities that have adopted indoor smoke-free policies and really made the statement that they believe all employees have the right to work in an environment free of smoke-born carcinogens. It's a public health area that has witnessed incredible changes. And those changes are largely the result of an evidence base that was built — by both government and the philanthropic sector — around the kinds of policy reforms that are effective, the kinds of individual behavioral changes that should be part of the picture, and the ways that communities can be helped to change laws and regulations to make it easier for people to make the healthy choice — benefiting themselves and their families and neighbors — of not smoking.
PND: Earlier, you described the foundation's Human Capital Portfolio and how it fits into the new grantmaking framework you've adopted. How does the Robert Wood Johnson Foundation define human capital?
Lavizzo-Mourey: We've always recognized the importance of having strong leaders as the backbone of our health and healthcare delivery systems. From its earliest days, the Robert Wood Johnson Foundation has invested a substantial amount of our assets into developing individuals, at both the leadership and workforce level, who can serve as change agents within our nation's health and healthcare delivery systems. We do that through programs such as the Robert Wood Johnson Clinical Scholars Program, which is making a substantial difference in how we create new leaders and thinkers in the areas of health and public health, and our Health and Society Scholars Program, which is really building a field of knowledgeable people who are doing cutting-edge population-based research. Similarly, our Community Health Leaders Program supports and celebrates the work of people who are working hard to transform their communities, often against great odds and without a lot of resources, into healthier places to live. Because this kind of work is so important to everything we are trying to accomplish, not only in the short term but in the long term as well, we tend to do a lot of it. And it's also why we have tended to focus on improving diversity in our health and healthcare delivery systems and taken a long view with respect to developing health and healthcare leaders.
PND: What is likely to be the most difficult challenge new leaders in the field will face over the next ten to twenty years?
Lavizzo-Mourey: Well, any leader in the field of health and health care is going to need to deal with the fact that the field is an increasingly complex enterprise. It relies on the knowledge of many different disciplines and specialties as well as the ability of individuals and institutions to work together in a coordinated way in order to keep the needs of patients and patient populations in focus. The amount of information that has to be synthesized and integrated into our work is more voluminous and complex, and our population is more diverse than it has ever been. Whether one looks at issue from the vantage point of the public health system or the healthcare delivery system, appreciating that diversity and reforming both those systems so that they provide the best care for our increasingly diverse and growing population is going to be a tremendous challenge. Ironically, doing this will require making an increasingly complex system more simple for the end user, namely the patient or consumer.
PND: What advice would you give to a nonprofit leader or practitioner who is grappling with some of the issues we've been talking about today?
Lavizzo-Mourey: I would simply say, "Be patient, be persistent, and stay true to your moral compass." It's going to be increasingly important for nonprofit leaders to be able to determine their organization's strengths and to understand how the organization can leverage those strengths to have the greatest impact. It will become ever more critical that organizations address problems that others may not have the capacity and capability to address, and to stick with them. By that I mean nonprofits and philanthropies will need to bring all of their resources, financial as well as intellectual, to bear on a problem and then — and this may be the hardest part of all — be hard-nosed in making themselves accountable to their stakeholders, whether that means funders, clients, or the community. I think it's the only way we will be able to move the needle on some of the difficult issues we face, and the only way we will truly create real change that makes a difference in the everyday lives of our neighbors, our families, and our fellow Americans.
MFN spoke with Dr. Lavizzo-Mourey in April 2005.