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for more lifeboats but a decision was made to fit it with a lower number that met the minimum requirements of an outdated law that based lifeboat numbers on tonnage not on number of passengers.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 which 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
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