Wednesday, September 18, 2013

Booker T. Washington, ASTHO, MDH, and health equity


I spent much of last weekend preparing talks that I need to give this week. Some of the talks, like the Monday Farm to School talk at Hopkins Junior High School, were easy to prepare. The topic was clear and the activity to highlight was straight-forward and well understood. Who could argue with the efforts to bring in fresh fruits from local farms to schools? The Friday talk to the Internal Medicine graduates of Hennepin County Medical Center of the last 25 years about the integration of medical care and public health will be a bit more complicated but the topic is one that I've been talking about for the last couple of years so I've got a lot of material already prepared. The one that occupied most of my time and caused me the most consternation was the presentation that I have to give at the Association of State and Territorial Public Health Officials (ASTHO) annual meeting on Wednesday about what we are doing to address infant mortality in our state. It's problematic because the answers to the problem are not straight-forward nor easy.

Overall, Minnesota has one of the best infant mortality rates in the country. Even when looking at the infant mortality rates of populations of color, Minnesota looks like it's doing well until you exclude babies born to foreign born mothers. When you do that, (especially among African-Americans), it becomes painfully evident that the disparities in Minnesota are some of the greatest in the country. There is something in Minnesota that is toxic to "minority" populations the longer they live in Minnesota. 

A closer look at the data reveals that factors amenable to medical intervention are handled quite well. We've got a great regional perinatal system and excellent newborn intensive care units. In fact, if you are a low birth weight infant, your chances of survival are as good in Minnesota as anywhere in the world. The problem is that we have way too many low birth weight babies who are overwhelming our medical care system. It appears that it's the social determinants of health, not the medical care system, in Minnesota that are causing most of the problems. Yet, most people look for a medical or health care fix to our infant mortality disparities. 

As I pondered how to address this topic in my ASTHO presentation, I remembered that on September 18th, the same date that I will be talking, Booker T. Washington in 1895 addressed the Cotton States and International Exposition in Atlanta and presented his "Atlanta Compromise" which is considered one of the most important and influential speeches in American history. I suspect you've never heard of it. In this address, which focused on social equity and how to deal with the plight of African-Americans, he said: 

"There is no defense or security for any of us except in the highest intelligence and development of all. If anywhere there are efforts tending to curtail the fullest growth of the Negro, let these efforts be turned into stimulating, encouraging, and making him the most useful and intelligent citizen. Effort or means so invested will pay a thousand per cent interest. These efforts will be twice blessed - blessing him that gives and him that takes. There is no escape through law of man or God from the inevitable:

The laws of changeless justice bind oppressor with oppressed;

In this speech Washington highlighted the fact that all humans inhabit one world and that the fate of one group affects the fate of all - a sentiment echoed by Dr. Martin Luther King, Jr. and Paul Wellstone. 

At the time, both whites and African-Americans resonated with these words. However, Booker T. Washington went on to say: 

"The wisest among my race understand that the agitation of questions of social equality is the extremest folly, and that progress in the enjoyment of all the privileges that will come to us must be the result of severe and constant struggle rather than of artificial forcing. No race that has anything to contribute to the markets of the world is long in any degree ostracized. It is important and right that all privileges of the law be ours, but it is vastly more important that we be prepared for the exercise of these privileges. The opportunity to earn a dollar in a factory just now is worth infinitely more than the opportunity to spend a dollar in an opera-house."

This incrementalist approach to equity was not universally accepted within the African-American community.  In fact, W.E.B. DuBois, who initially supported Booker T. Washington, later rejected this perspective and formed the NAACP and advocated for a more confrontational and activist approach to achieving equity.
After nearly 120 years, we are still asking the same questions: what is the best way to achieve health equity? And arguments about the answer still rage. Given the fact that our health disparities are some of the greatest in the country, it's obvious that we don't yet have the answer. And given the fact that our state is becoming increasingly diverse, finding the answer to that question becomes increasingly important. That's why the health equity report that we are preparing for the 2014 legislature could be one of the most important documents the department has drafted in the 142 years of its existence. I'll be getting more information to you about this report in the near future. Stay tuned.

In the meantime, consider the words of Ralph Bunch, who on September 18, 1948 exactly 53 years after Booker T. Washington gave his speech, was confirmed as U.N. mediator in the Arab-Israeli truce negotiations in Palestine. For his efforts, he won the 1950 Nobel Prize for Peace. He was the first person of color to receive that award. He said: "To make our way, we must have firm resolve, persistence, tenacity. We must gear ourselves to work hard all the way. We can never let up."
Achieving health equity is too important to ignore. We must have firm resolve to address this issue and we can never let up in our efforts.