Make the Health Desert Bloom

Forty years ago this month I moved to Salt Lake City to continue my medical training. It was an exhilarating time in health care. Major advances in medical technology seemed to occur every week. The first clinical CAT (computerize axial tomography) scanners came online just as I started my residencies. That advance was bracketed by the “Babybird” respirator, infant incubators, MRIs, ultrasound, fiber optics, the Jarvik artificial heart, lithium batteries, lasers, and many others. These new technologies allowed clinicians to diagnose and treat conditions in ways unimaginable ten years earlier; saving smaller and smaller babies and more seriously ill children and adults than ever before.

During this time, our medical care system was transformed. The new medical technologies fostered the development and expansion of newborn intensive care units, tertiary care hospitals, implantable pacemakers, medical transports, in vitro fertilization, and new micro surgical techniques to name just a few. They accelerated the trend toward specialization within the medical profession. We had great hopes and expectations that a technology-enhanced clinical care system would lead to a new level of health in our country.

Last week I returned to Salt Lake City for the “State Health Departments’ Senior Deputies and Legislative Liaisons Meeting” conducted by ASTHO (Association of State and Territorial Health Officials). As I entered the city, I was struck by how much it had changed in forty years. The Wasatch Mountains and the Great Salt Lake appeared the same but, due greatly to the influence of the 2002 Winter Olympics, there were more hotels, light rail, and one could now purchase alcohol in restaurants. There was also a large homeless population – something non-existent in SLC forty years ago. But the biggest change for me was the focus of the meeting presentations and attendee conversations. They were not talking about the promise and potential of our medical care system to improve health; they were talking about its failures and limitations.

With forty years of hindsight it is evident that, despite all its benefits, technology has not made us healthier when compared with similar countries. In almost every health category, including infant mortality, longevity, and health disparities, the U.S. has fallen farther and farther behind other OECD (Organization for Economic Co-operation and Development, i.e. industrialized) countries. And we have achieved those poorer outcomes at a tremendous cost – both human and financial. Until 1975, the percentage of the U.S. GDP (gross domestic product) spent on health care paralleled that of other OECD countries. Since then, our skyrocketing costs have significantly outpaced every other country.

Our supersized investments in medical care have been mostly at the expense of investments in public health and human services. The U.S. has the lowest percentage of GDP spent on human services among the 28 OECD countries which spend more than 15% of their GDP on the combination of medical care and human services. Yet, it is these investments in public health and human services that are proving to be the most effective in improving health. Moreover, the huge investments in high-tech medical care has also lead to lost opportunity costs by stifling investments in education, housing, transportation and other social determinants of health.

As I sat in the room listening to how we need to create a new 21^st century approach to protecting and improving health, I thought back to the Mormon and Utah history I learned during my three years in that unique state. On July 24, 1847, Brigham Young, sick with Rocky Mountain Spotted Fever, saw in the distance the Salt Lake Valley for the first time. Remembering an earlier vision about leading his followers to a place where they could "make the desert blossom like a rose," he proclaimed from the back of his wagon, "It is enough. This is the right place. Drive on." The Latter Day Saints did just that, they drove into the valley and helped make Young’s vision a reality.

The comments and questions from the senior deputies and legislative liaisons from state health departments throughout the country, made me aware that they were in one respect in the same place, both literally and figuratively, as Brigham Young. They understood that we’ve got enough data to know what creates health; that we’ve invested enough in the health care path we’ve taken over the last 40 years; that we know what needs to change to improve our health status; and that we don’t have to look further for the time and place to start. The question they had was how to instigate those changes? How do we invest in and implement a “health in all policies” approach that addresses the physical, emotional, environmental, and social determinants of health?

From what I heard last week in Salt Lake City and what I’m observing throughout Minnesota and the rest of the country, people are answering those questions. There is a growing consensus that, relative to our investment in health care, “it is enough.” There is a recognition that change needs to occur in the states because “this is the right place.”

The place and time are right to make our health deserts bloom so let’s “drive on” to create the policies, systems, programs, and conditions in which all people can be healthy. It’s a great time for you and me to be in public health and help shape the vision and the direction for all 21^stcentury health pioneers.

Ed

Health is Community

Every year I have the opportunity to provide the closing keynote address at the Minnesota Rural Health Conference. Not wanting to be repetitious, I continually look for new perspectives on rural health that might be helpful to conference attendees. As I began to prepare this year’s remarks, I was made aware of a book of essays by Wendell Berry, a poet, writer, and farmer from Henry County, Kentucky. Knowing that his writings deal with healthy rural communities, sustainable agriculture, appropriate use of technology, connection to place, and the interconnectedness of life, I thought he might provide some inspiration. 

I wasn’t disappointed. 

In his essay “Health is Membership” Berry wrote that “…the community in the fullest sense is the smallest unit of health…to speak of the health of an isolated individual is a contradiction in terms.” That statement both stunned and energized me. Public health is based on data and measurement of health and this statement challenges how we currently think about, define, and appraise health. Although we are learning how individual health is profoundly affected by the environment in which people live, work, and play, we struggle to find ways to measure and assess that influence and appropriately improve it. The question is why?

You don’t have to go further than the guiding mantra of today’s health care reform, the “Triple Aim,” to find the answer. The “Triple Aim of Health Care” is: better care for individuals, lower per capita costs, and better health for populations. The focus is entirely on individuals. Even the population health aim looks at populations as the summation of individually-focused data and interventions. There is no direct or implied acknowledgement of the importance of community, which reinforces the common narrative that health is due solely to high quality health care and good personal choices. 

The “Triple Aim” reinforces an industrial model of health care that rewards efficiency and assumes bigger is better. It focuses on the care of each individual and assumes that a person can be healthy independent of outside factors. It strives for standardization and evidence-based, best practices although only certain kinds of evidence are acceptable. To best treat individuals with specific disease conditions, health care has become increasingly specialized and technology dependent. This model, effective as it is in providing excellent care to some individuals, discounts the importance of communities.

With that perspective, I had to conclude that the “Triple Aim of Health Care” is potentially detrimental to health – particularly rural health and health equity – and made that the premise of my speech. Knowing that my audience would be mostly health care providers, I made note to emphasize that health care is not detrimental to health rather it’s the health care systems put in place by the values represented by the “Triple Aim.” Health care is an important and necessary contributor to health but how it’s organized and funded is not necessarily best for the health of communities and health equity. In other words, what’s good for our health care system may not be good for communities or health equity. 

The “Triple Aim” reinforces the notion that health is the responsibility of the health care system. It crowns our health care system as the benevolent dictator of health in our country. All of health is viewed through a health care lens further reinforcing the narrative that health is solely about health care. It allows the health care system to dictate where health investments are made. That’s why public health and social services are underfunded in the United States compared to other countries and why other sectors that influence health are also under-resourced due to the overly-resourced health care system.

Knowing that people would not want to leave the conference on a negative note, I decided to offer an alternative triple aim for consideration – the Triple Aim of Community Health and Health Equity:

• Expand our understanding about what creates health
• Implement a Health in All Policies approach with health equity as the goal
• Strengthen the capacity of communities to create their own healthy future

The value underlying these three components is community connectedness – the social capital and social cohesion that’s essential for individual and community health. 

The Triple Aim of Community Health and Health Equity is built on a community health model, not an efficiency model. It recognizes that health is created in communities by the social, economic, and environmental conditions in which people live, work, and play. It acknowledges that every sector of the community (including health care) impacts the community’s health. Most importantly, it recognizes the need for communities to possess the power to address the conditions that impact their health. 

To build healthy communities, the health care system should not be in charge of health nor should the public health system. The community needs to be in charge of health. Health care and public health are crucial to creating healthy communities but are only two of multiple partners who need to be at the program and policy tables where decisions are made about how to invest in health for current community members and for generations to come.

I made the above points in my speech and it was met with polite applause. No one commented or challenged me or even asked a question during the Q and A session so I was left wondering how the speech was received. That was partially answered when three different people approached me after the session and said, “We’ve been waiting for this speech for twenty years. Our present system isn’t working for rural communities. You explained why and you gave us a framework to change that.” 

As a farmer, Wendell Berry knows that the seeds he plants determines the crop he harvests. The seed in his essay that “health is membership” blossomed into my understanding that health and health equity is community. Who knows what crop will spring from my speech? If something grows, I hope it’s a crop of social connectedness that shows us that community really is the smallest and most basic unit of health.

Ed

For Want of a Nail in Public Health

In preparation for this summer’s “Pitch the Commissioner (PTC)” tour around Minnesota, I managed to find some time between rain showers this weekend to pitch a few horseshoes. Although the PTC events are non-competitive, I wanted to practice in hopes of not embarrassing myself in front of county commissioners, local public health officials, state senators and representatives, health care providers, and community activists who usually attend these functions. I discovered the 40 feet between stakes seems to be getting longer each year.

As I pitched shoe after shoe, an old proverb my mother frequently cited while I was growing up kept looping through my mind:

For want of a nail the shoe was lost.

For want of a shoe the horse was lost.

For want of a horse the rider was lost.

For want of a rider the message was lost

For want of a message the battle was lost.

For want of a battle the kingdom was lost.

And all for the want of a horseshoe nail.

I was hoping this proverb might be a sign that I would “nail” a few ringers but my errant throws quickly dispelled that notion. Obviously, the message was not about horseshoes but prevention. The more I pitched and the more I thought about the proverb the more I appreciated the appropriateness of the horseshoe metaphor in public health.

Getting a ringer in horseshoes requires the shoe to end up in the center of the pit. That means the shoe can’t be too far left or right and it can’t be too long or too short. Given the presence of those parameters, the shoe must also have the right orientation to encircle the stake.

Similarly, to achieve good health, among other things, there needs to be a balance between treatment and prevention and between innovation and regulation. With those conditions in place, optimal health also requires good choices by an individual.

The game of horseshoes is governed by rules that assure the match is played fairly. To provide equitable opportunity for everyone to compete, the rules allow a shorter pitching distance to accommodate age, gender, and disability. While not in the rules, it’s assumed that everyone who wants to play horseshoes has access to a horseshoe pitching venue. In Minnesota that assumption is accurate because most pitches are in parks or public spaces; free and open to everyone.

The rules and assumptions related to health in our society are not as accommodating and equitable as in horseshoes. As our 2014 Advancing Health Equity report notes, “…the opportunity to be healthy is not equally available everywhere or for everyone in the state.” Whether it’s housing, transportation, health care, education, food, or employment (the determinants of health), the opportunities to be healthy are too often governed by one’s race, income, education, sexual orientation, and geography. Unlike horseshoes, few accommodations are made to allow everyone equal opportunity to be health winners.

Having taken that metaphor as far as I could, my mind went back to the proverb my mother taught me. I began to wonder how each component in that verse linked with public health. It then struck me that the horseshoe could represent the principle of social justice upon which public health stands. And social justice is held in place by the nail of the narrative that what creates health is investment in the public good (the commons) and the social, economic, and environmental circumstances in which people live. Sadly, this public health narrative has been displaced by the currently dominant narrative which states that rugged individualism and market forces are preeminent in determining health and prosperity; a narrative that has brought us great disparities and inequities and limited the opportunities for many to be optimally healthy.

With that in mind, each pitch of a horseshoe brought forward a different line for the old proverb.

For want of a public health narrative social justice was lost.

For want of social justice equity was lost.

For want of equity opportunity was lost.

For want of opportunity hope was lost.

For want of hope health was lost.

For want of health the community was lost.

All for the want of a public health narrative.

Our job is to create and sustain (nail down) a public health narrative about what really creates health and then pitch that to as many people as possible. The “ringer” will be health equity and optimal health for all.

Ed

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.

Ed 

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!"

Ed

Beyond Insurance: Creating the Conditions for Health for Everyone

(I was invited to speak today at a church service and attend a post-service forum about what they could do to make health care more accessible and affordable. I was unable to stay for the forum so I’m not sure what they decided to do. However, I thought you might be interested in some of my comments to the congregation as preparation for their discussion.)

When I was a junior in high school and was debating what career path I should take, I came across the book The Other America by Michael Harrington. The book started with this passage:

“There is a familiar America. It is celebrated in speeches and advertised on television and in magazines. It has the highest mass standard of living the world has ever known… but, there is another America. In it dwells somewhere between 40,000,000 and 50,000,000 citizens of this land. They are poor. … tens of millions of Americans are, at this very moment, maimed in body and spirit, existing at levels beneath those necessary for human decency. … They are without adequate housing and education and medical care.”

It was that book and the picture that it painted about the disparities and inequities that existed in our country that prompted me to choose a career in medicine; thinking that being a physician and working in underserved areas would be an effective way to address those disparities.

Sadly, after more than 40 years as a physician, what was written in 1962 is as accurate and as relevant today as it was then. “There are millions of Americans maimed in body and spirit existing at levels beneath those necessary for human decency, without adequate housing, education, and medical care.”

The persistence of the health problems in our country is certainly not because we haven’t worked on the issues or spent money on them. Despite talking about health reform every year for the last four decades and spending more money on health care than any other country in the world, we are far from the healthiest population on the planet.

Fortunately, I was not the only one affected by Michael Harrington’s book The Other America. It was read by John F. Kennedy and it formed the basis of his social and economic agenda that ultimately led to the Johnson era Great Society programs and the War on Poverty.

I mention that today because it’s exactly 50 years ago this month that the 89^th congress was convened, arguably the most productive congress in history. It was a congress that addressed the inequities in our society in ways not seen since then. This is the congress that passed, among other things:

• Medicare and Medicaid
• The Voting Rights Act (a year after the Civil Rights Act)
• Job Corps
• VISTA
• Peace Corps
• School lunch program
• Food stamps
• Head Start
• Neighborhood health centers
• Older Americans Act
• Elementary & Higher Education Act
• Housing & Urban Development Act
• Vocational Rehabilitation Act
• The Freedom of Information Act
• Cigarette labeling and advertising act
• Public Works and Economic Development Act
• National Foundation on the Arts and the Humanities Act
• Immigration and Nationality Act
• Motor Vehicle Air Pollution Control Act
• Highway Beautification Act
• National Traffic and Motor Vehicle Safety Act
• National Historic Preservation Act
• National Wildlife Refuge System Act
• Department of Transportation Act
• many more 

People argue about whether or not the Great Society programs and the War on Poverty worked. From my public health perspective, they were a resounding success. Poverty rates declined, especially for the elderly. We had a more balanced investment in health and social services and what we spent on health care remained in-line with what other developed countries were spending. And our overall health status improved and health disparities were reduced.

The activities that emanated from this national effort reflected what I discovered in my first three months of medical practice – that medical care alone will not make us healthy. I learned quickly that even if I spent every day of my medical career treating dozens of people with diseases, injuries, and disabilities, the overall health of the community would not improve. The unhealthy physical, social, and economic environment in which my patients lived overwhelmed whatever care I could provide. I learned that access to high quality medical care is necessary, but not sufficient, to create a healthy society.

While understanding that medical care is of crucial importance, the policy makers in the 89^th congress recognized that it is the policies, systems, and the socioeconomic and physical environments that play the biggest role in determining health. That’s why they not only invested in medical care through Medicare and Medicaid, but also invested in economic development, education, housing, transportation, environmental protection, and a whole lot more. They also empowered communities to become engaged in the decision-making process that developed and implemented programs and initiatives. In addition, they understood that health is not solely under the purview of the health care sector – that every sector is necessary to create a healthy society. In the public health parlance of today, they took a health in all policies approach. They invested in the public good. They invested in the commons. They invested in communities.

We need to learn from that experience because our research now demonstrates the wisdom of that approach in that socioeconomic conditions have been shown to account for more than 50% of our health while medical care contributes about 10%.

We also now know that it’s the disparities in education, income, wealth, housing, and access to a variety of services that lead to health disparities and that those disparities affect the overall health of the community – even those at the top of the socioeconomic ladder. We also recognize that these disparities don’t happen by accident. They are the result of policies that systematically disadvantage some groups, particularly low income populations and people of color and American Indians. That’s why it’s not surprising that the Great Society efforts to improve the health of all Americans were linked with the Civil Rights movement. A socially just society leads to better health for everyone. That’s why the Minnesota Department of Health has made advancing health equity the central focus of our efforts to create a healthier Minnesota.

Unfortunately, the Great Society programs were affected by the Vietnam War which stressed our budget and undermined our trust in government. In the early 1980s a variety of factors led to the dismantling or reduction in support for some of those Great Society programs.

That was also the time when the conversation about what creates health was being systematically recrafted. What emerged was the narrative that health is determined by personal choices and access to medical care. The narrative was that if people simply had health insurance that provided access to high quality health care and they made good choices about diet, exercise, and drug use, they would be healthy.

Looking back, it was at that point that we began to disinvest in the public good and abandoned our community-oriented approach to health and increased our investment in medical care. It was also when our health status (compared to other countries) began to decline, when disparities began to increase, when homelessness and hunger began to reappear, and when our health care costs began to rise astronomically.

That narrative about the primacy of medical care and individual responsibility remains dominant today. It’s that narrative that drives our health policy and it distracts us from what really creates health.

The truth is that health care accounts for only about 10% of our health and personal behaviors account for less than 30% and many of those are often outside the control of the individual. It’s hard to choose healthy food when you are poor and live in a food desert. It’s difficult to be physically active when your neighborhood is unsafe or you are working three jobs just to survive.

Well over 50% of our health is determined by the physical and socioeconomic environment in which we live, learn, work, play, and pray. Despite that, over 95% of our rapidly increasing health expenditures go toward clinical care which obviates the investments in the social and economic conditions necessary to create health for everyone. Without these investments in the community good, which will help prevent the development of disease and disability, the costs of health care will continue to rise.

While it’s important to work for universal access to high quality, culturally appropriate health care, the health of our society cannot be improved solely by those efforts. Certainly, having universal access to a single-payer system would help. But, in fact, our myopic focus solely on health care, health insurance, and medical financing mechanisms, actually interferes with what needs to be done to effectively improve our health. It limits the scope of the needed discussions around health and it limits the discussion to experts in the field of health care. What really is required is the active involvement of all people from all sectors of our society who recognize and understand the broader determinants of health and are willing to work to create a society that is more socially responsible and socially just.

That’s where you come in. As individuals and as a community, you can help change the narrative about what creates health. You can attest to the fact that it’s the policies and systems that create the conditions that support or undermine health. And it’s not just the official health policies that are crucial but the education, housing, transportation, environmental, and economic policies. You can make the case that many in our society don’t have the opportunity to make healthy choices because they are limited by their income, their education, their neighborhood, or their mobility. You can work toward policies that assure a livable wage, paid parental and sick leave, safe and stable housing, effective transportation, incarceration justice, educational achievement, and much more. You can bring an equity lens, a social justice lens, to those conversations recognizing that as Paul Wellstone said, “We all do better, when we all do better.” And you can hold policy makers and public officials like me accountable for the decisions that affect our communities.  

Public health is defined as what we, as a society, do collectively to assure the conditions in which all people can be healthy. That definition doesn't say anything about doctors or nurses or hospitals or clinics. It doesn't even mention health departments. It includes all of us as a society. All of us are responsible for creating the conditions in which people can be healthy. It’s our job, not someone else’s. All of us are part of the collective effort necessary to build a socially just society.

What better place to start that work than here? What better time than now?

Ed

Inauguration 2015

Like every other commissioner in attendance, I listened closely to Governor Dayton’s 2015 Inaugural Address for any reference to issues related to my agency.  Although I didn’t hear specific references to health or the Minnesota Department of Health (MDH), I was pleased with what I heard – a speech constructed around principles, goals, and initiatives that should gratify anyone concerned about the long-term health of the public. 

The speech began with an emphasis on economic security and education – two of the greatest determinants of health – and concluded with a call for “community” recognizing that “what binds us together is much more important than what pulls us apart.  What helps one region usually benefits our entire state.”  It was the Governor’s take on the Institute of Medicine definition of public health as all of us working “collectively to assure the conditions in which people can be healthy.”

In between, the Governor underscored issues that are core to public health: inequities (“inequities in wealth and income are at record highs”) and the need to strike a balance between spending on current needs and investing in the future welfare of our state (“Spending is for now…Investing is for the future…to produce future benefits and rewards. Wise financial management requires understanding this difference and striking a proper balance between them.”)  That echoed what public health workers have been saying about balancing investments in treatment and prevention, medical care and public health.  He tied all these themes together by recommending “that our top priority be to invest in a better future – by investing it in excellent education…and making that educational excellence available to everyone.”

The Governor emphasized education because“…an excellent education unlocks the door to unprecedented opportunities.  Our future success – the health of our families, the vitality of our communities, and the prosperity of our state – will depend upon our making those excellent educations available to all Minnesotans…education is the key to our survival.”  That certainly underscored the MDH vision for advancing health equity – that everyone have equal opportunities to be healthy. 

In concluding his speech with a call for community, Governor Dayton urged that we should cast “Minnesota modesty aside – we should be proud because we so often are the best…(having) earned (that) through smart minds, good ideas, and hard work; through all of us pulling together and making our state – despite lacking the advantages of ocean beaches, or Rocky Mountains, or fossil fuel riches – into a place (that is) unique and extraordinary.  A state upon which we proudly emblazon our motto: ‘L’Etoile du Nord,’ ‘The Star of the North,’ and bequeath it even brighter to future generations.”

As I stood with the rest of the crowd applauding, I thought “that was a great public health speech;” a speech that should challenge all of us for the next four years in creating a legacy of health and equity for our children, grandchildren, and great grandchildren.  Perhaps we even have the opportunity to create another “Minnesota Miracle” – one appropriate for the 21^stcentury. 

Ed