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.


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