Tuesday, May 28, 2013

The Good Life In Minnesota

As I've toured the state over the last year talking about what it would take to make Minnesota the healthiest state possible, I've frequently started my presentations by showing the cover of the August 13, 1973 edition of Time magazine that I picked up as I drove through the state on my way to my National Health Service Corps assignment in Montana. The cover shows a smiling Governor Wendell Anderson holding up a large fish. The caption reads “The Good Life In Minnesota.  
Since today was a cold and wet Memorial Day that precluded the outdoor activities synonymous with the good life in Minnesota, I took the time to reread that old Timemagazine. 
August of 1973 was half-way between the Watergate break-in and Nixon’s resignation so a good portion of the magazine dealt with that historic scandal. It shared space with another tragedy of the time, Leaving the Quagmire of Indochina.”  However, several other topics in that edition seemed eerily current. There was the report on “individual privacy…in this electronic age” that listed 5 principles of privacy that are still relevant today. Of particular interest given the results of the just-completed legislative session, Time reported that “The Mayo Foundation has offered to invest $1,000,000 in face-lifting the downtown district of Rochester.
In an article titled Ghetto Homesteaders there was discussion of “...the grim urban paradox of a shortage of adequate housing accompanied by the abandonment of structurally sound homes” brought on by a poor economy. Another reminder that history often repeats itself was an article titled, Keeping a Little List at the IRS. It mentioned “…that the White House had used the IRS to try to harass radical organizations (and that)…Past Presidents have sporadically called upon the IRS to audit the income tax returns of certain political opponents or anybody else who made an undue amount of trouble for them.”
As fascinating as it was to read the myriad articles and cigarette ads in this issue of Time, it was the article on The Good Life in Minnesota that captured most of my attention. While there was a Chamber of Commerce boosterism feel to the article, it did highlight some of the shortcomings of Minnesota - besides the winters. It mentioned unemployment outside of the Twin Cities, asbestos in Lake Superior water, high income taxes, and a “contentment (that) can sometimes amount to middle-class complacency.”  But mostly, the article focused on what made Minnesota unique.
What stood out for the author was “civility and fairness of the precinct caucuses;” “courtesy and fairness, honesty, a capacity for innovation, hard work, intellectual adventure, and responsibility”.  In support of that he mentions that “…the Scandinavians…together with a large Anglo-Saxon and German strain, account for a deep grain of sobriety and hard work, a near-worship for education and a high civil tradition in Minnesota life. Such qualities helped to produce the intelligent calm - and stolidity - that characterize the efficient Minnesota atmosphere.”  
The author quotes several Minnesotans like Stephen Keating, president of Honeywell, “There is a hell of a lot of mutual trust.”  And Art Naftalin, former Minneapolis Mayor, “With our great variety (of immigrants and opinions) we have always had to form coalitions.”  And author Nell R. Peirce, “By taking politics out of the back room and engaging thousands in political activity, from women to college students, … the governmental process in Minnesota (is) a superior instrument of the people’s will.”
It was this latter point that most impressed the author. “Part of Minnesota’s secret lies in peoples’ extraordinary civic interest. The business community’s social conscience, for example …is reflected in annual reports: most of them carry a section called ‘Social Concerns.’…Minnesotans tend to be participants in their communities, perhaps because for so long they were comparatively isolated and developed traditions of mutual reliance. Citizens’ lobbies are a real force.”
It was that promise of the good life in Minnesota that brought me permanently to Minnesota 7 years after that Time article was published. It is that promise that has kept me here for 33 years and it is that promise that motivates me as I start each week. Unfortunately, that promise is yet to be achieved for too many Minnesotans; but it still remains a real possibility. To create The Good Life In Minnesota in 2013 requires exactly what it required in 1973 - civility and fairness; intellectual adventure and responsibility; a lot of mutual trust; social conscience; and peoples’ extraordinary civic interest. Minnesota is one of the healthiest states in the country because of the civic engagement and the investments in the common good by our predecessors of 40 and 50  and more years ago. It is our job to do the same for those who come after us. We've got a great foundation to build an Even Better Life In Minnesota but it will take a social conscious, a sense of community, and a level of civic engagement that now seems to be quite fragile. Let’s strengthen those characteristics by engaging citizens and our multiple partners throughout the state and joining with them to build a better Minnesota - one that assures a Good Life for every Minnesotan.


Monday, May 20, 2013

The difference between public health and community health

I was asked to write an article for Minnesota Physician, an independent newspaper focusing on health care and the business of health care. The request was to explain the difference between public health and community health. Because I thought you might be interested in my perspective on that topic, I’m including the article (Cultivating health - The intersection of public health and medical care) here. I hope the article helps germinate some thoughts about public health.

Thursday, May 2, 2013

Health Equity Week


My work week started on Sunday when I was a guest on a Somali radio program broadcast on KFAI. I was confronted with questions about why MDH, under my leadership, is not doing more to address the health disparities in the Minnesota Somali community.

On Monday I started my day by giving the welcome at an MDH-sponsored meeting entitled: Infant Mortality in the African-American community - Community Voices and Solutions. This meeting focused on the disparities in infant deaths between African-American  and white Minnesotans - one of the greatest disparities in the country. Preparing for this presentation was one of the most difficult tasks I've had since becoming Commissioner. It was not because I didn't know what to say but because what I had to say was personally painful.

I arrived in Minnesota in 1980 as a young, idealistic, and naive physician. I was excited to start my job as Maternal and Child Health (MCH) director for the Minneapolis Health Department at a time when the MCH program was well-funded and having a tremendously positive impact on infant health in the City. Infant mortality rates were decreasing  for all populations and the disparities were rapidly narrowing. I anticipated a continuation of that trajectory which would, in just a few years, lead to an elimination of this unacceptable disparity. I was looking forward to refocusing my attention to other critical MCH issues. Unfortunately, the world changed.

In 1981 a multitude of MCH programs were bundled into the MCH Block Grant while being cut 25 percent.  Numerous other public health programs met a similar fate and were included in the Preventive Health and Health Services Block grant. Among other things, block granting led to a elimination of some MCH services, a reduction in others, and means testing for those that remained. Almost immediately, infant health outcomes were affected - and not in a positive fashion.

In 1983, I testified before a US Senate  Committee for the first time. The hearing was about whether or not a special task force should be established to look at the increasingly disturbing infant mortality rates among people of color and American Indians in the United States. My testimony focused on the disparities in Minneapolis and they mirrored testimony by others from all parts of the country. Despite the overwhelming data, the decision was to wait and see what happened as a result of the block grant approach to MCH.

It wasn't until 1991 when the increasingly disturbing infant mortality data were so dramatic that the federal government was shamed into doing something to address this problem. Even then, the Healthy Start program, which was the response to infant deaths, was funded at such a paltry level that only a handful of communities could benefit from the program. Minneapolis and St. Paul were too small to receive any of this funding. While the Healthy Start program has expanded significantly since 1991, it remained as the only primarily infant mortality-focused federal program until 2010. During that time, the US  infant mortality rate deteriorated compared to other countries and disparities increased to some of  the  highest  levels in the industrialized world.  

It was this lack of investment in public health and infant health over a 30 year period and the outcomes that resulted, that were so painful for me to consider as I prepared my Monday welcome. My career as a physician and as a public health professional was altered dramatically from what I anticipated. Health disparities became an accepted fact of life in our state and country. Damage control rather than health improvement became the focus of my work.

Today, I'm in Washington, D.C. at a meeting that is trying to find ways to redress this tragedy in misplaced priorities. CDC (Centers for Disease Control and Prevention) and ASTHO (Association of State and Territorial Health Officials) brought together a diverse group of individuals representing a diverse group of organizations to look at how to develop strategic partnerships to advance health equity by focusing on: Awareness of the issue, Community capacity to address the issue, Workforce development needs, and Multi-secotoral collaboration. So far, we've admired the problem of health disparities - how bad it really is, why is it occurring, and what are some possible approaches to make it better. Tomorrow, I hope we agree on a collaborative action plan that can begin to move us to where I thought we'd be in the 1980s.

Given the two events that started my week, it's appropriate that I'm here because our progress in addressing disparities will probably be how I'm judged as a Commissioner. Fortunately, what I'm discovering at this meeting is that, despite the problems we face and the inadequate progress toward health equity, we have some great things in-place or in development that hold great potential for change. Our Healthy Minnesota Partership and our Healthy Minnesota 2020 Framework are an excellent foundation for our health equity work. Our increasing focus on "Health in All Policies" and "Health Impact Assessments" hold promise for addressing the social determinants of health and the social determinants of inequity. Our work on the State Innovation Model reforms of our health care delivery system and our efforts engage and empower communities to own this process, hold hope for some significant change as do our efforts to integrate medicine and public health and alter our workforce development approaches. And our Collaborative Innovation and Information Network (CoIIN) work on improving birth outcomes (something you'll hear about soon) will, I hope, allow me to work more effectively on the issue that brought me into public health in the first place.

Eliminating health disparities is the major challenge of our time. I'm optimistic that the direction we are taking at the end of my public health career will be markedly different than that which I experienced at the beginning. We have a better understanding of the importance of social determinants of health, a new awareness of importance of community in creating health, and a sense of urgency that, if we don't address health disparities, we will never achieve the goal of a truly healthy Minnesota. But more importantly, we have a well-trained and dedicated staff throughout the department who are committed to addressing health disparities and a large group of partners who want to join with us in this effort to create the highest level of health for all Minnesotans - ALL Minnesotans.