Monday, September 15, 2014

Science, Esthetics, Public Health, and the Social Determinants of Health

The closing session of the 2014 ASTHO (Association of State and Territorial Health Officials) Annual Meeting was entitled “The Intersection of Public Health and Clinical Medicine:  Addressing Social Determinants of Health.”  I was asked to give a Minnesota perspective on what needs to be done to assure “that all systems integrate to further address the social determinants of health.” 
As I prepared for the session, I reviewed the World Health Organization (WHO) definition of Social Determinants of Health:  “the conditions in which people are born, grow, live, work and age.  These circumstances are shaped by the distribution of money, power and resources at global, national and local levels.”  The WHO goes on to say that “social determinants usually identified as influencing health and health equity include those such as housing, employment and education.”  While clinical medicine is commonly viewed as a ‘downstream’ determinant of health, there is a growing realization that healthcare systems themselves are a social determinant of health because of their impact on the broader socio-political environment.  According to the WHO, ”when appropriately designed and managed, health systems can address…the circumstances of socially disadvantaged and marginalized populations…and they may be influential in building societal and political support for health equity.”
Health systems in Minnesota recognize the impact that social determinants of health have on the health of the population they serve and most, if not all, understand that they have a responsibility to help address those determinants.  The increasing focus on total cost of care and population health indicators underscores that responsibility.  How that gets realized is a work in progress.  Health Care Homes and the development of Accountable Care Organizations (ACOs) are part of that work.
Minnesota’s public health agencies also recognize the need to effectively engage with health care systems in order to use the strengths of both systems to affect the social determinants of health.  The work being done through the Statewide Health Improvement Program (SHIP) demonstrates that local public health agencies can serve as the backbone for magnifying the collective impact of community-based health equity efforts.  Embedding ACOs in a community context and using the Community Leadership Teams and the ‘policy, systems, and environment’ approach of SHIP in the development and implementation of the Accountable Communities of Health holds promise for effectively addressing the social determinants of health at a local level. (
Because this session was held on September 11th, a day when an act of violence changed the course of our history, and because “peace” is at the top of the WHO list of determinants of health, I felt compelled to add some comments about peace to my presentation. 
2001 was not the only year when acts of war occurred on September 11.  On 9/11 Scotsman William Wallace defeated the English in 1297, the French conquered Milan in 1499, Imperial troops under Eugene of Savoy defeated the Turks in 1695, Anglo-Dutch-Austrian forces defeated the French in 1709, the U.S. fleet destroyed a squadron of British ships in the Battle of Lake Champlain in 1814, and Mexican troops captured San Antonio in 1842 to name just a few battles and wars.  Most striking to me was that the groundbreaking ceremony for the Pentagon occurred on September 11, 1941 – exactly 60 years before an attempt was made to violently destroy it. 
I included these historical references near the end of my presentation and closed with a quotation from Isidor Isaac Rabi, a Polish-born American physicist, a 1944 Nobel laureate recognized for his discovery of nuclear magnetic resonance, and a participant in the Manhattan Project.  He died on September 11, 1988.  He said:  “Science is an expression of the human spirit, which reaches every sphere of human culture.  It gives an aim and meaning to existence as well as a knowledge, understanding, love, and admiration for the world.  It gives a deeper meaning to morality and another dimension to esthetics.”
Given that public health is both a science and an art, this quotation provides those of us in public health a way to approach peace and all the other social determinants of health.  The quotation begins with ‘Science’ and ends with ‘esthetics’ (“a set of principles underlying and guiding the work of a particular artist or artistic movement.”)  By including both science and esthetics, public health gives us a better understanding, love, and admiration of the world while providing a set of principles based on social justice that can guide the work of all sectors to create a better, peace-filled world for all.

Wednesday, September 10, 2014

The 1850 Compromise

The Annual Meeting and Policy Summit of the Association of State and Territorial Health Officials (ASTHO) began today in the Santa Ana Pueblo just outside Albuquerque, New Mexico. By circumstance, the meeting began on the anniversary of New Mexico becoming a United States territory. The “1850 Compromise” drafted by Henry Clay of Kentucky and brokered by Stephen Douglas of Illinois was a policy that changed the course of U. S. history. Not only did it make New Mexico and Utah U.S. territories but it created the present day borders of Texas and California.

The “Compromise” convinced Texas to give up claims of a large portion of the Southwest in return for the U.S. Government assuming responsibility for the debts it had acquired. But that wasn't the biggest compromise. The true “compromise” was around the issue of slavery. There was great debate at the time about whether or not the new territories or states would be “slave” or “free.” New Mexico was central in that debate. The “compromise” was that California would be admitted to the Union as a Free State and that the slave trade would be banned in Washington, D.C., while the Fugitive Slave Act would be strengthened and a decision on slavery in Utah and New Mexico would be postponed to some undetermined date in the future. It is believed that this Compromise delayed the start of the Civil War by about 10 years. The impact of that delay on the health and well-being of thousands of African Americans will never be known for certain.

Although most people were unaware of the anniversary, the relevance of this 164-year-old policy decision was in the background as participants in ASTHO’s Policy Forum discussed today’s policy issues. Whether the policy discussions related to access to care, environmental or infectious disease impacts on health, emergency preparedness, e-health, or prevention strategies, it was obvious that people in the policy forum recognized their deliberations and recommendations could have a huge impact on the health of millions of people far into the future ‑ especially on low-income individuals and populations of color and American Indians. The growing evidence that public policy decisions have a bigger impact on health than health care underscored the importance of public health focusing on policy, systems, and environmental change if public health is going to be relevant and have a significant impact in the 21st century. That’s why this meeting is so important.

I shared the history of the 1850 Compromise with some of my colleagues at the last session tonight. I will be curious to see how knowing about that bit of history changes the conversations, or not. I will let you know.

Today’s public health efforts emanate from the policies and actions of the past and lay the groundwork for the activities of the future. History gives us context for the public health struggles of today. I hope our grandchildren and great grandchildren will be pleased with the policy decisions we will be making over the next few years ‑ decisions that will have a profound impact on the health of our society.


Interview about health disparities

Earlier this summer I was interviewed for an article in MetroDoctors, the journal of the Twin Cities Medical Society (TCMS). The focus of the September/October issue was health disparities. I thought you might be interested in how I responded to their questions. My interview is included below. If you would like to see the entire content of the issue, go to: 

Colleague interview:
A Conversation with Edward Ehlinger, MD, MSPH

Minnesota is reported to be one of the healthiest states in the nation - what needs to be done to preserve that title from a population health standpoint?

Almost every study and report ranks Minnesota as one of the healthiest states in the country.  Minnesota has the second longest life expectancy at birth and one of the lowest infant mortality rates.  The state also has the sixth longest life expectancy after age sixty-five and Minnesota seniors are considered the healthiest in the country.  The common belief is that our good health is due to our great medical care system (rated number one in the country) and good insurance coverage (second best in the country).  The reality is that medical care is a relatively small contributor to our overall health – around 10% by most calculations. 

The biggest contributors to health (40% - 60%) are socio-economic factors like education, income, individual and community-level wealth, mobility, and housing.  Overall, Minnesota does well in these categories which is reflected in our health status.  However, Minnesota also has some of our country’s greatest disparities in these “social determinants of health,” so it’s not surprising that our state also has some of the greatest health disparities.  These disparities are manifested most dramatically in populations of color and American Indians.  Given the rapidly increasing number of individuals of color in our state, simple math tells us that unless we reduce these health disparities we will not be able to maintain our ranking as one of the healthiest states.  Evolving research on this topic is demonstrating that disparities negatively affect everyone in the community.  The health of people at the top of the socio-economic spectrum is diminished by health disparities.  Paul Wellstone was correct when he said that “we all do better when we all do better.”

To reduce these disparities, we must first change the narrative about what creates health.  We need to recognize that the biggest determinants of health are not medical care and personal choices but the socio-economic factors that affect all of us.  We also have to acknowledge that how these factors affect us didn’t occur by accident; they were established by policy decisions at national, state, and local levels and that many of these decisions benefit the white population and disadvantage populations of color and American Indians.  This is known as structural racism.

Achieving healthy equity is the central challenge for Minnesota if we are to remain one of the healthiest states in the nation.  Modifying our policies, systems, and environments to support the achievement of that goal is crucial to the success of our state.

How does Minnesota compare to the rest of the country in terms of health disparities? Are there any models of healthcare equality from other states/countries being used as guides for Minnesota's plan for the future?

Minnesota has some of the greatest health disparities in the country, including the greatest black/white disparity in infant mortality and the third greatest disparity in unhealthy life after age 65.  Some of that is due to the good health of the white population but a great deal is due to the poor socio-economic status of minorities in our state.  While national comparisons are useful, we’ve begun to focus our comparisons on the states in which Big 10 universities are located (states more comparable to MN and which also have some of the highest levels of disparities).  Even with this focus, Minnesota does not fare well.  Minnesota has the greatest black/white disparity in income, poverty, high-school graduation, and home ownership.  Given this, our health disparities are not surprising.

Even though Minnesota has some of the greatest health disparities in the country, no state is doing well in achieving health equity.  Although there are currently no good state models about how to effectively address disparities, there are some historical examples about what works.  During the “War on Poverty” in the 1960s and 1970s, there was a concerted, comprehensive, and community-based effort to address the social determinants of health.  Concurrent with that was a more balanced investment of health and human service resources between medical care, public health, and social services.  This strategy led to an overall improvement in health along with a narrowing of health disparities.  When this approach was abandoned for a more individual-focused, means-tested, and medically-based approach and funding for public health and social services was reduced, the rate of health improvement slowed, disparities increased, and health care costs began to rise. 

The experiences in other countries reinforce what was seen in the U.S. War on Poverty.  Where there is a community-based effort to address the social determinants of health and a more balanced investment in medical care, public health, and social services, health outcomes improve and disparities are reduced.  These experiences are serving as models for the Accountable Communities for Health that are being developed as part of Minnesota’s State Innovation Model (SIM) grant efforts.  A new collaborative between Big 10 universities and their state health departments will also be addressing these issues.

Disparities in health outcomes--what do you see as causes, possible solutions and what can individual health providers do to combat health disparities?  Is there a role for TCMS?

While health care accounts for only 10% of overall health, medical care can play a significant role in addressing disparities.  Increasing the focus on primary care and integrating that care with public health and social service interventions has been shown to help reduce disparities.  Including community health centers and community providers in healthcare networks can also help.  Other approaches that show promise are integrating behavioral and mental health services into primary care, care coordination, home visiting, and use of community care teams, navigators, community health workers, and trained interpreters.  Diversifying the workforce and enhancing cultural competence would also be helpful.  Standardized collection of race, ethnicity, and language data would help to better target and evaluate health care services. 

More importantly, the World Health Organization has noted that medical care is also a social determinant of health and that “when appropriately designed and managed, health systems can address health equity…when they specifically address the circumstances of socially disadvantaged and marginalized populations…excluded through stigma and discrimination…and they may be influential in building societal and political support for health equity.”  This is where TCMS can play a leadership role.  As the voice for physicians in the Twin Cities area, TCMS can continually raise health equity as an issue in policy and healthcare discussions and help influence the broader socio-political environment that impacts ’upstream’ factors like poverty, education, and housing.

Are there community/population specific unique health metrics?

One of the challenges in developing and evaluating programs to address and eliminate health disparities is the relative lack of data for many communities on many of the contributing factors/social determinants, and even on health status itself.  Improving the infrastructure for health data collection is a necessary and important step for the development and evaluation of programs to eliminate disparities.  Work is being done on standardizing the collection and reporting of race, ethnicity, and language data within the healthcare, public health, and social service systems.  Efforts are also underway to incorporate data into the analysis of community health metrics that impact the social determinants of health from non-health agencies, like education, transportation, housing, and economic development.

Federally Qualified Health Centers--how do they play into the mix of serving the underserved, especially in this new reality of expanded health care coverage? Do we need more centers or clinics willing to see people who still may be underinsured or confronting the higher than expected deductibles that they now have through their new health insurance plans?

Community Clinics will play an increasingly important role in advancing health equity.  Not only will they be sensitive and responsive to the financial issues that will continue to influence health care decisions by both the patient and provider but, more importantly, they are better suited to address the language, cultural, and community issues that attend many health concerns in immigrant and minority communities.  Their community-oriented approach to primary care will be increasingly important as our community becomes more diverse.  They can also play a role in organizing communities to advocate for policy changes at the state and local levels that address the disparities affecting their health and prosperity.

Does the psychological stress associated with poverty contribute to poor health? If so, how is this manifested? Are there specific approaches planned or in place to treat and support those afflicted?

The stresses of poverty, racism, historical trauma, and adverse childhood experiences are well documented as significant factors contributing to poor health.  On an individual level, the development and implementation of “trauma-informed care” is showing promise in reducing the harms caused by these stressors.  On a broader level, a “health in all policies” approach is being initiated to change the policies and systems that disproportionately affect populations of color and American Indians.  This approach has the potential to reduce the level of toxic stress experienced by some communities.  Reducing community-level poverty, improving educational outcomes, and stabilizing housing will help prevent the adverse childhood experiences that are negatively affecting the health of numerous children. 

Does the acknowledged shrinkage of the middle class contribute to poor health in our population? If so, is the eventual solution a political/socioeconomic one or a clinical one?

Where disparities in wealth are the widest, the disparities in health are the greatest.  As these disparities increase, the health of everyone suffers, even those at the top of the socio-economic strata.  Despite having the best medical care system in the country, our disparities have increased which puts our overall health at risk.  The long-term solution is socio-political, not  clinical.  Investing more in our clinical care system is not the answer.  The most effective approach is to invest in a community development strategy that provides everyone an equal opportunity to be healthy.  

What are some of the specific mechanisms in place for dealing with the health of children in poverty circumstances?

Family and community health and stability are at the core of addressing the issues of children in poverty.  The increase in the minimum wage will play a huge role in improving the health status of children and their families.  Minnesota data show that moving from the lowest quintile of income to the second lowest, increases life expectancy by over three years and reduces days of poor health by almost 50%.  The investments being made in safe and secure housing will also be significant.  Paid parental leave and paid sick leave would particularly help improve the economic and health security of low-income families.  Ten weeks of paid maternity leave has been shown to reduce infant mortality rates by 10%.  Other income enhancements and a focus on the prenatal to three period in a child’s life show promise of improving the health of low-income children.

Who will be able/eligible to use the services and resources of the Center for Health Equity?  How will the Center’s performance be judged?
Advancing health equity is the central focus of all of the activities of the Minnesota Department of Health.  Every division, office, program, and center will approach their work with the question of how does their efforts advance health equity.  The Center for Health Equity will be a resource for data and health equity expertise for all parts of the agency, help facilitate and coordinate health equity efforts across the agency, and identify new opportunities.  The Center for Health Equity contains the Center for Health Statistics, the Office of Minority and Multicultural Health, and the Eliminating Health Disparities Initiatives grants.  These resources will be available to anyone in the community.  In particular, racial and cultural liaisons and data related to health equity will be available to communities of color and American Indians and to organizations working with those communities.  Targeted grants addressing specific high priority needs will also be available. 

Where do you hope to see the most significant change in Minnesota's healthcare delivery in the next five years?

Health is not solely the responsibility of the healthcare sector.  Overall health is a community responsibility.  To optimize the health of all Minnesotans, healthcare must be embedded in the community and be responsive to the needs of the community as determined by the community.  Health is a public good and how resources are invested to create health should be determined by and accountable to the public.  The community-based models being implemented through the Statewide Health Improvement Program (SHIP), county-based purchasing, and Hennepin Health show promise in improving health, advancing health equity, and reducing healthcare costs.  Using what is being learned from these efforts to better integrate clinical care, public health, and social services and in Accountable Communities for Health will play a major role in designing a more effective approach to creating a healthy Minnesota. 
What has been your biggest "aha" moment since becoming Commissioner?

I’ve been (and continue to be) an advocate of a single-payer system for health care.  However, what I’ve learned since becoming health commissioner is that the mechanism of financing healthcare is far from the most important factor in creating a healthy society.  What’s most important are the conditions and circumstances in which people are born, grow, live, work, learn, play, pray, and age; and that these circumstances are often determined by forces beyond the control of the individual including: economics, social policies, politics, and the distribution of money and power.  Yet, most people have been indoctrinated into the narrative that health is created by their personal choices about diet and exercise and the quality of the health care system. 

The biggest “aha” moment for me was when I saw the energy unleased by articulating a different narrative about what creates health.  The narrative that health is really created by economic, environmental, and social conditions resonates with what most people intuitively know about health.  It also helps them realize that these conditions are not immutable and can be changed by an organized community effort; that creating a healthy society is their responsibility not just that of health professionals.  Seeing communities throughout the state becoming engaged in and empowered to create the conditions in which people can thrive and be healthy has been astounding and makes this an exciting time to be health commissioner. 


Reprinted with permission, MetroDoctors,September/October 2014.

Wednesday, September 3, 2014

Suffrage and Immunizations – Major Public Health Tools

North Dakota has been dramatically changed by the oil boom in the state’s Williston Basin. The influx of people to work in the Bakken oil fields has generated numerous social, economic, and public health issues.  While environmental concerns, violence, prostitution, housing shortages, and railroad safety have garnered most of the attention, it is the potential disruption of a core public heath function that prompted the North Dakota Department of Health to ask for help from the Centers for Disease Control and Prevention (CDC) and the Association of State and Territorial Health Officials (ASTHO). The issue? How to keep track of the immunization status of the thousands of people moving to North Dakota from all over the country.
To address this issue, experts in immunization registries and health informatics and immunization program staff from state health departments in the five states from which most oil workers emigrate came together last week in Minneapolis. The focus was how, within federal and state programmatic and legal frameworks, to share immunization information between state immunization programs. As the health commissioner in one of those states, I was invited to attend.
I have long-believed that immunization programs are a prototype for our health care system. If the public and private sectors can collaborate to get the right vaccines into the right people at the right time in a high quality and affordable way and can track and monitor the effectiveness of those efforts, we would have a model for the rest of our health care system.  The presentations and discussions at the Immunization Information Systems meeting reinforced that opinion. 
Yet, that was not the main lesson I learned from the meeting. Given that this meeting was held on August 26, the anniversary of the enactment of the 19th amendment to the U. S. Constitution, what struck me was the impact that an engaged, passionate, and organized constituency of nearly a century ago was still having on the health and wellbeing of today’s society. Without the 19th Amendment, our immunization discussion would most likely have been much different.
The 19th amendment, which gave women the right to vote, was the result of decades of effort by dedicated individuals and organizations committed to empowering women to have equal rights in shaping the future of our country.  Women’s suffrage didn’t come easy but, when achieved, made a significant difference in all aspects of society.  To me, enactment of the 19th amendment in 1920 was the greatest public health achievement of the 20th century. 
With women having the right to vote, elected officials recognized the need to address the issues important to women. High on that list of concerns was the heath of mothers and children. In response, congress passed the Sheppard-Towner act in 1921 with the goal of reducing maternal and infant mortality. The Maternity and Infancy (Sheppard-Towner) Act (PL 67-97) created a state/federal partnership around public health that continues to the present. It established the first public grants-in-aid program in the U.S., which led to the development of full-time Maternal and Child Health (MCH) programs in every state health department and provided training and support for public health nurses. In addition, recognizing the need for data to support research and program evaluation, the Act expanded Birth Registration/Vital Records systems to all states.
[As an aside, the Sheppard-Towner Act was opposed by the American Medical Association, which led some members to establish a new physician organization, the American Academy of Pediatrics. There was also discussion about who should be responsible for implementing the Act. The decision was to make it part of the Children’s Bureau, which was in the Department of Labor rather than in the Public Health Service.  Perhaps this was the beginning of a Health in All Policies perspective and a new narrative about what creates health.]
Although the Sheppard-Towner Act was repealed in 1929 because it was considered too “socialist,” it was the model for Title V of the 1935 Social Security Act, which continues to influence public health today. Without the existence of the federal/state partnerships, state MCH programs, and an accurate vital records system developed through the Sheppard-Towner Act, MCH activities and the immunization delivery and tracking systems of today would be much different. We can thank the Suffragettes for their influence on today’s immunization and public health system. 
As a post script:  Women’s Equality Day is celebrated each year on August 26, the anniversary of the enactment of the 19thAmendment. Although women have made great progress toward equality since 1920, major inequities remain. Similarly, even though all adult citizens theoretically were able to vote after 1920, it took the Voting Rights Act of 1965 to enforce the voting rights guaranteed by the 14th and 15thamendments and ensure the enfranchisement of racial minorities throughout the country. Despite all these laws, there are still efforts to limit the advancement of women and access to voting. Voting is a powerful public health tool because it helps shape public policies that profoundly influence our health. Along with all of our other Health in All Policies activities, empowering people to vote should be part of our Advancing Health Equity efforts.