Wednesday, March 18, 2015

Revisiting Lifeboats, Torpedoes, and Social Policies

Today I was part of a press conference that focused on the health benefits of paid leave – family leave and sick leave.  The event was prompted by last week’s release of our White Paper on Paid Leave and Health. As I was presenting our recent findings, I thought back to last year at about this same time when we released our White Paper on Income and Health. That report helped add a health frame to the policy discussions that ultimately led to an increase in Minnesota’s minimum wage.  My hope is that our recent report will also help bring a health perspective to another important public health and public policy issue. 

Given that the press conference relating to a significant social policy was held on St. Patrick’s Day, I decided to reprise a blog that I wrote at this time last year.  It’s as appropriate now as it was then.  Just replace Minimum Wage and Income and Health with Paid Leave.

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 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.


Tuesday, March 3, 2015

Zooks and Yooks

March 2, 2015

Every March I go to Washington D. C. to meet with federal agency heads and visit with the Minnesota congressional delegation. Today, my arrival in D.C. coincided with the arrival of Israeli Prime Minister Benjamin Netanyahu. Because of that coincidence, getting to my hotel took longer than usual as the cab had to navigate around police barricades and groups of protesters. That extra time in the taxi allowed me to ponder the polarization that’s so prevalent in our society. On almost every issue – from the Affordable Care Act through immigration reform to funding of Homeland Security and research on zoonotic diseases – the protagonists and antagonists appear to be acting like each other has an infectious disease that requires as much separation as possible. Sparked by the Prime Minister’s scheduled appearance before a joint session of Congress tomorrow, that polarization was blatantly evident throughout our nation’s capital today. 

Although the rhetoric is less intense and the issues not as prominent, Minnesota certainly hasn’t escaped from partisan polarization. 

With that thought in mind as I watched the green light turn red for the third time without the cab moving, I remembered that today was the birthday of Theodor Seuss Geisel. Not surprisingly, I immediately thought of one of my favorite Dr. Seuss books, The Butter Battle Book, which begins: 

On the last day of summer, ten hours before Fall…
my grandfather took me out to the wall.

For a while he stood silent. Then finally he said,
with a very sad shake of his very old head,
“As you know, on this side of the Wall we are Yooks.
On the far other side of this Wall live the Zooks.”

Then my grandfather said, “It’s high time that you knew
of the terribly horrible thing that Zooks do.
In every Zook house and in every Zook town
every Zook eats his bread with the butter side down!”

“But we Yooks, as you know, when we breakfast or sup,
spread our bread,” Grandpa said, “with the butter side up.
That’s the right, honest way!” Grandpa gritted his teeth.
“So you can’t trust a Zook who spreads bread underneath!

While the nuclear arms race was the basis of that story, Dr. Seuss could just as easily have used any of today’s controversies as his inspiration because, in Washington and throughout the country, people are using their Boom Blitzers, Blue Gooers, and Big-Boy Boomeroos to throw invectives at those who think differently than they do about myriad issues.  And what has it gotten us - a stalemate on most important issues and mutually assured destruction of anyone who tries to collaborate or compromise.  Health policy seems to be ground zero for many of these debates. 

Is it possible to get away from this brinksmanship and find a way to break down walls and collaboratively develop rational health policies?  Given the entrenched positions in Washington, it’s probably not possible there – at least not now.  Perhaps it can be done at the state level; especially in a state like Minnesota which has a history of coming together for the common good.  But who could help make that happen? 

I contend that it is our role as public health workers (some of whom are Yooks and some Zooks) to help make that happen.  Building on the fact that most people value health on both the individual and community level, we have the opportunity and responsibility to foster a conversation about what creates health.  We need to broaden that conversation beyond just the policy makers on one side of the aisle or the other and actively engage community members because everyone has a stake and responsibility in creating the conditions for health. 

The health of the public should not be a partisan issue – it is an issue that benefits everyone and everyone’s input is needed.  Our role in public health is to create the opportunity for all voices and perspectives on health issues to be heard and foster respectful and non-judgmental debate - essentials for the development of rational and effective approaches to creating health for everyone.  Now is the time to create that opportunity because, as was stated in Horton Hears a Who, another of my favorite Dr. Seuss stories: 

"This", cried the Mayor, "is your town's darkest hour!
The time for all Whos who have blood that is red
To come to the aid of their country!", he said.
"We've GOT to make noises in greater amounts!
So, open your mouth, lad! For every voice counts!"