Monday, April 15, 2013

Who Is the Vision Keeper for Health Equity?


The theme of this year’s Minnesota Public Health Association (MPHA) conference is “Health in All Policies-Creating Health Equity.” I’ve been invited to moderate a panel on the topic and have asked the commissioners of Education, Pollution Control, and Commerce to join me. I’m hoping they will all say yes because it could be an excellent conversation and a way to garner partners in our effort to create health equity in Minnesota.

This weekend, as I was thinking about the June conference, my thoughts wandered back to many of the MPHA conferences that I’ve attended. For some reason, my mind kept returning to the 1996 MPHA conference which talked about partnerships and a vision for the future of public health. Perhaps it was because we’ve been working hard to articulate a clear and compelling public health vision for the State during this time when the role of public health is being challenged. Perhaps it was because we just finished Public Health Week where we celebrated our public health partners (like MPHA) and the expertise they bring to our collaborative efforts. More likely, it was the snow on the ground and in the air outside my window that made my mind focus on that particular conference. For whatever reason, that MPHA meeting in Duluth 17 years ago was still crystal clear in my mind.

Although it was the middle of May, Lake Superior was still totally covered with ice. The cold wind blowing in from the Big Lake gave no indication that winter’s grip would be loosening any time soon. While the weather wasn’t what the planners had hoped for when they chose Duluth for the annual meeting, it did provide a perfect setting for Ann Bancroft’s keynote address to the conference - her recounting of the American Women’s Expedition (AWE) to the South Pole.

With beautiful slides and poetic language, Ann told the story of how four women with markedly different backgrounds and experiences had come together to challenge themselves and the perceptions of many in attempting to be the first group of women to reach the South Pole.  In describing the struggles of their quest, she shared how it was the differences in the group that made it possible for them to reach their goal.

All of the women were in tremendous physical shape and were seasoned arctic explorers. But each woman also had a special expertise. One was an expert in expedition food which was critically important to each team member who required 5,000 - 6,000 Calories per day over the 3 month trip.  This diet allowed them to pull a 200 pound sled in -70 F temperatures and remain physically and psychologically healthy.

Another was an equipment expert who was challenged by the ice, wind, and cold to keep their equipment working in the most inhospitable environment on the planet. A third was skilled in navigation, an expertise crucial to finding the South Pole in a place where there is no sunrise or sunset, no distinctive landmarks, and where the view in every direction looks exactly the same.

The last set of critical skills belonged to Ann. As the leader of the group, she was the vision keeper. When times were tough and discouraging, she had to remind the team why they were there and why they should continue on. Although each woman with her special skills was critically important for success, keeping the vision of the expedition turned out to be the most important and one of the most difficult tasks to perform.

Ann’s description of the vision surprised most of people in the audience. The vision and goal of the AWE was not personal accomplishment or acclaim or being the first to achieve a difficult feat. Rather, it was education, information gathering, and role modeling. The AWE goal was to be something of value to many people throughout the world (particularly girls), not just to those on the ice. As it turned out, it was this larger vision that sustained the progress of the group and kept them from abandoning their goal at the times when things looked hopeless. Personal goals were insufficient to keep the team going. A larger vision was necessary.

Ann also shared that although there were 4 women on the ice pulling heavy sleds toward the Pole, there was a large but invisible support staff who were just as important to the achievement of the AWE goals. She closed her address with a picture and a description of her feelings on reaching the South Pole. It was a poignant depiction of the power of teamwork aligned with individual determination and a strong support system.

“At the South Pole there actually is a pole with a large reflective ball on the top. As I looked at the ball and saw the reflection of me and the other members of the team, I also saw the thousands of people who supported us financially and emotionally, who followed us at school and on the Internet, who would be using the data we collected, and who would be encouraged to follow their own dreams.  We were just a small part of a very large effort.  Everyone involved was necessary for the AWE to succeed. We worked hard and were an awesome team but without the support and encouragement of people from around the world, we wouldn’t have been there.”

Ann’s captivating and inspirational story was a perfect start to that MPHA meeting and it seems as relevant to this year’s MPHA conference topic and to public health as it was to the conference attendees in 1996.

Although a journey to the South Pole and working for health equity in Minnesota are markedly different activities, they have some remarkable similarities. Both require a dedication to a shared vision that is broader than individual and personal goals and that benefits all of society. Both require a diverse set of skills that can be coordinated and counted on to address unexpected challenges. Both require a team of leaders whose dedication, cooperation, and hard work can inspire and be a role model for the many others who share the vision.  And both require highly visible efforts of some individuals supported by the everyday, behind-the-scenes actions of everyone who longs to achieve the goal.

Our goal is to make Minnesota the healthiest state possible, but the persistence of health disparities is the major barrier to achieving that goal. A “Health in All Policies”⃰ approach will be crucial for Minnesota to achieve health equity on our way to being the healthiest state. However, for that approach to be successful, we will need the engagement of lots of people with multiple skills and expertise. We will need partners whose efforts are well coordinated. We will need teamwork. But most importantly, we will need a vision keeper for health equity. Who will that be? I think it should be us because one of the core principles of public health is social justice – and health equity is a social justice issue.

⃰ Health in All Policies recognizes that health is influenced by many factors outside of health care. From agriculture policy that influences the food on our dinner table to national environmental decisions that put us at risk for disease, every policy, large and small, and every decision, personal and political, ultimately has an impact on health. Policy decisions have played a significant role in creating health disparities and a Health in All Policies approach holds promise for effectively addressing those disparities and creating health equity. No compromise should be reached without analyzing its health footprint, especially on vulnerable populations. From transportation and education to energy and trade, every political decision has a health and health equity cost or benefit - and these costs and benefits should be weighed in every decision. (Adapted from the Aspen Institute.)


Tuesday, April 9, 2013

Art, Truthiness, and Public Health Week

Knowing that “More Real?  Art in the Age of Truthiness” was the featured exhibit at the Minneapolis Institute of Arts (MIA), I squeezed in a museum visit following a shorter than expected meeting in the Whittier Neighborhood. Since public health prides itself on being data-driven and evidence-based and since I’m interested in how art can enhance public health, I easily justified this visit during the work day as part of my personal celebration of Public Health Week. 
On the entrance wall to the gallery was the statement:  “Videri quam esse” (“To seem to be, rather than to be.”) For those familiar with Comedy Central, this is the Latin inscription over the fake fireplace on the set of The Colbert Report. That’s when I realized that this exhibit evolved from one of Stephen Colbert’s sketches called “The Word” in which the word “truthiness” was coined. According to Colbert, “truthiness” is what we know with our heart or feel with our gut regardless of the evidence, logic, or facts. In the sketch he disparages books because “they are all facts and no heart…People think with their head but know with their heart.”  They “feel the truth.” 
As I wandered through the exhibit, I was fascinated by photos, paintings, sculptures, videos, and other creations which made the point that the relationship between truth and fiction is often quite murky. I came to learn that this this grey area between reality and fabrication is the realm of “parafiction,” an evolving perspective in the fields of art, literature, and social studies. It didn't take me long to appreciate that public health is also influenced by “parafiction.”
Wearing my public health hat as I viewed the exhibit, I quickly comprehended that one of the challenges that public health is facing is that we are truly living in the “Age of Truthiness – where things we wish to be true are preferred to things we know are true.” As I walked among the art, I began to assemble in my mind the beginnings of a public health parafiction list. 
  • We have the best medical care system in the world so, if we just assure universal access to that care, we will be a healthy society.
  • Technology has successfully addressed many of our health issues so research will bring us technical solutions to most of our health problems.
  • If individuals simply took responsibility for their lifestyle behaviors, our health problems would be resolved.
  • An intact family with a mother and father is all we need to have a healthy society.
  • Market forces, if allowed to function freely, will help us achieve the Triple Aim of improved population health, lower health care costs, and a better patient experience.
  • Government is the problem, not the solution.
  • Being the fifth healthiest state in the country is an accurate reflection of the health of all Minnesotans.
At that point I was at the end of the exhibit and had a mind full of questions, feelings, and opinions. Since stimulating these kinds of reactions is part of the reason Art exists, this exhibit was a form of great Art. This is also why Art can be such a powerful public health tool. 
Energized, I chose to view two other minor exhibits being featured in the MIA:  “Picturing Poverty: Artistic Views of the Poor in the Baroque Era” and “The World at Work: Images of Labor and Industry, 1850 to Now.” As I looked at the Art in both of these galleries and saw how the perspective of the artist colored the images of the poor and working classes, I realized that “truthiness” is not a modern concept. When the same scene of poverty or manual labor can be idealized, romanticized, or criticized depending on the artists’ point of view, I began to understand that parafiction is probably part of the human condition. 
As I left the MIA and headed back to work, I thought about Oscar Wilde’s statement that “Life imitates Art far more than Art imitates Life.” After spending a couple of hours viewing “truthiness” in Art in the context of my experiences in public health, I believe Wilde’s statement should replace “far more than” with “and.” Art and life are synergistic. They feed off each other, influence each other, and ultimately create something new. 
Our job in public health is to continue to search for the truth and link that truth to the life experiences of real people. The real challenge is to not let our focus be narrowed by our opinions or ideology or even our specialized scientific expertise but be expansive enough to bring in alternative perspectives that may offer a whole gallery of different ideas. 
In this “Age of Truthiness” we need to be advocates for truth but we also need to be humble in our advocacy and understand that truth and public health are not static and not the sole domain of one agency or profession. As Thomas Merton said in his “Dialogue with the enemy,”The basic falsehood is the lie that we are totally dedicated to truth, and that we can remain dedicated to truth in a manner that is at the same time honest and exclusive: that we have the monopoly of all truth, just as our adversary of the moment has the monopoly ...of all error.
Public health is “the constant redefinition of the unacceptable.” In that task we need data, information, and experiences to lead us to the truth. And we need an open and skeptical mind as to what is truth. That’s what makes public health so fascinating and important because as John Keats said in “Ode On a Grecian Urn,” ‘Beauty is truth, truth beauty,’ – that is all Ye know on earth, and all ye need to know.”