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