Three Little Pigs - A tale of unstable housing

Members of the Jackson Elementary School Student Council were strategically placed in the school’s media center during Thursday’s press conference on the release of “Heading Home: Minnesota’s Plan to Prevent and End Homelessness.” Their visible presence underscored the fact that half of the 10,000 Minnesotans who are homeless every day are families with children – just like these.  They were also a reminder that having stable housing is important for school success. Holding the press conference at a Promise Neighborhood School in Frogtown, also gave the message that resolving major social problems like homelessness is beyond the capacity of individuals – it requires a concerted community-wide effort.

During the course of presentations by commissioners Tingerthal and Jesson (co-chairs of the Minnesota Interagency Council on Homelessness [MICH]) and the mayors of Minneapolis and St. Paul, the students attentively listened and jotted down notes on their clipboards. Their attention never waned, even during the “in-the-weeds” question and answer period following the presentations. As I stood with the other commissioners who were part of MICH, I was impressed with these student leaders.

Following the event I took the opportunity to meet the Student Council Members. I shook their hands, introduced myself, and asked what they learned from the press conference. Most said that they learned a lot from the press conference and were glad that something was being done to help people find a place to live. Several knew students who were in unstable living situations. However, most admitted that they got lost in some of the details of the press conference. In response to that admission, one 4^th grade girl stepped forward and said, “It’s pretty easy to understand. It’s just like the Three Little Pigs.”

The other Student Council members looked perplexed so she went on. “The pigs that lived in a straw house or a house made out of sticks were never really safe. They always had to worry about the Big Bad Wolf coming and blowing their house down. They could never sleep well or settle into their house because they always had to be ready to move. Only when they got into a house made of bricks were they really safe from the wolf and able to relax. The wolf is like all the bad things people have to face that makes it hard to live and the brick house is what these people here today are trying build for everyone."

The other students said, “That makes sense.” All I could say was, “I think you got the idea quite well.”

I left the press conference with a smile on my face, confident that our future will be in good hands.

Ed

In dreams begins responsibility

I met Senator Edward Kennedy only once, in the fall of 1983. The occasion was a hearing on “Hunger in America” that the Senator held at the Plymouth Congregational Church in Minneapolis. I was asked to provide testimony on the nutritional status of children in urban areas. 

To set the context before expounding on the data garnered from the WIC program, food stamps, homeless shelters, and food shelves, I read a passage from Michael Harrington’s book “The Other America.” 

“There is a familiar America. It is celebrated in speeches and advertised on television and in the magazines. It has the highest mass standard of living the world has ever known… but, there (is) another America. In it (dwell) somewhere between 40,000,000 and 50,000,000 citizens of this land.  They are poor. 

To be sure, the other America is not impoverished in the same sense as those poor nations where millions cling to hunger as a defense against starvation. This country has escaped such extremes. That does not change the fact that tens of millions of Americans are, at this very moment, maimed in body and spirit, existing at levels beneath those necessary for human decency. If these people are not starving, they are hungry, and sometimes fat with hunger, for that is what cheap foods do. They are without adequate housing and education and medical care.”

When I finished my prepared remarks, Senator Kennedy thanked me for my presentation of the statistics that “underscored the need to address hunger in America” and then began to reflect on Michael Harrington’s book. As best I recall, his words were “Thank you for reminding me of Michael’s book.  My brother Jack read that book, so did I. It was an important book because it made Jack more acutely aware of the suffering in our country and prompted him to propose some of the programs that were subsequently implemented and which made a huge difference in people’s lives. Too bad we’re back to where we were twenty years ago.”

The fiftieth anniversary of President Kennedy’s death prompted me to recall not only where I was when I heard the news of his assassination but also the hearing with his brother twenty years later. It also provided an opportunity to reflect on the legacy of JFK through a public health lens. 

Although implementation fell to his successor, much of the “War on Poverty” and “Great Society” programs were built on the framework laid out by President Kennedy. Even a partial list of accomplishments is impressive: Civil Rights Act of 1964, Voting Rights Act of 1965, Immigration Act of 1965, Office of Economic Opportunity (which led to Community Action Programs and Neighborhood Health Centers), Medicare, Medicaid, Head Start, food stamps, Elementary and Secondary Education Act, Higher Education Act, Work Study, Peace Corps, VISTA, Job Corps, environmental protection, first nuclear test ban treaty, and expansion of Title V of the Social Security Act. 

The impact of these programs was also impressive. Poverty rates dropped dramatically among all population groups but particularly among the elderly. High school and college graduation rates improved as did economic and health disparities. Unfortunately, many of these trends were not sustained when support for some of the “Great Society” programs was lessened or eliminated in the 1980s. For the last 30 years, we’ve struggled to recapture that lost momentum which offered so much hope and promise. Sadly, Michael Harrington’s words in “The Other America” are as true and accurate today as they were when they were written in 1962. 

Still, there is reason to be optimistic because some of the same conditions that existed in the early 1960s are present today. From my perspective, there were three things that prompted JFK’s actions for social change: data, community engagement, and a sense of optimism - a belief that we could do better. The data compiled and summarized in reports and books like “The Other America” and “The Silent Spring” by Rachel Carson were compelling and helped inform our country about its unacknowledged problems. The Civil Rights Movement and the nascent environmental movement used these data and personal experiences to create a narrative that supported the need for change and pressure Kennedy to act to protect and improve civil and human rights and our environment. And, as the Baby Boom generation was moving into young adulthood, there was a sense that not only could we do better but that we needed to do better and that we had the energy to make change happen. 

Today, we also have data that powerfully show growing disparities in all sectors of our society - that there are many people “without adequate housing and education and medical care.” We have research that demonstrates which programs and policies work in improving the quality of life for everyone and those that don’t. This information is ripe for a communication vehicle to help stimulate action. We also have a growing number of community-based organizations who are beginning to use this information and community experiences to create a quality of life narrative to pressure program administrators and policy makers to address the needs of all people in communities throughout the country. While we don’t have another Baby Boom generation, we do have a rapidly diversifying population that recognizes that we can and must do better. From this is emerging a sense of hope and optimism (combined with a sense of urgency) that we have untapped potential and unlimited opportunities. 

John Kennedy’s idealism has been recently criticized for giving people unrealistic hopes. But history shows that the idealism and dreams of the Kennedy and Johnson administrations led to some profound and positive changes in our country. Many of these changes are now an ingrained part of our culture. Given the problems we face, the risks are too great to abandon as unrealistic the current dreams for a better and healthier world. 

JFK addressed those criticisms directly. “The problems of the world cannot possibly be solved by skeptics or cynics whose horizons are limited by the obvious realities. We need men who can dream of things that never were.”

His brother, Ted, reinforced this message. “For all those whose cares have been our concern, the work goes on, the cause endures, the hope still lives, and the dream shall never die.”

As workers in the field of public health where we are striving to eliminate health disparities and achieve health equity, the words of John and Ted Kennedy should challenge us to persist in our efforts. Our efforts may be labeled quixotic but it is more important now than ever to work to make those dreams for a healthier and more equitable world come true. 

“In dreams begins responsibility.”  - William Butler Yeats

Ed

APHA Opening Session

Greetings, 

The opening session of the 141st Annual Meeting of the American Public Health Association (APHA) was keynoted on Sunday by Sir Michael Gideon Marmot, Professor of Epidemiology and Public Health at University College London, and author of "The Status Syndrome: How your social standing directly affects your health and life expectancy." He had spoken to this large public health assembly 5 years earlier and was making a reprise to demonstrate that not much progress has been made in reducing health disparities during that time frame.  

He began his talk by quoting from W.H.Auden's poem Crisis and Upheaval, written at the beginning of World War II when European countries were under siege and were waiting for some support from their allies.

In the nightmare of the dark

All the dogs of Europe bark,

And the living nations wait,

Each sequestered in its hate.

He used this quotation to make the point that the problems of disparities in the U.S. today, like the threat to Europe posed by the Nazis of the 1930s, are blatantly evident, yet policy makers and leaders in the public and private sectors are choosing not to act. He went on to highlight some of the "nightmares" that we are facing. Among OECD (organization for economic cooperation and development - "developed" countries) the U.S. has:

* the lowest life expectancy for men and second lowest for women

* the 2nd worst maternal mortality

* the 2nd highest non-communicable disease mortality

* the 4th highest infectious disease mortality

* the highest injury mortality

* and the list went on

He recognized the the need to develop sustainable programs and policies but reminded the crowd that "We don't do things because they are cost effective and cheap. We do things because they are right."  He emphasized that we must "Put fairness at the core of all policies" and stated the obvious that "Policies that don't lead to fairness are unfair."

He closed his speech with this line from Pablo Neruda:  "Rise up with me, against the organization of misery." He encouraged - he pleaded with - the crowd of several thousand to get engaged in addressing the social conditions within our society that are literally killing people. He urged all present to change the dominant narrative in our society from one that has led to the "organization of misery" to one that embraces collective societal responsibility and supports programs and policies that improve the health of all members of our communities.  

The speech by Dr. Marmot set the tone for the entire conference. The theme of disparities and health equity was evident in almost every session. It was underscored and addressed most bluntly in a session that reported on an Institute of Medicine (IOM) study (Poorer Health - Shorter Lives) that compared the health status of the US with other OECD countries. The data shared mirrored those presented by Michael Marmot. What was different was that the members of the IOM panel that carried out the analysis of the data from around the world, concluded that the health outcomes in the US are the result of "A culture that values individualism, individual freedom and survival of the most fortunate over social solidarity."  

This blunt statement reinforces the importance of the work that is being done throughout MDH to address disparities by actively engaging our community partners in developing a new  narrative about what creates health and what we need to do to "rise up against the organization of misery."  If we are truly data-driven, the disparities in our state should challenge us to do what defines public health - working with the broad community to "collectively create the conditions in which everyone has the opportunity to be healthy."

Ed

APHA Annual Meeting

Sunday, November 3, 2014

Greetings from Boston,

For the next 3 days, 13,000 public health professionals from around the world will be in Boston for the 141st annual meeting of the American Public Health Association (APHA). I am here at the invitation of the Robert Wood Johnson Foundation (RWJF) and the Centers for Disease Control and Prevention (CDC) to do a couple of presentations on "Advancing Health Where It Starts - Where People live, Work, Learn, and Play," and on "Minnesota's Efforts to Build a Movement for Healthy Children."

The first presentation was on Saturday as part of a pre-conference workshop sponsored by RWJF and APHA. The workshop was keynoted by Mildred Thompson, Senior Director and Director of the Center for Health Equity and Place at PolicyLink. She focused on the fact that where one lives is important to one's health. Place matters. 

She also highlighted the increasing diversity in contemporary America and how that is affecting place. A heartening piece of information that she shared was that a recent poll by the Center for American Progress revealed that 71 percent of Americans support taking steps to reduce racial and ethnic inequality in our country. 

Ms. Thompson also outlined what she saw as the major roles for public health in today's world.  She stated that public health should be a:

* Catalyst for action

* Convener of broad groups

* Liaison to the community

* Developer of new practices and polices that get institutionalized

* Source of new and progressive data sources and analysis

Following her, David Fleming, Seattle and King County Health Officer, outlined a Framework for the Foundational Services of Public Health - the programs and capabilities that need to be present (not that we would like to be present) in any heath department at any level of government. The Foundational Programs were:

* Communicable Disease Control

* Chronic Disease and Injury Prevention

* Environmental Public Health

* Maternal, Child, and Family Health

* Access to Clinical Care

* Vital Records.

The Foundational Capabilities in each and all of these Programs are:

* Assessment  (surveillance and epidemiology)

* Emergency preparedness and response

* Communications

* Policy development and support

* Community partnership development

* Business competencies

I must admit that I have some disagreements with this list. Regardless, the first of these two presentations focused on the new directions and opportunities that are available for public health  agencies. The second outlined the core programs and competencies needed by governmental public health. They encompassed what many consider the "old" and  "new" public health - both of which are important.

The session I was part of followed these two. I was fortunate to be paired with Gretchen Musicant (Commissioner of Health for Minneapolis) and Doran Schrantz (Executive Director of ISAIAH). I started off by paraphrasing Garrison Keillor - we're from Minnesota, where the health care system is strong, public health good looking, and our health statistics are above average - unless you are a person of color or an American Indian. The three of us then talked about the collaborative approach among state and local public health and community organizations that has been influential in helping to change the narrative in Minnesota about what creates health. Our efforts with the Statewide Health Improvement Program (SHIP), Healthy Minnesota 2020, the State Innovations Model (SIM) grant, and the Health Equity report that we are crafting were used as examples of how to effectively engage and empower communities in creating a healthy physical and social environment that benefits everyone. I think we added some additional components to the "new" public health. 

The public health world is interested in what we are doing and anxious to see what results our efforts bring.  So am I.

The APHA meeting kicked-off in earnest this afternoon with a general session that featured Sir Michael Marmot and Sarah Weddington.  I'll fill you in with some of the highlights later.

Ed

The Last Minstrel Show

Greetings,

When I first heard that the Harlowton Kiwanis Club was going to stage a minstrel show in blackface, I reacted with righteous indignation.  I wrote a letter to the Harlowton Times.  I petitioned the County Board.  I met with the town leaders, most of whom were members of the Kiwanis.  The response I got from each of those venues was:  “How could a newcomer like you be so brazen as to question and challenge a town tradition that has been well-received and going on for years?” 

Despite presenting journal articles and solicited letters from African-American leaders in Montana and throughout the country on how minstrel shows had created and perpetuated black stereotypes and demeaned black culture, I was reassured that the show was just for fun and meant no disrespect to anyone.  The show went on.

The only thing I had accomplished in my efforts was to make myself persona non grata within this small Montana community.  My wife and I were shunned by many of our “friends” and the County Board sent a letter to the National Health Service Corps requesting that I be reassigned.  Because I was just a few months from completing my assignment, it was determined that I should remain in my position while the town looked for another physician.  Without a doubt, that was the most painful and stressful period of my professional life.

During those last few months in Harlowton, I had the opportunity to reflect on what happened.  I realized that I had been quite naïve and arrogant in my approach to changing a well-established cultural norm.  Besides that, I was ineffective.  Data and thoughtful analysis were no match for community values and tradition.  And, my direct and confrontational approach had served only to make people feel threatened, defensive, and resistant to change. 

It was only then that I remembered that 20 years earlier, my parents along with several of their friends, had worked behind the scenes to have our hometown parish stop holding its annual minstrel show.  Through numerous one-on-one conversations, they helped form a consensus about what was best for the parish to meet its mission and, a minstrel show did not fit into that narrative.  When a group of parishioners finally approached the pastor, it was inevitable that the minstrel show tradition would be abandoned.  I wish I had remembered that lesson a few months earlier before I had been abducted by the arrogance of youth. 

That Montana experience was 40 years ago but memories of it quickly and vividly returned one month ago after my talk on the issue of infant mortality at the annual meeting of the Association of State and Territorial Health Officials (ASTHO).  In my presentation I highlighted the racial disparities in infant mortality rates and the fact that, if we are to effectively reduce those rates, we must address the issue of race in our society.  Because my speech was given on the anniversary of Booker T. Washington’s Atlanta Compromise speech (see my September 18^th Blog http://www.commissionerblog.health.state.mn.us/2013_09_01_archive.html), I also made the point that there is still debate about how best to proceed in achieving racial equity – incrementalism, accommodation, confrontation, etc.. 

In the Q and A after the talk I was thanked for having the “courage” to bring up the issue of race.  Later, several of my State Health Officer colleagues shared that they feel restrained from bringing up the issue in their state.  I was surprised by these responses because I always assumed that one of the main tasks of public health is to shine a light on the things that interfere with health – public health is the constant redefinition of the unacceptable – and that our reluctance to talk about race and racism is one of those things.  I was also surprised by the fact that, while many things have changed in the last 40 years, our willingness and ability to talk about race is not much better in 2013 than it was in 1973.  This week’s controversy about changing the name of the Washington Redskins underscores that point. 

But we have an opportunity to change that.  On Tuesday of this week we will be launching our Advancing Health Equity effort.  In preparation for a report to the legislature on how to advance health equity in Minnesota, we will be critically looking at our organization and the structural barriers to health equity that currently exist.  A major part of this effort will be a conversation about race focused on developing a sense of what each of us, and the Department, can do to advance our goal of health equity.  The leadership role we must take in advancing a state-wide conversation about race and heath equity will also be part of our agenda.  I’m sure it will initially be a difficult conversation but one that needs to happen. 

In that conversation there will be no interlocutor, no “Mr. Tambo,” and no “Mr. Bones.”  http://en.wikipedia.org/wiki/Minstrel_show  My hope is that there will be multiple authentic conversations taking place where all voices and all perspectives are heard and considered.  My hope is that our efforts will take us to a place where we can say that we have seen the last of the minstrel show and the legacy it created. 

Ed

My Whole World, Soon Gonna Be Get Mixed Up

At the intermission of a 1971 Pete Seeger concert, one of the leaders of an activist graduate student group on campus got up and asked for donations to help pay the legal fees of some of the group’s members who had been arrested during a protest outside the university’s administration building. Several people in the audience vociferously disagreed with the speaker and tried to shout him down.  Soon there were shouts and angry words flying from every corner of the pavilion. The political disagreements that were so uncompromising and bitter and so evident throughout the country at that time were being played out in microcosm before my eyes. 

Today, I can still recall the protest and the passionate disagreements among audience members, but most vivid is the image of what happened when Pete Seeger returned to the stage. With his banjo in-hand, he began deftly picking the melody of the first song of his second set. While the audience continued to roil, Pete announced, “I don’t fully agree with what the group is demanding, but I fully support their right to voice those demands. Because of that, I will be donating my fee for tonight’s performance to help pay their legal fees. I am confident that this will be an investment that will benefit everyone here.” 

Before the stunned audience had a chance to react, Pete began singing a song I had never heard before. The song was simple, lively, and catchy. By the second verse, the audience had stopped arguing and shouting and was beginning to join in the singing of the chorus. From that point on there was a sense of community among the crowd that hadn’t been evident before. 

For the last 42 years, whenever the world seemed to be spinning out of control and the increasing diversity among us seemed more of a curse than a blessing, I have thought about the events of that night to help bolster my spirits that things will get better.  But I could never recall the specific song that transformed the crowd. Recently I was given a CD containing some of Pete Seeger’s lesser known songs. As I listened to the music, I heard a song that I immediately recognized as the song that calmed the crowd and created a sense of community during a very divisive time. Listening to the words, I realized the song is just as relevant today as it was in 1971. Perhaps the message of this simple song can help us get through the struggles of dealing with differing perspectives and conflicting opinions in 2013 as effectively as it did 42 years ago.

ALL MIXED UP by Pete Seeger

You know, this language that we speak

Is part German, part Latin, and part Greek,

With some Celtic and Arabic and Scandinavian all in the heap,

Well amended by the people in the street.

Choctaw gave us the word “okay,”

“Vamoose” is a word from Mexico way,

And all of this is a hint, I suspect,

Of what comes next:

Chorus:           I think that this whole world

                        Soon mama, my whole wide world

                        Soon mama, my whole world,

                        Soon gonna be get mixed up.

I like Polish sausage, I like Spanish rice

Pizza pie is also nice.

Corn and beans from the Indians here

Washed down by some German beer,

Marco Polo traveled by camel and pony

Brought to Italy the first macaroni.

And you and I, as well as we’re able

Put it all on the table.                          Chorus

There were no redheaded Irishmen

Before the Vikings landed in Ireland.

How many Romans had dark curly hair

Before they brought slaves from Africa?

No race on earth is completely pure;

Nor is any one’s mind and that’s for sure.

The winds mix the dust of every land,

And so will woman and man.              Chorus

On, this doesn’t mean we will all be the same.

We’ll have different faces and different names.

Long live many different kinds of races

And difference of opinion; that makes horse races.

Just remember The Rule About Rules, brother:

“What’s right with one is wrong with another.”

And take a tip from La Belle France,

“Vive la difference.”                           Chorus

As we strive to adapt to and benefit from the increasing racial, ethnic, and cultural diversity in our state and the markedly different political perspectives of some of our hyper-partisan elected leaders, I hope we can be respectful of differing views even if we disagree with them. That may be the only way to develop the sense of community needed to successfully address the challenges that face all of us and allow us to come together to take the next step toward the creation of a better world. When we eventually realize that we are all in this world together and that “We’re All Mixed Up,” perhaps we may finally reap the benefits of the diversity with which we have been blessed.

Ed

Booker T. Washington, ASTHO, MDH, and health equity

Greetings,

I spent much of last weekend preparing talks that I need to give this week. Some of the talks, like the Monday Farm to School talk at Hopkins Junior High School, were easy to prepare. The topic was clear and the activity to highlight was straight-forward and well understood. Who could argue with the efforts to bring in fresh fruits from local farms to schools? The Friday talk to the Internal Medicine graduates of Hennepin County Medical Center of the last 25 years about the integration of medical care and public health will be a bit more complicated but the topic is one that I've been talking about for the last couple of years so I've got a lot of material already prepared. The one that occupied most of my time and caused me the most consternation was the presentation that I have to give at the Association of State and Territorial Public Health Officials (ASTHO) annual meeting on Wednesday about what we are doing to address infant mortality in our state. It's problematic because the answers to the problem are not straight-forward nor easy.

Overall, Minnesota has one of the best infant mortality rates in the country. Even when looking at the infant mortality rates of populations of color, Minnesota looks like it's doing well until you exclude babies born to foreign born mothers. When you do that, (especially among African-Americans), it becomes painfully evident that the disparities in Minnesota are some of the greatest in the country. There is something in Minnesota that is toxic to "minority" populations the longer they live in Minnesota. 

A closer look at the data reveals that factors amenable to medical intervention are handled quite well. We've got a great regional perinatal system and excellent newborn intensive care units. In fact, if you are a low birth weight infant, your chances of survival are as good in Minnesota as anywhere in the world. The problem is that we have way too many low birth weight babies who are overwhelming our medical care system. It appears that it's the social determinants of health, not the medical care system, in Minnesota that are causing most of the problems. Yet, most people look for a medical or health care fix to our infant mortality disparities. 

As I pondered how to address this topic in my ASTHO presentation, I remembered that on September 18^th, the same date that I will be talking, Booker T. Washington in 1895 addressed the Cotton States and International Exposition in Atlanta and presented his "Atlanta Compromise" which is considered one of the most important and influential speeches in American history. I suspect you've never heard of it. In this address, which focused on social equity and how to deal with the plight of African-Americans, he said: 

"There is no defense or security for any of us except in the highest intelligence and development of all. If anywhere there are efforts tending to curtail the fullest growth of the Negro, let these efforts be turned into stimulating, encouraging, and making him the most useful and intelligent citizen. Effort or means so invested will pay a thousand per cent interest. These efforts will be twice blessed - blessing him that gives and him that takes. There is no escape through law of man or God from the inevitable:

The laws of changeless justice bind oppressor with oppressed;

In this speech Washington highlighted the fact that all humans inhabit one world and that the fate of one group affects the fate of all - a sentiment echoed by Dr. Martin Luther King, Jr. and Paul Wellstone. 

At the time, both whites and African-Americans resonated with these words. However, Booker T. Washington went on to say: 

"The wisest among my race understand that the agitation of questions of social equality is the extremest folly, and that progress in the enjoyment of all the privileges that will come to us must be the result of severe and constant struggle rather than of artificial forcing. No race that has anything to contribute to the markets of the world is long in any degree ostracized. It is important and right that all privileges of the law be ours, but it is vastly more important that we be prepared for the exercise of these privileges. The opportunity to earn a dollar in a factory just now is worth infinitely more than the opportunity to spend a dollar in an opera-house."

This incrementalist approach to equity was not universally accepted within the African-American community.  In fact, W.E.B. DuBois, who initially supported Booker T. Washington, later rejected this perspective and formed the NAACP and advocated for a more confrontational and activist approach to achieving equity.

 

After nearly 120 years, we are still asking the same questions: what is the best way to achieve health equity? And arguments about the answer still rage. Given the fact that our health disparities are some of the greatest in the country, it's obvious that we don't yet have the answer. And given the fact that our state is becoming increasingly diverse, finding the answer to that question becomes increasingly important. That's why the health equity report that we are preparing for the 2014 legislature could be one of the most important documents the department has drafted in the 142 years of its existence. I'll be getting more information to you about this report in the near future. Stay tuned.

In the meantime, consider the words of Ralph Bunch, who on September 18, 1948 exactly 53 years after Booker T. Washington gave his speech, was confirmed as U.N. mediator in the Arab-Israeli truce negotiations in Palestine. For his efforts, he won the 1950 Nobel Prize for Peace. He was the first person of color to receive that award. He said: "To make our way, we must have firm resolve, persistence, tenacity. We must gear ourselves to work hard all the way. We can never let up."

Achieving health equity is too important to ignore. We must have firm resolve to address this issue and we can never let up in our efforts.

Ed

Duke University roundtable

Twelve representatives from the Republic of China (Taiwan) were visiting Duke University in Durham, North Carolina to learn about the U.S. public health system and  share some of their successes and challenges. The delegation included the heads of the Taiwan FDA and the Taiwan CDC (they do use some of the same agency  names as the U.S.), the directors of their National Health Insurance Administration and their Department of Social Insurance, the Director-General of their Department of Medical Affairs, and several hospital administrators and clinicians. I was invited, along with several other state health officials, to provide some thoughts on "Driving Public Health Transformation in Communities."

I started my presentation by noting that this meeting was being held on the anniversary of what I consider to be the most significant U.S. public health achievement of the 20th century. On August 26, 1920 the 19th Amendment of the U.S. Constitution became law. That amendment stated:  "The  right of citizens of the United States to vote shall not be denied or abridged by the United States or by any State on account of sex." 

Because of the 19th Amendment several things occurred, but I highlighted the fact that it lead to the  passage of the Sheppard Towner Act which was a way to satisfy women voters. This Act was the first grants-in-aid program in the U.S. It also led to the  development of Maternal and Child Health Programs in all state health departments, the initiation of birth registries (vital records) in all state health departments, and the expansion of public health nursing. It established a partnership of federal and state government that continues to today. The passage of the 19th Amendment and the Sheppard Towner Act led to a precipitous drop in maternal and infant mortality rates. This was a great example of how public policies can dramatically influence health.

I linked the passage of the 19th Amendment to the topic of public health transformation by noting that Women's Suffrage did three things that we should consider today:

1. It demonstrated the need to engage ALL of the population in creating  health.

2. It demonstrated the power of engaged individuals and communities to create the conditions for health.

3. It changed the conversation about what creates health. It took the discussion about health beyond the clinical to include what we now speak of as the social determinants of  health.

Using those three learnings I explained how we put together our Healthy Minnesota Partnership and created our Healthy Minnesota Framework. I particularly  focused on how we are trying to change the conversation about what creates health. In doing that I used one of  the quotations on the first page of Healthy Minnesota 2020. It's from Antoine de Saint Exupéry - "If you want to build a ship, don't drum up people to collect wood and don't assign them tasks and work, but rather teach them to long for the endless immensity of the  sea." 

That quotation exemplifies what we are trying to do with our Healthy Minnesota Framework - expand people's vision and create a narrative about what a healthy community and a healthy future might really look like if we embraced a perspective based on possibilities and abundance rather than diseases and scarcity. 

I then went on to explain our Framework and how it is influencing our SHIP (Statewide Health Improvement Program) efforts and our SIM (State Innovation Model) grant. People were interested in this latter part of my talk but it was evident that the interest wasn't as high as it was for the first part. Several hours later while enjoying a lovely beverage during a reception in the backyard of a former NC State Health Official, I discovered the reason why.

The people from Taiwan had not been exposed to the notion of health in all policies and were still trying to comprehend the concept that Women's Suffrage is a public health issue (women in Taiwan got the right  to vote in 1945). The concept of community engagement and empowering communities to create the opportunities for health was also new. They were more interested in the concepts than in the specifics of what is happening in Minnesota.

The response from the U.S. attendees was also fascinating. They also weren't interested in the specifics but my presentation sparked an in-depth and engaging conversation about racism, cultural diversity, sexism, community engagement, and power and control. It was one of the most interesting and informative conversations in which I've participated. 

As I listened to the conversation, I silently thanked Genevieve Clark, Elizabeth Cady Stanton, Lucy Stone, Julia Ward Howe, Lucretia Mott, Susan B. Anthony, Sojourner Truth, Jeannette Rankin, and multitudes of others who worked hard for many years to gain this civil right for half of our citizens. Tonight's conversation  would not have been possible without them. However, it was also pointed out during the conversation - two days before the 50th anniversary of Martin Luther King's March on Washington - that the work of engaging and empowering communities to better the human condition of all of its members will never be done.

We all decided that we also have a dream - a dream that we will all, as a community, work collectively to assure the conditions in which  people can be healthy. While that may be the definition of public health, it's also the challenge and the vision of public health. It is a challenge that I hope we can meet in Minnesota and throughout our country. I also hope it is a challenge that will be met in Taiwan and every other country throughout  the world.

Ed

Omelas and ESPHL

The Ones Who Walk Away from Omelas, a story  by Ursela K. Le Guin, was one of the reading assignments for the Aspen Institute/Robert Wood Johnson Foundation "Excellence in State Public Health Law" (ESPHL) conference in Glen Cove, New York. The gist of this story is that the people in the town of Omelas are living a Utopian life where everything appears to be perfect. The town is beautiful, the people are happy and healthy, everyone has good housing and nutritious food, recreational opportunities abound, the weather is exceptional, and crime is absent.

However, under one of the community's beautiful buildings a child is kept imprisoned in "abominable misery" and squalor. Everyone knows about this child but no one offers help or even a kind word to the child because "if the child were brought up into the sunlight out of that vile place, if it were cleaned and fed and comforted, that would be a good thing, indeed; but if it were done, in that day and hour all the prosperity and beauty and delight of Omelas would wither and be destroyed. Those are the terms...The terms are strict and absolute."

Most of the people in Omelas have accepted those terms and have reconciled that the greater good justifies the prolonged misery of this child. But not everyone. "At times one of the adolescent girls or boys who go to see the child does not go home to weep or rage, does not, in fact go home at all. Sometimes also a man or woman much older falls silent for a day or two, and then leaves home. These people go into the street and walk down the street alone. They keep walking, and walk straight out of the city of Omelas....they walk ahead into the darkness, and they do not come back." No one knows where they go, "the ones who walk away from Omelas."

Discussion of this story was the first exercise of our meeting which focused on the impact of law and policy on public health. Some of the questions raised by the discussant were: why were some people walking away from Omelas? What was in their minds? What was their motivation? Where were they going?

The answers from the meeting participants were varied. Some attributed positive motivations (seeking a better and more honest society) to the "ones who walk away" while others criticized them for abandoning a child in distress when they knew that the treatment of the child was wrong.

Then the discussant asked, "what if there were two children, or a hundred, or a thousand? Would that have made a difference to people in Omelas? How many children would it have taken to change people's attitudes about the situation?

As I listened to the discussion, I began to see this child as a metaphor for the disparities in our own Omelas. We know they exist but ignore them for fear of potentially upsetting our comfortable existence and the "business as usual" approach to our daily routine. We justify their perpetuation as the price we must pay for our way of life.

While the story was fiction, I felt obligated to question the premise of the story - that the Utopian character of Omelas depended on the misery of one child. The reality is that a society is kept from its optimal potential by the presence of disparities. Even the people at the top of the socioeconomic ladder are negatively impacted by disparities in their community. This made me comment that the people of Omelas were either misguided or dishonest about how good their existence really was. I thought that they probably knew they could be better but changing the status quo was too risky. The people doing well had too much to lose to question what was going on.

At that point, the discussant changed the focus and asked, "What if the child was an elder near the end of life. What if that elder was put on an ice flow and set adrift? Would your thoughts about this story be different?"

That question certainly altered my thoughts. It transported me back to Grand Portage and the American Indian Health Symposium where I had been 48 hours earlier. It brought to mind a storyline that was frequently referenced at the Symposium. It was the story of American Indian children being taken away from their families and community and put into boarding schools - educational prisons as one tribal leader described them. The story also included the plight of elders (some of whom were part of the first storyline) who were being transferred off the reservation because of the lack of long-term care facilities. Victimized at both ends of life.

It was at that point that it struck me that the story of Omelas was not dystopian fiction but a realistic story about what has happened and is happening in our state. The questions raised in the discussion of the hypothetical Omelas story at Glen Cove were the questions also being raised about today's world at Grand Portage. They are the questions that all of us should be asking. What will it take for us to become motivated to effectively address disparities? One child? One senior? A thousand? Or an entire population group? And, if we become motivated, what should we do?

Whatever the answer, we should not be “the ones who walk away.” We need to be the ones who stay and help make the world better for those who are tortured and kept out of sight and in the process make our world more joyous for everyone.

Ed

Travels of a Health Commissioner

[Written on Friday Aug. 2, 2013]

Greetings,

Part of my job as Health Commissioner is to use the Bully Pulpit afforded me to educate people in Minnesota about the heath issues facing them and to advocate for programs and policies that could effectively address those issues. But another part of my job (and probably the most important part) is to listen to the stories of people in the state about what they think is important in creating health for themselves and their communities, what's getting in the way of creating that  health, and what ideas do they have to eliminate those barriers.

This was a week filled with listening and a great deal of learning.

On Tuesday I held a Pitch the Commissioner event in Duluth and heard lots of "pitches" about the struggles of how to create a way to get kids to bike or walk back and forth to school in a safe manner, the mental health issues in their community, the substance abuse issues, the needs of the elderly, and many other problems. Overwhelming those problems were the positive stories I heard about the power of the Statewide Health Improvement Program (SHIP) to mobilize a community to create health-enhancing policies  like "complete streets" and "safe routes to school", to link and leverage resources to create effective programs, and to bring real hope to a community. 

I ended the day  with a stop in Grand Marais where I met with community leaders in their community garden that has helped transform that community. Around the squash, beans, and broccoli I heard from 3 county commissioners about how they see SHIP as not only  a  health program but a community development program. I heard a businessman state that without SHIP, his business would not have succeeded (he sells and repairs bikes). I heard a community elder state that SHIP was crucial to keeping her healthy, in her home, and a contributing member of her community.

These stories - with facts to back them up - convinced me (again) of the power of communities coming together to implement policy, systems, and environmental change to create healthy people in healthy communities. 

From Grand Marais I went to Grand Portage to attend the 2 day American Indian Health Symposium. It was there that the stories became almost too painful to hear. But balancing that was the commitment that I saw in the tribal leaders to craft a new narrative. Despite the painful stories, I left the Symposium with a sense of hope and some new partners in our efforts to create a healthy  future for all people of this state.

Now, less than 24 hours from being in Grand Portage, I'm in Glen Cove, NY at an Excellence in State Public Health Law sponsored by the Aspen Foundation with funding from the Robert Wood Johnson Foundation.The purpose of this meeting is "to establish a dialogue among policy makers, scholars, commentators, and analysts about the most important public health law policy issues facing the country." Despite being in a markedly different environment, the focus is exactly the same as the  focus of our discussions in Duluth, Grand Marais, and Grand Portage - how do we create a healthier society.

The meeting started with a presentation by former Washington Governor Christine Gregoire. She talked about the importance of public health to all parts of our society/economy. She gave one of  the best Health in All Policies speeches I've heard. It resonated with the agency heads and staff, elected officials, and Governor's office staff. 

Minnesota is one of 8 states invited to this meeting along with Arkansas, Connecticut, Louisiana, Virginia, Rhode Island, Washington, and Hawaii. Our team consists of four legislators (2 senators and 2 representatives with both parties represented), the Governor's legislative director, commissioners of Public Safety and Human Services, Manny Munson-Regala, and me. Our focus will  be to find ways to address alcohol misuse through public policies. The meeting starts in earnest tomorrow and I'll let you know what I learn.

What I've already learned from this interesting week is that health is core to everyone's existence and that the creation of health in our communities will require the efforts of everyone, not just those in the medical care and public health sectors. And there's more learning ahead.  I'm hoping that tomorrow we learn how to engage people in all sectors and get them to work together to make our society as healthy as possible.

Ed

Preparing for “Pitch the Commissioner” 2013

The late afternoon sun was nearing the crest of the Rocky Mountains 70 miles to the west as we drove into Shelby, Montana on a hot mid-summer Sunday. After 12 hours in an old non-air conditioned car, my 7-month pregnant wife and I were anxious to be done with our day’s travels, find our new apartment, and collapse into bed. Because we had never been in the town before, we were diligently checking every sign to make sure we didn’t miss any clues that would direct us to the apartment that would be our home for the next 2 years.  

A few blocks inside the city limits we noted a sign: “Toole County Rodeo – Finals Today!” Having never experienced a rodeo and figuring this might also be a place where we could find something to eat on a Sunday evening, we decided to stop and check it out. Not wanting to spend a lot of money for what I thought would be a quick visit I asked the woman at the gate what it cost to get in. I was taken aback when she replied, “For you doc, admission is free.”

“This is the first time I’ve been in this town,” I said with a bit of surprise. “How do you know who I am?”

“Oh, one of the county commissioners said you’d probably be coming into town today and that you might stop here on your way. He said that if I saw some young guy with a goatee and a pregnant wife, it would probably be the new doc and that I should give them a good Toole County welcome.”

Before I could respond, I was approached by a burly, smiling, middle-aged man in cowboy boots who extended his hand and said, “Welcome to Shelby. I’m John Nesbo, one of the Toole County Commissioners. Come on, let me show you around and introduce you to a few folks.”

My wife and I were immediately escorted into the rodeo grounds where, for the next two hours, we were introduced to the Who’s Who of the Montana Hi-line, to the fine points of rodeo, and to rodeo cuisine. While watching bull and saddle bronc riding, barrel racing, and calf roping, we also learned about how the county had worked to become a designated physician-shortage area so that they could qualify for a National Health Service Corps physician like me. We heard stories about how the county had worked with various constituencies in the state and community to build a hospital, clinic, and nursing home. We were given an overview of the public health, social service, housing, education, and economic issues facing the county.  

Near the end of our conversation Robert Tomcheck, another Commissioner, remarked, “I probably spend more time dealing with health issues than any doc in Montana. And I’m not unique.”

As the rodeo continued, it became evident to our guests that my wife and I were fading. Commissioner Nesbo stated the obvious, “You need to get home and get some rest. Tomorrow’s going to be a busy day.”

“Can you give us directions to our new apartment?” I asked.

“I can do better than that,” replied the Commissioner. “I forgot to mention that we just upgraded our ambulance service. Our new rig is parked close to where you came in. I’ll have the crew escort you to your apartment.”

As we followed the ambulance to our new residence, I realized for the first time the major role that counties play in assuring adequate health care for their residents. It was an epiphany for me. That brief rodeo grounds visit opened my eyes to the vital role of counties in a wide array of health and human services. But, it was just the beginning of my on-going education into how much time, energy, and resources are dedicated at the local level in protecting and improving the health of our communities. It was the first step in my eventual understanding the importance of an effective collaborative among strong federal, state, and local public health partners.

I thought about this long-ago introduction to county health and human services when I wrote my first article for the Association of Minnesota Counties (AMC) shortly after becoming commissioner. I also thought of it when I attended my first State Community Health Services Advisory (SCHSAC) meeting and saw the number of county commissioners actively and effectively involved in improving our state’s public health system. I thought of it again today as I’m preparing to embark on my 2013 Pitch the Commissioner visits throughout Minnesota.

As I go around the state, I hope to learn more about how cities and counties can help assure good health for their citizens. I also hope to get some ideas about how MDH and state government can best support, facilitate, and sustain those local efforts.  And, in the process, I hope to make some new acquaintances, have some fun, and perhaps throw a few ringers.

On the hall tree by my back door hangs a 40 year old tattered and torn yellow jacket. It was given to me by the Toole County Ambulance crew for my work in helping them become a top notch ambulance service. It should have been thrown out long ago but I hang on to it as reminder of the role Toole County played in my development as a physician and as a public health professional. It’s sort of a daily “tip of the hat” to our “local partners” in public health – a partnership that I hope to celebrate and enhance as county commissioners and others Pitch the Commissioner in communities throughout our state.

Ed