Violence is a public health problem

Greetings,

On April 16, 2007, I was in Florida on vacation from my job at Boynton Health Service. I was rocking my 8 day old grandson when my daughter hollered from another room, “Dad, something bad is happening at Virginia Tech.” When I walked into her study and saw the headlines on her computer screen, my mind immediately traveled to Blacksburg, Virginia where I pictured my college health and counseling friends and colleagues at Virginia Tech in the midst of a nightmare that had become a frightening and deadly reality. I knew they would be among the people responding to the carnage that had occurred, but given the stressed and distressed students who seek assistance every day at college health and counseling services, my first thought was for their personal safety. I silently hoped that my friends had been spared physical injuries so that they would be available to help others with recovery and not have to first deal with their own.

Unconsciously, my mind quickly jumped to my own campus, a large urban university with a complex and diverse student body 850 miles from Virginia Tech. While the University of Minnesota has many unique characteristics and is located in a markedly different part of the country, it has more similarities to Virginia Tech and other post-secondary institutions than differences. What was happening in Blacksburg could have been happening on any college campus anywhere in the country.  

Five years later I was in the middle of the State Community Health Services Advisory Committee (SCHSAC) meeting when I heard the news from Newtown, Connecticut that multiple students and staff at the Sandy Hook Elementary School had been shot. With a sense of déjà vu, my mind traveled to the Connecticut school where I pictured the well-rehearsed response of school, law enforcement, and medical personnel doing what they were trained to do in the face of great danger and tragedy. But my mind also jumped to the elementary schools in Blaine, MN and Jacksonville, FL where my grandchildren are matriculating. 

My mind travels and my sense of fear, anger, and disbelief reminded me that all of us are affected by violence wherever it occurs. No one and no area is immune to these kinds of events. We are all vulnerable.  Having had shooting events at Red Lake and Rocori High School reinforces that vulnerability. 

In 2007 I felt an intensely personal connection to the tragedy that had occurred. I’m feeling the same way about last week’s tragedy in Connecticut. This personal connection makes me want to do something as an individual to keep similar events from happening again; but what can an individual do? Looking back on 2007 when I was monitoring a terrible situation with an 8 month old in my arms, I realized that what I had done in raising my children, getting involved in their schools and in our neighborhood, coaching soccer, volunteering with special needs individuals, and being a present and supportive father and grandfather were probably the best things that I could have personally done to help prevent similar events in the future. The importance of staying involved in the lives of one’s children, grandchildren, and community is probably no different today. 

However, as someone working in public health, there is also a profound professional obligation to work to prevent these kinds of events from happening again. Violence is a major public health problem. It affects a large number of individuals directly and it affects everyone in our society indirectly. It affects both our physical and our emotional health and it detracts from our ability to optimally enjoy our environment and our society. It is also a problem that is preventable. The precursors of violence are evident throughout our society – adverse childhood experiences (ACEs), unaddressed (or ineffectively addressed) mental health problems, bullying, easy access to firearms, racial and economic disparities, sexual exploitation, family disruption, substance abuse, lack of economic opportunity, media messages, and many more. While all of these have been seemingly intractable problems, we should not assume that they are impossible to change. I believe they are amenable to changes in appropriate policies, in the environment that fosters violent behaviors, and in the social, education, and mental health systems that fail to effectively deal with troubled individuals.

The precursors to violence can be changed with a systematic and comprehensive approach. We need to review whatever epidemiological information we have on violence and determine what other information is needed. We need to learn more about “best practices” and/or “evidence-based” approaches to violence reduction. And we need to solicit partners in the effort to prevent violence, if it is to be successful. We also need to recognize that implementing these measures will take a long-term commitment to some bold actions and changing some of the ingrained patterns of functioning in our society.

As I watched my daughter care for her infant son in 2007, I realized that all of the work that people do to reduce poverty, improve child development, support families, foster social justice, increase educational achievement, enhance communication, and strengthen parent-child bonds serves to prevent myriad future physical and mental health problems. These, in-turn, help to prevent violence. There is no vaccine that will prevent violence, but I’m hoping that what we do today to address all forms of violence in our communities through policy, systems, and environmental change will help reduce the problem and alleviate the worry and the fears from my grandchildren and all children so that they can reach their full potential and help lead us all into a more peaceful future.

Ed

Greetings from Arizona

Greetings,

I’m sorry that I had to miss this morning’s First Monday meeting.  I was in Scottsdale, Arizona attending an Association for State and Territorial Health Officers (ASTHO) Board meeting.  While you may dream about changing places with me - your being in a cloudy 38 degree environment while I’m in a sunny 75 degree one – consider the fact that it’s quite disheartening to be in a pleasant environment and not be able to enjoy it.  Because of the packed agenda, I was not able to get outside at any point during the entire day.  Being in a meeting and seeing the palm trees, green grass, and  people in short sleeve shirts enjoying the day and not be able to join them is less than pleasant.  I continue to make the case to ASTHO that, since we never get to enjoy the city where the meeting is held, it would be much more efficient to simply hold our meetings at the O’Hare Hilton. 

Despite the environment issues, the board meeting was quite good.  We covered a multitude of topics that are pertinent to our activities at MDH.  Given the late hour, I’ll share just a couple of things that I heard – things that are relevant to our budget and to the functioning of our department. 

As most Minnesotans have heard, the Governor is concerned about three things:  balancing the budget in a fair and equitable way, creating jobs, and providing children with a quality education.  If you don’t happen to be part of the Department of Labor and Industry, the Department of Employment and Economic Development, the Department of Revenue, or the Department of Education, you might wonder how you might fit into the upcoming budget discussions. 

What I heard today should give us some hope.  Several states mentioned that major corporations had been considering establishing new plants/operations in their states but backed-off because of the increasing rate of obesity in those states.  The message was that obesity means both an unhealthy workforce and an environment that does not support health.  Since poor health is a drag on the bottom-line of business, a healthy population is a major determinant of where they want to do their business.  These anecdotes reinforce the view that health is a major determinant of a vibrant economic environment.  For the sake of jobs, we need to invest in health – health that prevents disease and disability.  That needs to be a part of our budget presentation.

The other thing in the Board meeting that particularly caught my attention came out of our discussion about the characteristics of a good board member and a good leader.  Among the characteristics of a good leader listed by ASTHO board members - good listener, integrity, strategic thinking, courageous, honest, value driven, etc. – one stood out for me.  It was the characteristic of humility.  Really good leaders are humble.  That is, they recognize that their view of the world is incomplete and that they need to hear the points of view of others. 

As Commissioner, I’m officially the leader of MDH.  In that role I have to deal with all of the things that MDH is responsible for.  I’ve come to realize that I know a lot about a few things, I know a little bit about a lot of things, and I know nothing about some things.  Yet, I have to speak about and represent MDH on all of the issues within the MDH portfolio.  Because of that, there are many instances when I need to hear the points of view and the expertise and the advice of others.  From my perspective, I don’t know if this is humility or simply honesty.  I’ve come to realize that “it takes a village to support a health commissioner.” 

I’m appreciative of all the help that MDH staff have given me over the last 2 years and I look forward to even more consultation.  It has been invaluable.  It reinforces the wisdom of the Institute of Medicine definition of public health – “what we, as a society, do collectively to assure the conditions in which people can be healthy.”

Thanks for all your help.

Ed

Happy Public Health Thank You Day

Greetings,

Philanthropist and musician Shlomo Rechnitz Most mornings I wake up thinking about the myriad of challenges that await me in the upcoming day. These challenges vary from day to day, week to week, and month to month, but recently my attention has gravitated toward:

How to respond to the federal budget cuts that have already occurred and wonder when more cuts will be announced.

How to best frame and advocate for our 2014-2015 budget.

How to incorporate a long-term viewpoint into a biennial budget framework.

How to integrate a public health perspective into Minnesota’s health reform efforts.

How to best support staff as they face the innumerable issues that come to each MDH division every day.

How to keep everyone at MDH informed about and engaged in addressing these challenges.

My normal routine includes skimming the newspaper headlines to see what new public health challenge might be facing me and the MDH team when we get to work. There is no shortage of issues like:

New cases of fungal meningitis, drug diversions in a hospital, vaccine preventable diseases, influenza, food-borne illnesses, etc.

Reports of new research highlighting emerging or expanding public health problems like obesity, diabetes, sexual and domestic violence, autism, etc.

Political skirmishes that complicate our assessment, policy development and assurance roles.

Because this is Thanksgiving week and Monday, Nov. 19 is “public health thank you day,” I decided to break my normal routine and think first of the numerous things that public health has done that we should be thankful for but that we too often take for granted; things like:

Clean water and air.

Safe food and access to it.

A well-vaccinated population.

Smoke-free air in most public places.

Safe and high quality health care, child care, and long-term care systems.

Well-functioning emergency medical and disaster preparedness systems.

Enumeration, surveillance, and monitoring systems.

Screening and early intervention programs.

Many, many, more too numerous to list.

But as I think of all those things, I realize the only reason we can be thankful for these blessings is because of people dedicated to protecting and improving the health of everyone in our society and committed to making our world a healthier place. 

As I travel around the state and see the positive impact that MDH staff in the metro area and in district offices are having on the health of all Minnesotans and on local public health agencies, I am honored to have been given the opportunity to be health commissioner and be part of those efforts.  The greatest joy in my job is being able to work with people with incredible expertise and dedication to the mission of public health. I am better for these interactions. 

From now on when I turn on the water in the morning to brush my teeth and before I begin to worry about what the day might bring, I will first give thanks for all the gifts of public health and for all the people in public health that make those gifts possible. In particular, I will give thanks for you. You and your efforts are a gift to all Minnesotans – a gift that will persist far into the future.

Happy “Public Health Thank You Day.”

Ed

Pitching you a note from Bemidji

Greetings from Bemidji,

Tonight I’m in Bemidji – half-way through my last “Pitch the Commissioner” trip of 2012. Unfortunately, just when I’ve started to get the hang of pitching and have increased my ringer percentage, the weather has intervened to shut me down until next spring. However, Bemidji is the curling capital of the U.S. so tomorrow I will be throwing a 35-pound curling stone for the first time in my life, tutored by an Olympic Curling Champion.  I’m sure there will be a crowd there to “Rock the Commissioner” – an option much better than “stoning the commissioner.”

Today I pitched horseshoes on the Red Lake Nation and was pitched ideas about long-term care, diabetes, nutrition, suicide/mental health, breastfeeding, childbirth in rural communities, and the need for health educators outside of the metro area, among other things. Earlier in the day at the Sanford Hospital in Bemidji I was educated about the hospital’s community needs assessment, an innovative dental access clinic, and a large NIH grant studying social determinants of health among various tribes in Minnesota and the Dakotas. 

Tomorrow I meet with the staff in the MDH District Office, multiple SHIP partners, the Clearwater County Commissioners, and the Headwaters Food Sovereignty Council; bicycle with local supporters of several bike initiatives; and end the day curling. It should be interesting and I’m glad someone else will be driving on our way back to St. Paul. 

As I sit in my room tonight overlooking beautiful Lake Bemidji (I’ll take people’s word for that because it’s too dark to see), I’m remembering all the faces of health that I saw today – faces from hospitals, clinics, dental practices, community organizations, research institutions, tribes, advocacy organizations, government, and schools. Tomorrow, I’m sure I will see many more faces. 

That image of faces reminded me of the welcome that I gave at the Many Faces of Health Conference in Bloomington last Thursday. I’ll close this note with some of what I shared with that group.

I mentioned to the attendees of the conference that the day of the meeting (October 25) was the 50^th anniversary of the announcement that John Steinbeck had won the Nobel Prize for Literature for his works that elegantly and starkly articulated the plight of the poor and dispossessed during the Great Depression. I read part of Steinbeck’s Nobel Prize acceptance speech during which he reflected on the efforts of writers. He said:

“Literature was not promulgated by a pale and emasculated critical priesthood singing their litanies in empty churches--nor is it a game for the cloistered elect, the tin-horn mendicants of low-calorie despair.

Literature is as old as speech. It grew out of human need for it and it has not changed except to become more needed.

The ancient commission of the writer has not changed. He is charged with exposing our many grievous faults and failures, with dredging up to the light our dark and dangerous dreams for the purpose of improvement.

Furthermore, the writer is delegated to declare and to celebrate man's proven capacity for greatness of heart and spirit--for gallantry in defeat, for courage, compassion and love. In the endless war against weakness and despair, these are the bright rally flags of hope and of emulation.”

I then reflected that if that’s the role of a writer, what about all the folks working in community and public health – the community health workers, primary health care and social service providers, sanitarians, epidemiologists, regulators, lab scientists, community organizers, statisticians, policy makers and policy specialists, and many more? 

I answered that question by paraphrasing John Steinbeck’s speech:

“Public health was not promulgated by a pale and emasculated group of naysayers with a defeatist approach to community health -- nor is it a game for cloistered and tin-horn mendicants of despair.

You, public health professionals, are healers and protectors and health promoters and truth seekers creating health -- a cause as old as humanity itself. You are here because of human need and more needed now than ever.

The ancient commission of public health has not changed. You are charged with exposing our many grievous faults and failures, with dredging up to the light our dark and dangerous realities for the purpose of improvement.

Furthermore, you are delegated to declare and to celebrate humanity’s proven capacity for greatness of heart and spirit -- for courage, compassion and love. In the endless war against weakness and despair and injury and disease, you are the bright rally flags of hope and of emulation.”

That certainly describes those who work in public health in Minnesota.

Ed

Symposium on Fragmented Families

Greetings,

A couple of months ago I was invited by Mitch Pearlstein, Founder and President of the Center of the American Experiment, to submit an article for a published symposium entitled “Fragmented Families and Splintered Classes:  Why So Much Churning?  What Can be Done? What Will America Come to Look Like?”  The premise of the publication was that divorce, single parenthood, and out-of-wedlock births were the source of many of the problems facing our society and that we need to do something to address this major problem. 

I agreed to be part of the symposium because I thought a public health perspective was needed in the discussion. I thought you might be interested in what I wrote. The article can be accessed at: http://www.americanexperiment.org/issues/culture-religion/fragmented-families-and-attribution-errors

Ed

Greetings from Austin, Texas

One of the slogans that the locals in this city use is “Keep Austin Weird.” You see it in many of the gift shops, clothing stores, bars, and live music venues throughout the downtown area. I can’t say whether or not the slogan has been successful in keeping this place weird but the city (13^th largest in the country) certainly has managed to keep the feel of a college town that also happens to be the state capital – think Madison. You decide if that is weird.

One thing I do know for sure is that the things covered in today’s ASTHO meeting were anything but weird. In addition to the numerous topics covered in our Prevention Policy Committee, of which I’m a member, the agenda today covered 3 major topics: the Integration of Public Health and Primary Care, Working with Hospitals to Improve Prevention, and Making the Case for Prevention. Superb presenters from the Institute of Medicine, the Catholic Hospital Association, and the Robert Wood Johnson Foundation (among others) made the day rich with information and new ideas.

I learned a great deal from the sessions but the thing that struck me most was a passing reference to the writings of psychologist Justin Menkes. This was mentioned in the context of the challenges facing public health today. In his book “Better Under Pressure,” Menkes writes that people who maximize their own potential and the potential of their colleagues and their organization embody “three essential capabilities or drivers:

• Subservience to purpose,
• Finding order in chaos. and
• Realistic optimism and sense of agency.

The first two are somewhat self-explanatory. Dedication to a purpose gives people the drive to realize their potential and that of their organization. For the sake of a larger good, people who demonstrate this quality put the mission of their agency or organization ahead of their own personal interests.

Finding order in chaos means being able to see the opportunities that crises provide, which sets the stage for the possibility of tremendous progress. This requires clarity of thought and the drive to solve the puzzling problems that arise every day.

“Realistic optimism and sense of agency” is a bit more complex. In the face of today’s multiple challenges and unpredictable circumstances, successful people display a sense of that the future can be better and thus are willing to prepare for whatever comes their way. “Realistic optimism” helps people minimize constraining fear and maximize their odds of success in a world of overwhelming ambiguity. A person’s “sense of agency” is the single most important factor in being able to cope with all these multiple challenges and unprecedented change. According to Menkes, a sense of agency is “the degree to which people see their circumstances and the outcomes they experience as within their control. For people who look outside themselves for explanations, long-term success becomes much more difficult. For those who look inward, learning and adaptive behavior come more readily.”

This brief reference to Menkes in today’s opening session struck me because it seemed very relevant to the situation of public health in Minnesota and to the Minnesota Department of Health. I have never been in an agency that is so mission-driven as MDH. Staff are experts in their fields but also dedicated to the mission of improving and protecting the health of all Minnesotans. I am confident that, as an agency, we possess the first characteristic. I think we are also looking to find order in chaos. There are great threats that face us but our current situation also contain great opportunities. I think we have the clarity of thought and desire to solve these puzzling problems for us to legitimately claim that we possess the second characteristic.

That brings us to realistic optimism and sense of agency. This is an area on which those of us in public health need to focus. We (myself included) often complain about the paucity of funding, invisibility because we prevent things from happening, the lack of understanding by policy makers of the importance of public health, the short-term focus of budgets, and the dominance of the medical care system. We need to learn that we can’t look to others to take the lead in advancing public health. We can’t be victims and succeed. We have to recognize and believe that the future of public health is really within our control. That realistic optimism and sense of agency will foster creative thinking, increase comfort with risk-taking, and create a confidence to move forward a programmatic and policy agenda that breaks new ground for 21^st century public health.

The longer I’m at MDH, the more I’m recognizing that we do possess realistic optimism and a sense of agency. We are an agency poised, in this time of chaos, to take advantage of some unique opportunities to improve the health of all Minnesotans in both the short and long-term. I am confident that we will not only do “Better Under Pressure” but we will actually do great under pressure.

Ed