The difference between public health and community health

Greetings,
I was asked to write an article for Minnesota Physician, an independent newspaper focusing on health care and the business of health care. The request was to explain the difference between public health and community health. Because I thought you might be interested in my perspective on that topic, I’m including the article (Cultivating health - The intersection of public health and medical care) here. I hope the article helps germinate some thoughts about public health.
Ed

Health Equity Week

Greetings,

My work week started on Sunday when I was a guest on a Somali radio program broadcast on KFAI. I was confronted with questions about why MDH, under my leadership, is not doing more to address the health disparities in the Minnesota Somali community.

On Monday I started my day by giving the welcome at an MDH-sponsored meeting entitled: Infant Mortality in the African-American community - Community Voices and Solutions. This meeting focused on the disparities in infant deaths between African-American  and white Minnesotans - one of the greatest disparities in the country. Preparing for this presentation was one of the most difficult tasks I've had since becoming Commissioner. It was not because I didn't know what to say but because what I had to say was personally painful.

I arrived in Minnesota in 1980 as a young, idealistic, and naive physician. I was excited to start my job as Maternal and Child Health (MCH) director for the Minneapolis Health Department at a time when the MCH program was well-funded and having a tremendously positive impact on infant health in the City. Infant mortality rates were decreasing  for all populations and the disparities were rapidly narrowing. I anticipated a continuation of that trajectory which would, in just a few years, lead to an elimination of this unacceptable disparity. I was looking forward to refocusing my attention to other critical MCH issues. Unfortunately, the world changed.

In 1981 a multitude of MCH programs were bundled into the MCH Block Grant while being cut 25 percent.  Numerous other public health programs met a similar fate and were included in the Preventive Health and Health Services Block grant. Among other things, block granting led to a elimination of some MCH services, a reduction in others, and means testing for those that remained. Almost immediately, infant health outcomes were affected - and not in a positive fashion.

In 1983, I testified before a US Senate  Committee for the first time. The hearing was about whether or not a special task force should be established to look at the increasingly disturbing infant mortality rates among people of color and American Indians in the United States. My testimony focused on the disparities in Minneapolis and they mirrored testimony by others from all parts of the country. Despite the overwhelming data, the decision was to wait and see what happened as a result of the block grant approach to MCH.

It wasn't until 1991 when the increasingly disturbing infant mortality data were so dramatic that the federal government was shamed into doing something to address this problem. Even then, the Healthy Start program, which was the response to infant deaths, was funded at such a paltry level that only a handful of communities could benefit from the program. Minneapolis and St. Paul were too small to receive any of this funding. While the Healthy Start program has expanded significantly since 1991, it remained as the only primarily infant mortality-focused federal program until 2010. During that time, the US  infant mortality rate deteriorated compared to other countries and disparities increased to some of  the  highest  levels in the industrialized world.  

It was this lack of investment in public health and infant health over a 30 year period and the outcomes that resulted, that were so painful for me to consider as I prepared my Monday welcome. My career as a physician and as a public health professional was altered dramatically from what I anticipated. Health disparities became an accepted fact of life in our state and country. Damage control rather than health improvement became the focus of my work.

Today, I'm in Washington, D.C. at a meeting that is trying to find ways to redress this tragedy in misplaced priorities. CDC (Centers for Disease Control and Prevention) and ASTHO (Association of State and Territorial Health Officials) brought together a diverse group of individuals representing a diverse group of organizations to look at how to develop strategic partnerships to advance health equity by focusing on: Awareness of the issue, Community capacity to address the issue, Workforce development needs, and Multi-secotoral collaboration. So far, we've admired the problem of health disparities - how bad it really is, why is it occurring, and what are some possible approaches to make it better. Tomorrow, I hope we agree on a collaborative action plan that can begin to move us to where I thought we'd be in the 1980s.

Given the two events that started my week, it's appropriate that I'm here because our progress in addressing disparities will probably be how I'm judged as a Commissioner. Fortunately, what I'm discovering at this meeting is that, despite the problems we face and the inadequate progress toward health equity, we have some great things in-place or in development that hold great potential for change. Our Healthy Minnesota Partership and our Healthy Minnesota 2020 Framework are an excellent foundation for our health equity work. Our increasing focus on "Health in All Policies" and "Health Impact Assessments" hold promise for addressing the social determinants of health and the social determinants of inequity. Our work on the State Innovation Model reforms of our health care delivery system and our efforts engage and empower communities to own this process, hold hope for some significant change as do our efforts to integrate medicine and public health and alter our workforce development approaches. And our Collaborative Innovation and Information Network (CoIIN) work on improving birth outcomes (something you'll hear about soon) will, I hope, allow me to work more effectively on the issue that brought me into public health in the first place.

Eliminating health disparities is the major challenge of our time. I'm optimistic that the direction we are taking at the end of my public health career will be markedly different than that which I experienced at the beginning. We have a better understanding of the importance of social determinants of health, a new awareness of importance of community in creating health, and a sense of urgency that, if we don't address health disparities, we will never achieve the goal of a truly healthy Minnesota. But more importantly, we have a well-trained and dedicated staff throughout the department who are committed to addressing health disparities and a large group of partners who want to join with us in this effort to create the highest level of health for all Minnesotans - ALL Minnesotans.

Ed

Who Is the Vision Keeper for Health Equity?

Greetings,

The theme of this year’s Minnesota Public Health Association (MPHA) conference is “Health in All Policies-Creating Health Equity.” I’ve been invited to moderate a panel on the topic and have asked the commissioners of Education, Pollution Control, and Commerce to join me. I’m hoping they will all say yes because it could be an excellent conversation and a way to garner partners in our effort to create health equity in Minnesota.

This weekend, as I was thinking about the June conference, my thoughts wandered back to many of the MPHA conferences that I’ve attended. For some reason, my mind kept returning to the 1996 MPHA conference which talked about partnerships and a vision for the future of public health. Perhaps it was because we’ve been working hard to articulate a clear and compelling public health vision for the State during this time when the role of public health is being challenged. Perhaps it was because we just finished Public Health Week where we celebrated our public health partners (like MPHA) and the expertise they bring to our collaborative efforts. More likely, it was the snow on the ground and in the air outside my window that made my mind focus on that particular conference. For whatever reason, that MPHA meeting in Duluth 17 years ago was still crystal clear in my mind.

Although it was the middle of May, Lake Superior was still totally covered with ice. The cold wind blowing in from the Big Lake gave no indication that winter’s grip would be loosening any time soon. While the weather wasn’t what the planners had hoped for when they chose Duluth for the annual meeting, it did provide a perfect setting for Ann Bancroft’s keynote address to the conference - her recounting of the American Women’s Expedition (AWE) to the South Pole.

With beautiful slides and poetic language, Ann told the story of how four women with markedly different backgrounds and experiences had come together to challenge themselves and the perceptions of many in attempting to be the first group of women to reach the South Pole.  In describing the struggles of their quest, she shared how it was the differences in the group that made it possible for them to reach their goal.

All of the women were in tremendous physical shape and were seasoned arctic explorers. But each woman also had a special expertise. One was an expert in expedition food which was critically important to each team member who required 5,000 - 6,000 Calories per day over the 3 month trip.  This diet allowed them to pull a 200 pound sled in -70 F temperatures and remain physically and psychologically healthy.

Another was an equipment expert who was challenged by the ice, wind, and cold to keep their equipment working in the most inhospitable environment on the planet. A third was skilled in navigation, an expertise crucial to finding the South Pole in a place where there is no sunrise or sunset, no distinctive landmarks, and where the view in every direction looks exactly the same.

The last set of critical skills belonged to Ann. As the leader of the group, she was the vision keeper. When times were tough and discouraging, she had to remind the team why they were there and why they should continue on. Although each woman with her special skills was critically important for success, keeping the vision of the expedition turned out to be the most important and one of the most difficult tasks to perform.

Ann’s description of the vision surprised most of people in the audience. The vision and goal of the AWE was not personal accomplishment or acclaim or being the first to achieve a difficult feat. Rather, it was education, information gathering, and role modeling. The AWE goal was to be something of value to many people throughout the world (particularly girls), not just to those on the ice. As it turned out, it was this larger vision that sustained the progress of the group and kept them from abandoning their goal at the times when things looked hopeless. Personal goals were insufficient to keep the team going. A larger vision was necessary.

Ann also shared that although there were 4 women on the ice pulling heavy sleds toward the Pole, there was a large but invisible support staff who were just as important to the achievement of the AWE goals. She closed her address with a picture and a description of her feelings on reaching the South Pole. It was a poignant depiction of the power of teamwork aligned with individual determination and a strong support system.

“At the South Pole there actually is a pole with a large reflective ball on the top. As I looked at the ball and saw the reflection of me and the other members of the team, I also saw the thousands of people who supported us financially and emotionally, who followed us at school and on the Internet, who would be using the data we collected, and who would be encouraged to follow their own dreams.  We were just a small part of a very large effort.  Everyone involved was necessary for the AWE to succeed. We worked hard and were an awesome team but without the support and encouragement of people from around the world, we wouldn’t have been there.”

Ann’s captivating and inspirational story was a perfect start to that MPHA meeting and it seems as relevant to this year’s MPHA conference topic and to public health as it was to the conference attendees in 1996.

Although a journey to the South Pole and working for health equity in Minnesota are markedly different activities, they have some remarkable similarities. Both require a dedication to a shared vision that is broader than individual and personal goals and that benefits all of society. Both require a diverse set of skills that can be coordinated and counted on to address unexpected challenges. Both require a team of leaders whose dedication, cooperation, and hard work can inspire and be a role model for the many others who share the vision.  And both require highly visible efforts of some individuals supported by the everyday, behind-the-scenes actions of everyone who longs to achieve the goal.

Our goal is to make Minnesota the healthiest state possible, but the persistence of health disparities is the major barrier to achieving that goal. A “Health in All Policies”⃰ approach will be crucial for Minnesota to achieve health equity on our way to being the healthiest state. However, for that approach to be successful, we will need the engagement of lots of people with multiple skills and expertise. We will need partners whose efforts are well coordinated. We will need teamwork. But most importantly, we will need a vision keeper for health equity. Who will that be? I think it should be us because one of the core principles of public health is social justice – and health equity is a social justice issue.


⃰ Health in All Policies recognizes that health is influenced by many factors outside of health care. From agriculture policy that influences the food on our dinner table to national environmental decisions that put us at risk for disease, every policy, large and small, and every decision, personal and political, ultimately has an impact on health. Policy decisions have played a significant role in creating health disparities and a Health in All Policies approach holds promise for effectively addressing those disparities and creating health equity. No compromise should be reached without analyzing its health footprint, especially on vulnerable populations. From transportation and education to energy and trade, every political decision has a health and health equity cost or benefit - and these costs and benefits should be weighed in every decision. (Adapted from the Aspen Institute.)

Ed

Art, Truthiness, and Public Health Week

Knowing that “More Real?  Art in the Age of Truthiness” was the featured exhibit at the Minneapolis Institute of Arts (MIA), I squeezed in a museum visit following a shorter than expected meeting in the Whittier Neighborhood. Since public health prides itself on being data-driven and evidence-based and since I’m interested in how art can enhance public health, I easily justified this visit during the work day as part of my personal celebration of Public Health Week. 

On the entrance wall to the gallery was the statement:  “Videri quam esse” (“To seem to be, rather than to be.”) For those familiar with Comedy Central, this is the Latin inscription over the fake fireplace on the set of The Colbert Report. That’s when I realized that this exhibit evolved from one of Stephen Colbert’s sketches called “The Word” in which the word “truthiness” was coined. According to Colbert, “truthiness” is what we know with our heart or feel with our gut regardless of the evidence, logic, or facts. In the sketch he disparages books because “they are all facts and no heart…People think with their head but know with their heart.”  They “feel the truth.” 

As I wandered through the exhibit, I was fascinated by photos, paintings, sculptures, videos, and other creations which made the point that the relationship between truth and fiction is often quite murky. I came to learn that this this grey area between reality and fabrication is the realm of “parafiction,” an evolving perspective in the fields of art, literature, and social studies. It didn't take me long to appreciate that public health is also influenced by “parafiction.”

Wearing my public health hat as I viewed the exhibit, I quickly comprehended that one of the challenges that public health is facing is that we are truly living in the “Age of Truthiness – where things we wish to be true are preferred to things we know are true.” As I walked among the art, I began to assemble in my mind the beginnings of a public health parafiction list. 

• We have the best medical care system in the world so, if we just assure universal access to that care, we will be a healthy society.
• Technology has successfully addressed many of our health issues so research will bring us technical solutions to most of our health problems.
• If individuals simply took responsibility for their lifestyle behaviors, our health problems would be resolved.
• An intact family with a mother and father is all we need to have a healthy society.
• Market forces, if allowed to function freely, will help us achieve the Triple Aim of improved population health, lower health care costs, and a better patient experience.
• Government is the problem, not the solution.
• Being the fifth healthiest state in the country is an accurate reflection of the health of all Minnesotans.

At that point I was at the end of the exhibit and had a mind full of questions, feelings, and opinions. Since stimulating these kinds of reactions is part of the reason Art exists, this exhibit was a form of great Art. This is also why Art can be such a powerful public health tool. 

Energized, I chose to view two other minor exhibits being featured in the MIA:  “Picturing Poverty: Artistic Views of the Poor in the Baroque Era” and “The World at Work: Images of Labor and Industry, 1850 to Now.” As I looked at the Art in both of these galleries and saw how the perspective of the artist colored the images of the poor and working classes, I realized that “truthiness” is not a modern concept. When the same scene of poverty or manual labor can be idealized, romanticized, or criticized depending on the artists’ point of view, I began to understand that parafiction is probably part of the human condition. 

As I left the MIA and headed back to work, I thought about Oscar Wilde’s statement that “Life imitates Art far more than Art imitates Life.” After spending a couple of hours viewing “truthiness” in Art in the context of my experiences in public health, I believe Wilde’s statement should replace “far more than” with “and.” Art and life are synergistic. They feed off each other, influence each other, and ultimately create something new. 

Our job in public health is to continue to search for the truth and link that truth to the life experiences of real people. The real challenge is to not let our focus be narrowed by our opinions or ideology or even our specialized scientific expertise but be expansive enough to bring in alternative perspectives that may offer a whole gallery of different ideas. 

In this “Age of Truthiness” we need to be advocates for truth but we also need to be humble in our advocacy and understand that truth and public health are not static and not the sole domain of one agency or profession. As Thomas Merton said in his “Dialogue with the enemy,” “The basic falsehood is the lie that we are totally dedicated to truth, and that we can remain dedicated to truth in a manner that is at the same time honest and exclusive: that we have the monopoly of all truth, just as our adversary of the moment has the monopoly ...of all error.”

Public health is “the constant redefinition of the unacceptable.” In that task we need data, information, and experiences to lead us to the truth. And we need an open and skeptical mind as to what is truth. That’s what makes public health so fascinating and important because as John Keats said in “Ode On a Grecian Urn,” “ ‘Beauty is truth, truth beauty,’ – that is all Ye know on earth, and all ye need to know.” 

Ed

Follow-up of my DC trip

Greetings,

After the debacle of “Snowquester” had passed, Washingtonians were feeling quite sheepish about shutting down the federal government for a non-event. Because of that, they were very accommodating to out-of-town visitors whose schedules had been needlessly disrupted so I had little difficulty rescheduling all my “Hill visits” for the following day.

Well stocked with talking points, charts and graphs, and “leave behinds,” I headed for Capitol Hill and a day of visiting members of the Minnesota Congressional delegation. As I met with members of Congress and their staffs in the Hart Senate Office Building or the Longworth or Rayburn House Office Buildings, the conversations generally focused on the need, despite budget deficits, to support basic public health infrastructure for the long-term benefit of our state and country. Specific discussions also occurred around the Public Health and Health Services Block Grant (something MDH has received since 1981 to support state and local public health services throughout Minnesota), the Prevention and Public Health Fund (part of the Affordable Care Act that funds Community Transformation Grants, quality improvement efforts, and environmental public health tracking, among others), Section 317 Immunization grants, and several more. However, as important as these issues are, most of the conversation revolved around Sequestration which had just gone into effect six days earlier.

There seemed to be consensus that Sequestration was not a good tool for making budget cuts, yet there was also consensus that it wouldn’t get resolved quickly. A great deal of blame and hostility was evident on both sides of the political aisle. Recognizing the animosity and divide between the two political parties, I left the Hill discouraged because it is obvious that the effort needed to sustain an effective public health system is going to be long and difficult.

On my way back to the hotel I saw a week-old sign in a bookstore touting the birthday of Theodor Seuss Geisel. [His birthday (3/2/1904) was the day after the Sequester began.] The day’s experiences made me immediately think of one of my favorite Dr. Seuss books, The Butter Battle Book, which begins:

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

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

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

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

While the nuclear arms race was the basis of that story, Dr. Seuss could just as easily have used Sequestration or health care reform as his inspiration because, in Washington and throughout the country, people are using their Boom Blitzers, Blue Gooers, and Big-Boy Boomeroos to throw invectives at those who think differently than they do about deficit reduction and health care reform.

And what has this gotten us – a stalemate on most issues that affect the health and quality of life of everyone in our country and mutually assured destruction of anyone who tries to collaborate or compromise. Ironically, as Dr. Seuss clearly points out, what most people want is exactly the same – their bread and butter issues are similar. Most public health issues (safe food and water, safe and healthy environments, control of infectious diseases, healthy people at all ages, etc.), are bread and butter issues. Whether the butter is up or down, they shouldn’t be partisan issues.

As I continued on my cab ride, I wondered what it would take to get away from our current polarization on seemingly every issue of importance to our overall health. How could the voice of reason be heard among policy makers so they could come together and collaboratively develop rational health policies? It was then that it dawned on me that I wasn’t the only person from Minnesota visiting our congressional delegation on that day. At every office I saw Minnesotans raising their voices as they advocated for expanded bicycle use, affordable housing, women’s health, improved nutrition, expanded wetlands, and better health professional training in human and animal health. And these were just the ones I talked with in the waiting rooms. I’m sure there were many more throughout the day.

It was then that I realized the answer to my question also resided in another of my favorite Dr. Seuss stories, Horton Hears a Who.

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

I hope my voice will help make a difference. That’s why I took the time to go to Washington. But I do know that my voice combined with your voice and those of our neighbors, family, and colleagues will certainly make a difference. For the collective good of our society, every voice is needed and every voice counts. For democracy to be effective it needs to be noisy. So, use your voice for public health and make some noise.

Ed

Greetings from D.C.

In the midst of Tuesday’s snow, I flew out of Minneapolis to attend the ASTHO (Association of State and Territorial Health Officials) board meeting and Day on the Hill in Washington D.C. My flight was delayed so I missed the morning meetings with the Assistant Secretary for Preparedness and Response, OMB Director for Health, and the Assistant to the President for Homeland Security. I was disappointed not only because I couldn’t meet with these folks but because I had never been in the Eisenhower Executive Office Building. My security clearance was for naught. Perhaps next year.

However, I was able to meet with the majority staff for the Senate Labor-HHS Appropriations Committee, and the majority staff for the House Labor-HHS Appropriations Committee. The two meetings were markedly different. Although both meetings focused on sequestration and the impact it would have on public health, the discussion in the Senate meeting was much more about the long-term strategy to protect and enhance public health. The House meeting discussion was much more about increasing efficiency, reducing duplication, and lowering spending. It was obvious that the 2 chambers have different agendas. Regardless of their differences, the bottom line in both meetings was that the next couple of years are going to be difficult ones for public health.

Of note with the Senate staffer was the discussion about Iowa Senator Harkin, who is on the Appropriations Committee and chairs the Health, Education, Labor, and Pensions Committee.  Senator Harkin has been a champion of public health and particularly the Community Transformation Grants and services to people with disabilities. He will not be running for reelection so the question was asked what he would be working on for the next two years. Besides specific public health issues, it was mentioned that he would be mentoring other Senators to take on leadership roles around public health. Of interest to those of us in Minnesota, Senator Al Franken’s name came up as someone who is being groomed to deal with chronic diseases.

This morning I woke up to the news that the federal government was closed because of the forecast of the biggest snowstorm of the season. Because of that, all my Hill visits were cancelled. Fortunately, we were able to hold the ASTHO board meeting today and I was able to reschedule all my Hill visits for Thursday. The irony in all of the weather drama was that there was no snow accumulation in D.C. all day. The temperature remained in the high 30s and the precipitation went back and forth between snow and rain. It was strange to have the federal government shut down because of snow when there was no snow. I hope tomorrow brings less drama.

Part of the ASTHO board agenda was honoring Mary Selecky one of its long-term members who will be retiring in the next couple of months. Mary has been the Secretary of Health for the State of Washington since 1999 and has served three governors. Her tenure is quite unusual. From what I’ve been told, the average tenure of a SHO is between 18 and 24 months. Since this was Mary’s last Board meeting, a surprise celebration party was held for her on Wednesday night. Many public health big-wigs showed up and said wonderful things about Mary. She has played a huge role in public health in the state of Washington and nationally. Most impressive, at least to me, was how she nurtured talent. She has been a mentor, supporter, and role model for hundreds of public health leaders throughout the country, including me. I think that will be one of her greatest legacies.

In talking about her entrance into public health and what has guided her throughout her career, she mentioned that as a child whenever she and her siblings complained about the chores they were required to do, her dad would recite the Henry Wadsworth Longfellow poem “A Psalm of Life.” The message she got from the poem and from her father was “don’t complain – do something to make the world better.” She then recited the following stanzas of the poem:

Life is real! Life is earnest!
And the grave is not its goal;
Dust thou art, to dust returnest,
Was not spoken of the soul.
Not enjoyment, and not sorrow,
Is our destined end or way;
But to act, that each to-morrow
Find us farther than to-day.
Lives of great men all remind us
We can make our lives sublime,
And, departing, leave behind us
Footprints on the sands of time;
Footprints, that perhaps another,
Sailing o'er life's solemn main,
A forlorn and shipwrecked brother,
Seeing, shall take heart again.
Let us, then, be up and doing,
With a heart for any fate;
Still achieving, still pursuing,
Learn to labor and to wait.

There were lots of misty eyes in the room when she finished. I also sensed that there was a renewed resolve among all present to follow Mary’s example and not let the problems of sequester and inadequate investment derail our public health efforts. Instead, I felt a new resolve in the group to “be up and doing” for the sake of the people we serve. Still, most of us acknowledged that, given our short tenure as SHOs, it is difficult to “Learn…to wait.”

Ed

Heritage Trail of Public Health

Greetings,

At the eastern edge of downtown Minneapolis, the Mississippi River Heritage Trail leads past some of the most important historical structures in Minnesota. At strategic points along the path, informational kiosks are provided to point out these structures and to highlight some of the significant events that occurred in the area. As I walked part of the Heritage Trail this weekend, I was struck by the numerous evolutionary (and sometimes revolutionary) changes that have occurred along this short stretch of river. Hiking the Heritage Trail was like taking a short course in the socioeconomic history of Minnesota.

The crown jewel of the Trail is the beautiful Stone Arch Bridge which was built by James J. Hill to allow expansion of his railroad empire into new territories. However, with the declining importance of the railroad in the country’s transportation system, the bridge became superfluous and stood idle and unused for many years. Twenty years ago it was refurbished to provide bicyclists and pedestrians access to both sides of the river and the historical treasures located there.

The rise and decline of the lumber industry is chronicled along the east side of the river. Spurred on by a bountiful supply of timber from the north woods and the easily accessible energy created by St. Anthony Falls, the Minneapolis lumber industry flourished and great fortunes were made until the supply of trees was depleted. In a relatively short period of time, Minneapolis went from being the leading producer of wood products to being a mere historical note in the evolution of the forest products industry.

The kiosks on the west bank of the river record the evolution of the flour industry in the area. They point out the flour mills of Pillsbury, General Mills, and the Washburn Crosby Company that made Minneapolis the center of flour trade in this county. They particularly note the building that, at one point in time, was the world’s largest producer of wooden flour barrels. Also noted is the fact that the barrel company went out of business four years after reaching that pinnacle; cloth flour sacks were invented and the market for flour barrels disappeared almost overnight. 

The final link in the Heritage Trail is the Hennepin Avenue Bridge. While providing thousands of cars daily access to the state’s largest city, the bridge also provides pedestrian access to the city’s earliest history. Because of the bridge, someone can travel from the oldest to the newest buildings in the city in just a few hundred paces. As I took those paces, I paused to watch the water of the Mississippi River flow under the bridge. The constantly flowing and ever-changing river reinforced the message that I had slowly assimilated during my brief walk along the Heritage Trail - the message that change is an integral and unavoidable part of our existence.  It is part of our history, it is part of our present, and it will be a part of our future.

Nowhere is that change more evident than in the field of public health where, on a daily basis, we see the emergence of new problems like fungal meningitis, ehrlichiosis, type 2 diabetes in children, and Alzheimer’s disease among others. At the same time, we are faced with budget deficits, the implementation of the Affordable Care Act, and discussions about the role of government in health; all of which greatly impact and change what we do.  

As we work our way through the 2013 legislative session, I wonder how we, as a state, will respond to these challenges. Will we be like the Stone Arch Bridge - a symbol of a vision limited to being a “railroad” and not a “transportation” industry? Will we be like the lumber industry that uses up all existing resources, leaving ourselves no support for the future? Will we be like the flour barrel company that couldn’t meet the challenge of a better and more efficient way of delivering a product? Or will we be like the Hennepin Avenue Bridge with a longer term vision that links the past with the present and is periodically refurbished so that it can continue doing important tasks well into the future? And can we be like the Mississippi River which fluidly responds to all the forces on all sides while continuing to set its own steady course to the sea? 

Long range planning and having a vision for the future we would like to create is vitally important but how we prepare ourselves to respond to the unpredictable and immediate outside forces is just as important. Although many of these forces are beyond our control, our responses are not.  How we respond will be part of our Heritage Trail linking our present with both our past and future. I am confident that at MDH we can embrace and integrate both a short and long-term vision of public health and effectively articulate that vision to state policy makers. Because of that, I look forward to walking with you down that Heritage Trail of Public Health with smiles on our faces while creating smiles on the faces of all Minnesotans as we go.

Ed