Memorial Day 2014

May 26, 2014

Even though he was 25 years old when the United States entered World War II, my dad never served in the military. Instead, he used his machinist skills to help build tanks for the war effort. He was proud of his contributions but, like most men of his generation, he seldom talked about the war. “I did my part but the soldiers should get the attention and praise because they risked their lives” was about the extent of his conversation on the topic.

The wartime actions of my father resurfaced today (Memorial Day) when I paused to reflect on the lives lost in war in defense of our country and the values on which it is based. My dad won’t be honored in speeches today, but that’s OK. He would want it that way. He did the best with the skills and talents that he had and he was secure in the knowledge that he was a vital part of the war effort. That was recognition enough.

My mom was less reticent to talk about those war years. “Winning the war was truly a national effort. All of us contributed in whatever way we could. Your father had some unique skills that were best used here at home. Few people could do what he did. He certainly did his part in winning the war.” She would frequently use the occasion of these conversations with her children to reinforce her belief that any really big accomplishment is usually the result of a community effort and that the “behind the scenes” efforts are oftentimes the most important. It was in those chats that she would often quote a couple of verses from the poem “Be the Best of Whatever You Are” by Douglas Malloch:

We can't all be captains, we've got to be crew,
There's something for all of us here,
There's big work to do, and there's lesser to do,
And the task you must do is the near.

If you can't be a highway then just be a trail,
If you can't be the sun be a star;
It isn't by size that you win or you fail —
Be the best of whatever you are!

People in the public health field understand the importance of behind the scenes work. Like my dad’s behind the scenes efforts in winning the war, most people don’t recognize the behind the scenes reasons for losing most wars. Throughout history, the greatest number of casualties in wars has not been due to the conflict but infectious diseases. Over two-thirds of the deaths in the U.S. Civil War were due to infectious diseases – cholera, dysentery, yellow fever, etc.  And despite the homage given to cannons in Tchaikovsky’s 1812 Overture, Napoleon’s advance into Russia was not stopped by artillery but by typhus. As Charles Hewitt, the founder of the Minnesota Department of Health learned during the Civil War, the armies with the best public health infrastructure are usually victorious.  

Another “behind the scenes” fact is that civilians also suffer casualties because of war. And, as with troops, infectious diseases have been the major cause. It is estimated that one-fourth of the 4 million freed slaves died from infectious diseases in the wake of the Civil War. War disrupts the public health infrastructure that helps keep people safe and alive. That’s why the World Health Organization places “peace” at the top of the list of determinants of health.   

As my Memorial Day thoughts evolved, I began to more fully appreciate the fact that war and peace are public health issues. I also began to better understand what my mom meant when she stated during our war conversations that any really big accomplishment is usually the result of a community effort. Certainly the outcomes of the 20th century wars in which the U. S. participated – whether military victory, negotiated settlement, or withdrawal – were determined by community engagement and support (or lack thereof).  Getting into wars is often not a community decision, but getting out of wars, one way or another, most often is.  

But what about peace? Is that also a community effort? There is growing recognition that investing in public health is one way to assure peace. One example is that the State Department's Strategic Plan for International Affairs lists protecting human health and reducing the spread of infectious diseases as strategic U. S. goals. This doesn’t get much attention but, if accomplished, could dramatically change the war/peace dynamic in the world. It is this kind of “behind the scenes” efforts of public health that could really make the world a more peaceful and healthy place. But this will happen only if the community comes together to support local, state, national, and international public health efforts.  

Public health may never get the public accolades it deserves but that’s not the goal. The ultimate goal is to protect and improve health and create the conditions for peace. We can do that by following the poetic advice quoted by my mother:  

There's something for all of us here,
There's big work to do, and there's lesser to do,
And the task you must do is the near. 

If you can't be the sun be a star;
It isn't by size that you win or you fail —
Be the best of whatever you are!

On this Memorial Day I honor our soldiers and all the people behind the scenes in our many war efforts. I also honor all public health workers because they are doing some of the most important work in creating a peaceful world and they are doing it the best way that they can from behind the scenes.  

Ed

“The sparrow is sorry for the peacock at the burden of his tail.”

One of the challenges of my job is the frequent opportunity to provide an opening welcome or keynote address at a health-related conference, participate in a panel discussion on some health topic, or attend an event highlighting the work of an individual or organization.  The challenge is that I’m often speaking to an audience that knows a lot more about the topic than I do.  The opportunity is the chance to broaden the horizons of a specialized audience by providing a broader public health context for an issue or challenging the attendees with an alternative narrative about what creates health.  

Last week typified those challenges and opportunities.  While monitoring and testifying at hearings related to therapeutic cannabis, I had the opportunity to:

• provide opening remarks at the “Perinatal Hospital Leadership Summit” that was focused on supporting breast feeding,
• speak on a panel at a “Forum on Science, Democracy and A Healthy Food Policy” convened by the Union of Concerned Scientists,
• participate in a press conference on school-based and school-linked mental health services,
• join in a panel interacting with Elmo at an event highlighting the work of Sesame Street in addressing the issues of children of incarcerated parents, and
• attend the “150^th Anniversary Celebration” of the founding of the Mayo Clinic.

In looking back at the week I recognized that the events that focused on some of our public health challenges (obesity, food insecurity, behavioral health, and Adverse Childhood Experiences) were bracketed and overshadowed by events celebrating the role of medical care in improving our health.  That’s when I recognized the insight of Rabindranath Tagore (born May 6, 1861), a Bengali poet, novelist, composer, and the first non-European to win the Nobel Prize in Literature, when he said, “The sparrow is sorry for the peacock at the burden of his tail.”

Minnesota is an overall healthy state.  We are ranked number 3 in the United Health Foundation’s State Health Rankings.  We have the lowest infant mortality rate and the highest male and second highest female longevity in the country.  The Commonwealth Fund just ranked Minnesota as number 1 in the country in “health care access, quality, cost, and outcomes.”  Our birth weight specific infant survival and many 5-year cancer survival rates are also among the best in the country.  On an overall population level Minnesota is doing well and the medical care provided in Minnesota is of the highest quality.  Minnesota has a lot to be proud of. 

But like the peacock, we are burdened by our visible successes.  While we focus on our noteworthy medical accomplishments, we often ignore the fact that most of Minnesota’s good health status is due to previous investments in public health.  Also overlooked are the health disparities in Minnesota that are some of the greatest in the country.  Disparities in infant mortality rates and in years of unhealthy life after age 65 are just two of the many disparities that are greater in Minnesota than in most other states.  As we are discovering, overall health and health disparities are not determined by just medical care but mostly by social, educational, and economic factors – the social determinants of health. 

To effectively address these determinants, we must move beyond the common narrative that health is created by good medical care and individual choices to a new narrative that health is created in communities by people in many sectors addressing the social determinants of health.  But creating that new narrative is difficult.  Our public health stories of preventing diseases don’t have the emotional impact of stories depicting daring surgeries or advanced technologies that bring people back from the brink of death.  Few of our stories about collaborative efforts to improve community health contain individual heroes who serve as role models for the next generation.  Seldom are our stories told by a person who can say, with tear-filled eyes, that he/she is alive today because of the work done to address social inequities.  We are burdened by the peacock’s medical care tail while we need the sparrow’s public health perspective. 

The peacock is a beautiful bird but its ability to fly is limited.  While it is charismatic in the space it occupies, its range of influence is restricted.  The sparrow is plain in comparison but has the ability to cover a great deal of space quickly and easily.  Medical care will continue to garner most of the attention and accolades in our society.  Yet, it is becoming increasingly clear that a broader and more inclusive public health approach will be necessary if we are to effectively create a healthy world for all.  As we work to create that healthy world, we shouldn’t feel sorry for the successes of our medical care system.  We should celebrate and support them because they are necessary.  However, we need to find ways to raise the visibility of our public health system that expands the horizons of what is needed to create a healthy and equitable world.  Despite the struggles that public health has endured over the last few decades, I have faith that public health’s future is bright because as Rabindranath Tagore also said:  “Faith is the bird that feels the light when the dawn is still dark.”  Do you feel the light?  I do.

Ed