Duke University roundtable

Twelve representatives from the Republic of China (Taiwan) were visiting Duke University in Durham, North Carolina to learn about the U.S. public health system and  share some of their successes and challenges. The delegation included the heads of the Taiwan FDA and the Taiwan CDC (they do use some of the same agency  names as the U.S.), the directors of their National Health Insurance Administration and their Department of Social Insurance, the Director-General of their Department of Medical Affairs, and several hospital administrators and clinicians. I was invited, along with several other state health officials, to provide some thoughts on "Driving Public Health Transformation in Communities."

I started my presentation by noting that this meeting was being held on the anniversary of what I consider to be the most significant U.S. public health achievement of the 20th century. On August 26, 1920 the 19th Amendment of the U.S. Constitution became law. That amendment stated:  "The  right of citizens of the United States to vote shall not be denied or abridged by the United States or by any State on account of sex." 

Because of the 19th Amendment several things occurred, but I highlighted the fact that it lead to the  passage of the Sheppard Towner Act which was a way to satisfy women voters. This Act was the first grants-in-aid program in the U.S. It also led to the  development of Maternal and Child Health Programs in all state health departments, the initiation of birth registries (vital records) in all state health departments, and the expansion of public health nursing. It established a partnership of federal and state government that continues to today. The passage of the 19th Amendment and the Sheppard Towner Act led to a precipitous drop in maternal and infant mortality rates. This was a great example of how public policies can dramatically influence health.

I linked the passage of the 19th Amendment to the topic of public health transformation by noting that Women's Suffrage did three things that we should consider today:

1. It demonstrated the need to engage ALL of the population in creating  health.

2. It demonstrated the power of engaged individuals and communities to create the conditions for health.

3. It changed the conversation about what creates health. It took the discussion about health beyond the clinical to include what we now speak of as the social determinants of  health.

Using those three learnings I explained how we put together our Healthy Minnesota Partnership and created our Healthy Minnesota Framework. I particularly  focused on how we are trying to change the conversation about what creates health. In doing that I used one of  the quotations on the first page of Healthy Minnesota 2020. It's from Antoine de Saint Exupéry - "If you want to build a ship, don't drum up people to collect wood and don't assign them tasks and work, but rather teach them to long for the endless immensity of the  sea." 

That quotation exemplifies what we are trying to do with our Healthy Minnesota Framework - expand people's vision and create a narrative about what a healthy community and a healthy future might really look like if we embraced a perspective based on possibilities and abundance rather than diseases and scarcity. 

I then went on to explain our Framework and how it is influencing our SHIP (Statewide Health Improvement Program) efforts and our SIM (State Innovation Model) grant. People were interested in this latter part of my talk but it was evident that the interest wasn't as high as it was for the first part. Several hours later while enjoying a lovely beverage during a reception in the backyard of a former NC State Health Official, I discovered the reason why.

The people from Taiwan had not been exposed to the notion of health in all policies and were still trying to comprehend the concept that Women's Suffrage is a public health issue (women in Taiwan got the right  to vote in 1945). The concept of community engagement and empowering communities to create the opportunities for health was also new. They were more interested in the concepts than in the specifics of what is happening in Minnesota.

The response from the U.S. attendees was also fascinating. They also weren't interested in the specifics but my presentation sparked an in-depth and engaging conversation about racism, cultural diversity, sexism, community engagement, and power and control. It was one of the most interesting and informative conversations in which I've participated. 

As I listened to the conversation, I silently thanked Genevieve Clark, Elizabeth Cady Stanton, Lucy Stone, Julia Ward Howe, Lucretia Mott, Susan B. Anthony, Sojourner Truth, Jeannette Rankin, and multitudes of others who worked hard for many years to gain this civil right for half of our citizens. Tonight's conversation  would not have been possible without them. However, it was also pointed out during the conversation - two days before the 50th anniversary of Martin Luther King's March on Washington - that the work of engaging and empowering communities to better the human condition of all of its members will never be done.

We all decided that we also have a dream - a dream that we will all, as a community, work collectively to assure the conditions in which  people can be healthy. While that may be the definition of public health, it's also the challenge and the vision of public health. It is a challenge that I hope we can meet in Minnesota and throughout our country. I also hope it is a challenge that will be met in Taiwan and every other country throughout  the world.

Ed

Omelas and ESPHL

The Ones Who Walk Away from Omelas, a story  by Ursela K. Le Guin, was one of the reading assignments for the Aspen Institute/Robert Wood Johnson Foundation "Excellence in State Public Health Law" (ESPHL) conference in Glen Cove, New York. The gist of this story is that the people in the town of Omelas are living a Utopian life where everything appears to be perfect. The town is beautiful, the people are happy and healthy, everyone has good housing and nutritious food, recreational opportunities abound, the weather is exceptional, and crime is absent.

However, under one of the community's beautiful buildings a child is kept imprisoned in "abominable misery" and squalor. Everyone knows about this child but no one offers help or even a kind word to the child because "if the child were brought up into the sunlight out of that vile place, if it were cleaned and fed and comforted, that would be a good thing, indeed; but if it were done, in that day and hour all the prosperity and beauty and delight of Omelas would wither and be destroyed. Those are the terms...The terms are strict and absolute."

Most of the people in Omelas have accepted those terms and have reconciled that the greater good justifies the prolonged misery of this child. But not everyone. "At times one of the adolescent girls or boys who go to see the child does not go home to weep or rage, does not, in fact go home at all. Sometimes also a man or woman much older falls silent for a day or two, and then leaves home. These people go into the street and walk down the street alone. They keep walking, and walk straight out of the city of Omelas....they walk ahead into the darkness, and they do not come back." No one knows where they go, "the ones who walk away from Omelas."

Discussion of this story was the first exercise of our meeting which focused on the impact of law and policy on public health. Some of the questions raised by the discussant were: why were some people walking away from Omelas? What was in their minds? What was their motivation? Where were they going?

The answers from the meeting participants were varied. Some attributed positive motivations (seeking a better and more honest society) to the "ones who walk away" while others criticized them for abandoning a child in distress when they knew that the treatment of the child was wrong.

Then the discussant asked, "what if there were two children, or a hundred, or a thousand? Would that have made a difference to people in Omelas? How many children would it have taken to change people's attitudes about the situation?

As I listened to the discussion, I began to see this child as a metaphor for the disparities in our own Omelas. We know they exist but ignore them for fear of potentially upsetting our comfortable existence and the "business as usual" approach to our daily routine. We justify their perpetuation as the price we must pay for our way of life.

While the story was fiction, I felt obligated to question the premise of the story - that the Utopian character of Omelas depended on the misery of one child. The reality is that a society is kept from its optimal potential by the presence of disparities. Even the people at the top of the socioeconomic ladder are negatively impacted by disparities in their community. This made me comment that the people of Omelas were either misguided or dishonest about how good their existence really was. I thought that they probably knew they could be better but changing the status quo was too risky. The people doing well had too much to lose to question what was going on.

At that point, the discussant changed the focus and asked, "What if the child was an elder near the end of life. What if that elder was put on an ice flow and set adrift? Would your thoughts about this story be different?"

That question certainly altered my thoughts. It transported me back to Grand Portage and the American Indian Health Symposium where I had been 48 hours earlier. It brought to mind a storyline that was frequently referenced at the Symposium. It was the story of American Indian children being taken away from their families and community and put into boarding schools - educational prisons as one tribal leader described them. The story also included the plight of elders (some of whom were part of the first storyline) who were being transferred off the reservation because of the lack of long-term care facilities. Victimized at both ends of life.

It was at that point that it struck me that the story of Omelas was not dystopian fiction but a realistic story about what has happened and is happening in our state. The questions raised in the discussion of the hypothetical Omelas story at Glen Cove were the questions also being raised about today's world at Grand Portage. They are the questions that all of us should be asking. What will it take for us to become motivated to effectively address disparities? One child? One senior? A thousand? Or an entire population group? And, if we become motivated, what should we do?

Whatever the answer, we should not be “the ones who walk away.” We need to be the ones who stay and help make the world better for those who are tortured and kept out of sight and in the process make our world more joyous for everyone.

Ed

Travels of a Health Commissioner

[Written on Friday Aug. 2, 2013]

Greetings,

Part of my job as Health Commissioner is to use the Bully Pulpit afforded me to educate people in Minnesota about the heath issues facing them and to advocate for programs and policies that could effectively address those issues. But another part of my job (and probably the most important part) is to listen to the stories of people in the state about what they think is important in creating health for themselves and their communities, what's getting in the way of creating that  health, and what ideas do they have to eliminate those barriers.

This was a week filled with listening and a great deal of learning.

On Tuesday I held a Pitch the Commissioner event in Duluth and heard lots of "pitches" about the struggles of how to create a way to get kids to bike or walk back and forth to school in a safe manner, the mental health issues in their community, the substance abuse issues, the needs of the elderly, and many other problems. Overwhelming those problems were the positive stories I heard about the power of the Statewide Health Improvement Program (SHIP) to mobilize a community to create health-enhancing policies  like "complete streets" and "safe routes to school", to link and leverage resources to create effective programs, and to bring real hope to a community. 

I ended the day  with a stop in Grand Marais where I met with community leaders in their community garden that has helped transform that community. Around the squash, beans, and broccoli I heard from 3 county commissioners about how they see SHIP as not only  a  health program but a community development program. I heard a businessman state that without SHIP, his business would not have succeeded (he sells and repairs bikes). I heard a community elder state that SHIP was crucial to keeping her healthy, in her home, and a contributing member of her community.

These stories - with facts to back them up - convinced me (again) of the power of communities coming together to implement policy, systems, and environmental change to create healthy people in healthy communities. 

From Grand Marais I went to Grand Portage to attend the 2 day American Indian Health Symposium. It was there that the stories became almost too painful to hear. But balancing that was the commitment that I saw in the tribal leaders to craft a new narrative. Despite the painful stories, I left the Symposium with a sense of hope and some new partners in our efforts to create a healthy  future for all people of this state.

Now, less than 24 hours from being in Grand Portage, I'm in Glen Cove, NY at an Excellence in State Public Health Law sponsored by the Aspen Foundation with funding from the Robert Wood Johnson Foundation.The purpose of this meeting is "to establish a dialogue among policy makers, scholars, commentators, and analysts about the most important public health law policy issues facing the country." Despite being in a markedly different environment, the focus is exactly the same as the  focus of our discussions in Duluth, Grand Marais, and Grand Portage - how do we create a healthier society.

The meeting started with a presentation by former Washington Governor Christine Gregoire. She talked about the importance of public health to all parts of our society/economy. She gave one of  the best Health in All Policies speeches I've heard. It resonated with the agency heads and staff, elected officials, and Governor's office staff. 

Minnesota is one of 8 states invited to this meeting along with Arkansas, Connecticut, Louisiana, Virginia, Rhode Island, Washington, and Hawaii. Our team consists of four legislators (2 senators and 2 representatives with both parties represented), the Governor's legislative director, commissioners of Public Safety and Human Services, Manny Munson-Regala, and me. Our focus will  be to find ways to address alcohol misuse through public policies. The meeting starts in earnest tomorrow and I'll let you know what I learn.

What I've already learned from this interesting week is that health is core to everyone's existence and that the creation of health in our communities will require the efforts of everyone, not just those in the medical care and public health sectors. And there's more learning ahead.  I'm hoping that tomorrow we learn how to engage people in all sectors and get them to work together to make our society as healthy as possible.

Ed