Monday, March 31, 2014

Take Me Out to the Chaos!

Research in nonlinear dynamics has demonstrated that cells in healthy hearts seem to behave in a random, complex and unpredictable fashion. Contrary to conventional wisdom, it is this variability, or chaos, that keeps healthy hearts beating normally. Loss of complexity and variability leads to simple and fragile rhythms that put a heart at high risk for sudden cardiac arrest.  

“It is this variability that gives a living, dynamic system, such as the heart, the robustness it requires to cope with change.”
-Ary L. Goldberger, MD – cardiologist, Harvard University

Winter, Baseball, Health, and Chaos
The lack of variability this winter (cold, cold, cold, and more cold) made me ponder the benefits of chaos. A little more variety and unpredictability in the weather would have been welcomed by most Minnesotans. The foot of snow on the ground outside my window the day before Opening Day of the Major League Baseball season helped me finally understand why people wanted an open-air baseball stadium in Minnesota – it assures variability, unpredictability, and chaos.  Same, same, same, is not as much fun. This made me wonder if our health care system is also influenced by the dynamics of chaos.  The more I thought about it, the more I became convinced that baseball and our health care system are prime examples of the power of chaos theory. Let me explain.

My childhood summers were filled with baseball – collecting baseball cards, keeping track of batting averages, listening to Milwaukee Braves games, and playing the game as often as I could. Even though I played baseball almost every day, no two days were alike. Baseball brought me new adventures, new insights, and new challenges almost every day. Baseball was the heart of my summer.

After finishing my morning chores, I would jump on my bike and head to one of the many local ball diamonds. With my baseball glove hooked to the handlebars, a ball in my pocket, a bat in my hand, and a blessing from my mom to “play hard and have a good time,” I would stop by the houses of my friends to recruit participants for the day’s game.

Sometimes only two or three people would be available. At other times 15 or 20 would play.  Regardless of the number, we’d always have a game and we’d always follow an unwritten rule that no one would sit on the bench.  his meant we made up new rules to accommodate the number and skill level of players available. Except for the fact that we used bats, balls, and gloves, our games often bore little resemblance to the official version of baseball advanced by Abner Doubleday. Each day we found new, creative, and unconventional ways to play the game that all of us loved. Each day was wonderfully satisfying and we always looked forward to the next game.

As I got older and became more involved in “organized” baseball, the pick-up games became less frequent – not because of lack of time but because “real” baseball began to put limits on what we could do. In hopes of becoming “better” players we began to pay more attention to the rules that the Little League coaches taught us and work on the “weaknesses in our game” that they had noticed.  The game became a more serious undertaking. Soon the afternoon pick-up games stopped completely and our only baseball time was team practices or games. Since the number of people on the team roster was limited, many of the neighborhood players who hadn't made the team hung up their gloves and moved on to other things. In the process, my circle of friends became smaller and baseball lost much of its variability and spontaneity.

It appears that my experience may not be unique because fewer children are playing baseball today than at any time during the last 50 years. Some of this decline may be the result of increased activity options available to children, but I believe a major reason is that baseball has lost the spontaneity and dynamism that could have kept it fun, robust, and inclusive. Youth baseball has become adult-directed and tied to a set of confining rules so that the variability and innovation needed to survive in our ever-changing world has been curtailed. Baseball has become less chaotic and interesting and increasingly irrelevant to most American children. While baseball still claims to be America’s pastime, that status is now in doubt.

In many ways our health care system parallels baseball. Over the last several decades there has been an increased emphasis on uniformity in health care. Consolidation of health care clinics, providers, and systems has occurred while standardization of disease management protocols has become the norm. Definitions and measures of success have also been standardized and policies have been put in place to facilitate progress toward the desired and defined outcomes. Evidence-based practices are touted as the ideal, leaving little tolerance for spontaneity, individuality, creativity, and variability.

Like baseball’s development system which continues to produce some superstar players, this standardization of health care has also provided some tremendous benefits.  The quality, safety, and value of services have increased and overall health outcomes have improved.  These efforts have helped create one of the best medical care systems in the world and they need to be maintained and expanded.

However, as our society becomes increasingly diverse and complex, we are seeing that the things that most affect health are beyond the scope of “traditional” medical care. The diseases and disabilities affecting society today are influenced mostly by socio-economic and environmental conditions and lifestyle choices rather than health care. Income, economic policies, education, housing, community livability, and social capital are the real determinants of health today. Yet, our health care system with its traditional focus on preventing and treating disease rather than creating health has limited capacity and ability to address or influence these factors. While health care continues to be important, we are learning that its impact on overall health has limitations.

To maximize health, we need a broader approach to health that identifies, embraces, and supports the opportunities to create health in our communities. It needs a bit of disruptive, chaotic innovation that will stimulate complex, diverse, flexible, and dynamic approaches to health. To me, public health’s role in the 21st Century is to bring a bit of chaos (in the non-linear dynamics sense) to our health system.

If we continue to invest most of our resources in disease treatment and management and not in creating health, our health care system will, like baseball, risk becoming somewhat irrelevant – a casualty of its own inflexibility.  Our health system, like a healthy heart, must maintain a high level of variability and chaos. It can only do that by embracing a broader public health context that allows the flexibility to deal with not only the medical determinants of health but the social and environmental determinants as well.

Although we probably can’t do much about the current state of baseball, public health is in a unique position to help stimulate changes in how we create health. By encouraging and supporting creativity, diversity, innovation, risk-taking, and inclusivity in discussions about the social determinants of health, we can maintain a healthy and necessary level of chaos. Changing the current culture and modifying the rules of the health care will be a challenging, chaotic, and rewarding process – one that will most likely go into extra innings. Do you want to play?


Monday, March 17, 2014

Wages are a public health issue

When people think about minimum wage, they most often think about the impact on their bank account and their job. But policies that impact employment and income are actually about health – the health of individuals, families, and communities.

When 19th Century industrialization drove workers from farms and home workshops into urban areas and factory work, our economic system changed dramatically. This change was particularly devastating for poor families and children. Working conditions were unregulated and often unsafe, leading to tens of thousands of work-related deaths. Millions of children were forced to work long hours in hazardous conditions at low wages because their poor families desperately needed the income to supplement the parents' low wages. Factory owners benefitted from child labor because children were more manageable, cheaper, and less likely to strike. The reality for children was poor health and loss of educational opportunities.

These horrid conditions persisted for decades until progressive 20th Century laws restricted child labor, improved working conditions, and established a minimum wage. These laws significantly reduced fatalities and improved overall health. Families at the lower end of the socio-economic scale benefited the most. Low-income communities saw improvements in life expectancy and lifetime earning capacity.

Even though Minnesotans no longer work in sweatshops or send children into dangerous mines, how we work and what we earn continues to impact our health and that of our communities. Studies show that income is the strongest and most consistent predictor of health and disease. People with higher incomes are healthier and live longer than people with lower incomes. Lower incomes are consistently associated with higher rates of disabilities and chronic physical and mental conditions. Poverty also leads to faster disease progression, more complications, and poorer survival rates. The vast majority of diseases are much more common among the poor and near-poor at all ages. Recent data show Minnesotans making less than $20,000 a year were more than twice as likely to have diabetes compared to those making $75,000 or more a year.

Children are particularly vulnerable to the health impacts of poverty, and the more years a child spends in poverty, the more negative outcomes accrue. Poor children are more likely to experience injuries, violence, inadequate health care, poor nutrition, and insecure housing. These conditions have a powerfully negative affect on health and development. Children from poor families are less likely to live in a neighborhood with healthy food options, safe places to play, good schools, libraries, or other quality public services that help set them on the path to a successful, healthy life.

The relationship between health and income is not just about individual access to medical care, but how income affects a range of opportunities for health. Communities with residents with higher incomes are likely to have better recreational amenities, housing stock, food access, and schools, and tend to be safer – all of which impact health. Income is also associated with other factors that create the opportunity to be healthy, such as employment opportunities, reduced environmental contamination, and greater transportation options.

Health improves with increasing income, and the impacts of a rise in income are greatest for those at the lowest end of the wage scale. Moving from the lowest income level to the next lowest provides the largest percentage increase in life expectancy and health status. In other words, a family living on minimum wage realizes greater health benefits from an increase, in that low salary, than a middle-class family receiving the same raise. Increasing the minimum wage is a sound public health investment for Minnesota. The health of Minnesota’s lowest wage earners will improve along with that of their families and communities.

We all benefit from and have a role in creating healthier communities. It’s time for us to come together to implement a minimum wage that further enhances the health benefits of employment and lifts more than 350,000 Minnesotans out of poverty. As Health Commissioner and a physician, I prescribe an increase in the minimum wage to improve the lives and health of vulnerable Minnesota children and families. It will be a great investment in the health of individuals, families, communities, and our state.


P.S.  Check out our White Paper on Income and Health -

Monday, March 10, 2014

Lifeboats, Torpedoes, and Social Policies

On the south coast of County Cork, Ireland is the sheltered seaport town of Cobh.  The town is best known as the final port of call of the RMS Titanic which sank on April 15, 1912 with a death toll of 1,517. Another maritime disaster that is part of Cobh’s history is the sinking of the RMS Lusitania on May 7, 1915. The Lusitania was torpedoed by a German U-boat ten miles off the shore of Cobh with a loss of 1,198 lives. 

Less well known is the fact that for over a hundred years Cobh was the single most important emigration center in Ireland. Between 1845 and 1851 over 1.5 million adults and children emigrated from Ireland.  Ultimately, over 6 million Irish people emigrated, with over 2.5 million departing from Cobh. 

I visited Cobh 6 years ago and this quaint town resurfaced in my mind this weekend when I purchased some corned beef in preparation for St. Patrick’s Day. I remembered that as I walked along the docks of Cobh, the specter of those three traumatic events was everywhere. Wherever I looked, whatever I read, and with whomever I talked, these historical events which occurred 100 + years ago were still vivid in people’s minds. 

The more engrossed I became in the stories of Cobh, the more I realized that the unifying lesson in all of these events was the role of policy decisions in causing these tragedies. Different individual or societal decisions could have prevented or significantly reduced the loss of lives and the human trauma caused by these events. 

On the Titanic the number of lifeboats was inadequate for the number of passengers. The ship had been designed for more lifeboats but a decision was made to fit it with a lower number that met the minimum requirements of an outdated law that based lifeboat numbers on tonnage not on number of passengers. Plans were to add more only if the law required them. 

In early 1915 a policy decision was made by the German military to do whatever was necessary to gain control of the waters of the Atlantic Ocean. This decision led to the torpedoing of the passenger ship Lusitania and the eventual US entry into World War I – a war that killed or injured over 37 million people.  

The policy decisions that led to the starvation and mass emigration of the Irish were more subtle and indirect but just as lethal as the iceberg and the torpedo that sunk the Titanic and the Lusitania. Decades of state-sponsored discrimination promoted laws that influenced all aspects of Irish life including the restriction of education, the practice of religion, and the use of Gaelic by the Irish people. It also fostered passage of the “penal laws” that affected land ownership and which led to total dependence on the potato for sustenance. These prejudicial policies inevitably caused the 1.5 million deaths and mass emigration precipitated by the potato famine that plagued Ireland for decades.

In each of these situations, conscious policy decisions led to catastrophic results that negatively affected the life and health of large numbers of people. Yet, none of these policy decisions was related to health care. They were policies emanating from consideration of business and political needs or the maintenance of a social and economic order that favored those in power.

I relate this story about Cobh not just for historical interest but because the impact of policies on health continues to play out every day. The discussion around minimum wage, one of the 2014 legislative session’s major policy issues, is a good example. The debate has centered mostly on the business, economic, and political ramifications of increasing the minimum wage. Yet, our recent report on “Income and Health” points out the fact that minimum wage is a public health issue – as income increases, health improves. Even though minimum wage is not being heard in health committees, policy makers need to be aware of the individual and community health implications of this policy decision. 

Similarly, last month MDH submitted a report to the legislature entitled “Advancing Health Equity in Minnesota.” The report notes that “(w)hen groups face serious social, economic and environmental disadvantages, such as structural racism and a widespread lack of economic and educational opportunities, health inequities are the result.” The report underscores the fact that health is determined by much more than just health care. In fact, the majority of the health of individuals and communities is influenced by the “non-health” sectors. When health is not considered, policy decisions in these sectors often establish barriers that inhibit equal opportunities for health for all. These policies particularly affect“(t)hose with less money, and populations of color and American Indians, (who) consistently have less opportunity for health and experience worse health outcomes.”

Certainly, “health care policies” need to be part of the policy milieu that influences health. However, the example of Cobh demonstrates that business, occupational, educational, transportation, economic, and social policies can have an even larger impact on the survival and health of individuals and communities. 

As the state’s lead public health agency, MDH has a responsibility to help create the conditions in which all Minnesotans can be healthy and that responsibility goes far beyond just dealing with issues in the clinical care and public health arenas. To be true to the vision of advancing health and health equity, MDH and all public health professionals need to be actively involved in assessing and monitoring policies at the local, state, and national levels that could have a health impact and advocating for decisions that will ultimately benefit the health of all Minnesotans and every community in our state. 

The history of Cobh reminds us that policy decisions are important to the health of the public. There is health in all policies. 


Thursday, March 6, 2014

Greetings from the ASTHO Day at the capitol

Wednesday, March 5, 2014 
Greetings from Washington, D.C.,
I’m in Washington for the Association of State and Territorial Health Officials’ (ASTHO) Day on the Hill.  Actually, I’m here for three days, two of which are “on the hill.”  Since I’m on the Board of ASTHO as the Region V representative, I spent the first day of this Washington visit at the ASTHO board meeting discussing the various issues facing states and territories, and preparing for visits with our congressional delegation and Obama administration leadership. 
The fiscal year 15 budget is the biggest issue of immediate concern for ASTHO and MDH.  Congress is in the process of preparing that budget and it has great implications for public health.  Conversations were quite animated because the President released his budget on the same day as our board meeting.  As with most budgets there is some good news and some bad news.  But since congress has to act on a budget of their own, the President’s budget is just the first step in a long and complicated process of coming up with a final budget – if they ever do.  However, the President’s budget served as the basis for the subsequent visits on “the hill.”
Today, I joined a group of 7 ASTHO board members in meetings with agency leaders within the Obama administration at the Hubert Humphrey Office Building. (Please excuse the acronyms that follow.) I got to meet with Tom Frieden, CDC Director; Pamela Hyde, SAMHSA Administrator; Mary Wakefield, HRSA Administrator; Sally Howard, FDA Deputy Commissioner; Nicole Lurie, Assistant Secretary for Preparedness and Response; and Anand Parekh, Deputy Assistant Secretary for Health.  We were scheduled to meet with Marilyn Travenner, CMS Administrator, and Kathleen Sebelious, HHS Secretary, but their visits got pre-empted by some public announcements they were making today. 
Each of the visits dealt with some important and pressing problems.  Each of the meetings could warrant a separate note.  Since I’d lose you before getting to the second visit, I’ll relate the events of just one of the meetings – the one with CDC Director Thomas Frieden, MD.
Dr. Frieden spent a few moments talking about the budget but spent most of the time talking about his priorities and some of his thinking about public health.  In the next fiscal year, CDC has three major priorities:  Global Health Security, Anti-microbial resistance, and prescription drug overdose. 
Global Health Security:  On February 13, 2014 the U.S. joined 26 countries and international partner organizations to accelerate progress toward a world safe and secure from the threat of infectious disease.  From the point of view of CDC, the importance of global health security has never been clearer;  influenza could affect millions, new microbes are emerging and spreading, drug resistance is rising, and laboratories around the world could intentionally or unintentionally release dangerous microbes. Globalization of travel and trade increase the change and speed of these risks, spreading disease. 
Anti-microbial resistance:  Drug resistance is a growing problem and creates risks for all medical procedures.  CDC is looking to work with hospitals and health departments on developing antibiotic stewardship programs in hospitals and with health departments.
Prescription Drug Overdose:  The rapid rise in drug overdoses and deaths in the last few years has highlighted the problem of prescription drug overdosing.  One of the ways to address this is with a Prescription Drug Monitoring Program (PDMP).  Dr. Frieden stated that, in his view, an ideal PDMP has 4 components:  it’s universal (covers all patients and all providers), it’s real time (should be able to get data immediately), it’s embedded into the EMR, and it’s actively managed.  Many states have PDMPs but few contain all of the necessary components which would include monitoring both patients and providers.  Minnesota doesn’t have an ideal PDMP.
After an hour of dialogue, Dr. Frieden ended his time with us by stating that he’s concerned about how public health is viewed.  He said that too often, public health gets criticized for working toward a “Nanny state.”  To combat that, he has started to say that public health is about increasing freedom.  There are three ways that public health increases freedom:
  1. Public health provides information to citizens, providers, policy makers so that they can make decisions based on the most recent information and knowledge available.  Public Health information gives people the freedom to choose, knowing the risks, from a list of options.
  2. Public health protects individuals from the actions of others.  Public health protects individuals from being injured by a drunk driver, from unsafe food, from  poor quality care, etc.  These protections give people freedom to act without worry.
  3. Public health does certain things that could be done by individuals but is more efficiently done for all by a public agency.  For example, everyone could boil his/her water but it’s much cheaper and more efficient to have water made pure and safe by a publically-accountable public agency.  This collective action leads to more freedom for individuals to pursue other activities.
I thought this was one good way to characterize public health. These ways to increase freedom are also relevant to our advancing health equity efforts.  These freedoms, if enhanced, would allow everyone the opportunity to be healthy. 
Tomorrow, I meet with our congressional delegation.  It will be a long day but I’m hoping it will be a productive one.