Wednesday, August 17, 2016

Creating the Good Life in Minnesota August 13, 1973 to August 13, 2016 - Reflections on Wendell Anderson (1933-2016)

(The funeral for Governor Wendell Anderson was held on 8/15/16. A version of this note was published in MinnPost on 8/10/16.)

As a young doctor driving from Pennsylvania to my National Health Service Corps assignment in Montana, I stopped to get gas in Alexandria, Minnesota. Although I had never considered Minnesota as a place to live, the iconic image of Wendell Anderson on the August 13, 1973 cover of Time magazine proclaiming “The Good Life in Minnesota” prompted me to purchase a copy, which I still have today.

The values behind that promise of the good life brought me permanently to Minnesota seven years after that Time article was published, kept me here for 36 years, and guide my efforts as commissioner of health.

Governor Anderson’s vision captured in that cover story remain relevant today. During the past six years, I have frequently referred to it in speeches and use it as the “North Star” for what we must do as Minnesotans to address our health challenges.

What stood out for the Time article’s author was Minnesota’s “civility and fairness, courtesy, honesty, a capacity for innovation, hard work, intellectual adventure and responsibility.” In support of that he mentioned there is “…a deep grain of sobriety and hard work, a near-worship for education and a high civil tradition in Minnesota life.”

Community leaders quoted in the article focused on the ability of Minnesotans, despite a great variety of opinions and immigrant backgrounds, to engage in political activity and form coalitions that could further the people’s will.

It was this latter point that most impressed the author. “Part of Minnesota’s secret lies in peoples’ extraordinary civic interest. The business community’s social conscience…is reflected in annual reports: most of them carry a section called ‘Social Concerns.’…Minnesotans tend to be participants in their communities, perhaps because for so long they were comparatively isolated and developed traditions of mutual reliance. Citizens’ lobbies are a real force.”

In the reception room after Governor Mark Dayton’s 2015 State of the State Address, I had a chance to talk with Governor Anderson about that 1973 article. I asked him, “What created the good life in Minnesota?” Without hesitation he responded, “The article accurately captured most of what we were doing. But two things stand out. First, we had a social conscience that led us to invest in the common good; things that benefit everyone, like education. Second, we cooperated. We didn’t always agree, but we cooperated and compromised. That’s an approach I wish was embraced today.”

Governor Anderson helped make some wise public investments 40-plus years ago that are still paying dividends today. I contend that Minnesota is a healthy state today mostly because of those investments. Governor Anderson helped set a tone of “civility and fairness; intellectual adventure and responsibility; a lot of mutual trust; social conscience; and extraordinary civic interest” that helped build a foundation which created “The Good Life in Minnesota.”

For the sake of those generations who follow us, our challenge is to build on that foundation to create an even Better Life in Minnesota. That will take a social conscience, a sense of the common good and a level of civic engagement that sometimes seems antiquated and in short supply these days. My hope is that the spirit of Wendell Anderson resurrects those values and helps us cooperatively build a better Minnesota – one that assures a good life for every Minnesotan.


Monday, June 27, 2016

Capitalism and Democracy: Shaping the American Enterprise and Our Health

One faces the future with one's past. Pearl S. Buck (born 6/26/1892)

The Smithsonian’s National Museum of American History has assembled a major exhibition on the “American Enterprise,” which “…chronicles the tumultuous interaction of capitalism and democracy that resulted in the continual remaking of American business—and American life.”

I visited the exhibit just after being part of a Congressional Briefing on health equity where I made the point that the dominant worldview in the United States has led to policies and systems that systematically disadvantage some population groups while advantaging others; contributing to health inequities. Using the Triple Aim of Health Equity as the framework, I challenged congressional leaders to embrace a worldview that is based on community good and social justice rather than on individual needs and market justice. It was with that mindset that I entered the “American Enterprise” exhibition.

From the first to the last display I saw contrasting and conflicting worldviews impacting not just our health but the evolution of American business and democracy. During the “Merchant Era” (1770 - 1850s) when there was abundant land and vast natural resources fueling economic opportunities, the population was mostly rural. During that time, Thomas Jefferson saw the future optimally tied to farming, not factory work, while Alexander Hamilton favored an economy based on industry.

Those differing perspectives have persisted throughout the development and evolution of our economy and society. In the “Corporate Era” (1860s – 1930s) industrialization and business expansion brought major economic growth and social change to the United States, including massive immigration, financial crises, and labor/management confrontations. Business and political leaders “disagreed over the power of big business and whether it endangered the balance between private gain and common good.”

Industrialist Andrew Carnegie argued that competition was good for the country, while Supreme Court Justice Louis Brandeis was concerned that the rights of common citizens would be abridged by the wealthy few. Likewise, President Theodore Roosevelt championed the government’s role in controlling the negative aspects of unbridled big business. In anticipation of a more interdependent world, President Woodrow Wilson suggested the ideal of social responsibility and social cohesion.

In the “Consumer Era” (1940s – 1970s) “production boomed and consumerism shaped the American marketplace. Innovations in technology, expansion of white-collar jobs, more credit, and new groups of consumers fueled prosperity. Business and political leaders claimed consumerism was more than shopping: it defined the benefits of capitalism. This era marked a high point of American productivity and a high standard of living. But it ended with many Americans questioning the promises of consumer capitalism.”

Contrasting worldviews became starker during this time. Economist John Kenneth Galbraith opined that an unregulated marketplace resulted in “private opulence and public squalor.” Philosopher Ayn Rand contended that individuals thrive best in a free and unregulated marketplace. Labor and civil rights leader A. Philip Randolph argued that equality of opportunity could not be left to the marketplace.

In the “Global Era” (1980s – present) the pace of change has rapidly accelerated. Computers, smart devices, and “big data” have affected all aspects of life. There is increased global interdependence expanding markets and opportunities for some while eliminating traditional stability, employment, and safeguards for others.

While some of the debate around the role of government and free enterprise has existed since the founding of our country, the debate now has global ramifications. Economist Milton Friedman advocated for a limited role for government in the American economy while Secretary of Labor Robert Reich argued that access to opportunity was the right of all American citizens.

After two hours in the “American Enterprise” I was acutely aware that the differing worldviews that have jousted with each other over our economy also impact health. Given that socio-economic conditions are the greatest determinants of health, that wasn’t a surprise but I had never seen it articulated so clearly. I also realized that there is no “best” or “perfect” worldview. Every worldview by itself is inadequate for developing the policies and systems needed for everyone to thrive. That’s why the debate that has been going on in this country for 240 years is so crucial. That’s also why it’s essential for those of us in public health, who have a worldview that embraces advancing health equity and optimal health for all, need to be engaged in the debate.  And that’s why the questions that we have framed around the Triple Aim of Health Equity need to be part of every conversation:

Who is at the decision/policy-making table, and who is not?
Who is being held accountable and to whom?
What are the health and equity implications of any decision?
Who is benefiting and who is left out?
What values/worldviews underlie the decision-making process?

As I headed back to my hotel, I wondered how this museum visit would influence the speech that I was to give in five days at the Minnesota Rural Health Conference. The tension between capitalism/economy and democracy/community seemed like a theme to be explored especially as it relates to rural communities. Those tensions reminded me of a statement in "Racism and the Economy" by farmer, poet, and essayist, Wendell Berry – a statement that ultimately framed my speech: “Cultivating Health Equity and Optimal Health for All In Resilient Rural Communities – How the Dominant Worldview of Society Impacts Health.”

“A proper community, we should remember also, is a commonwealth: a place, a resource, an economy. It answers the needs, practical as well as social and spiritual, of its members - among them the need to need one another. The answer to the present alignment of political power with wealth is the restoration of the identity of community and economy."


Tuesday, May 31, 2016

Sisyphus, Higher Fidelity, and the Work of Public Health

As president of the Association of State and Territorial Health Officials (ASTHO), I’ve had multiple opportunities over the past year to travel to Washington DC to meet with congressional leaders and federal agency heads to advocate for enhanced support for public health and the advancement of sound public health policies. Whenever I’m there, I get a strange sense of déjà vu.

For the 36 years I’ve been in public health, we’ve been asking for the same things over and over again: increase investments in prevention, move “upstream” on issues, take a long-range perspective, address health disparities and advance health equity, focus on social determinants of health, build a strong public health infrastructure at all levels of government, and reform our healthcare system (to name just a few). But the only things that seems to change are the people doing the advocating. In my ASTHO role, it’s now my turn.

These efforts often make me feel like the protagonist in the Myth of Sisyphus. In his 1942 essay on this myth, Albert Camus wrote “The gods had condemned Sisyphus to ceaselessly rolling a rock to the top of a mountain, whence the stone would fall back of its own weight. They had thought with some reason that there is no more dreadful punishment than futile and hopeless labor.”

Many of us in public health feel like we are in the Sisyphus Business. And in many ways we are. Each year we are confronted with a cohort of 68,000 plus infants born in our state who will be facing many of the same problems as the previous cohort and numerous cohorts before that. Recurrent episodes of infectious diseases, sexual violence, suicides, alcohol and other drug problems, motor vehicle deaths, and natural disasters require us to repeat our public health “best practices” over and over and over again. Just like Sisyphus.

This never-ending struggle made me think of the legend of a couple of individuals who had passionately dedicated their long public health careers to improving the healthcare and public health systems in this country. They happened to die on the same day (and of course they went to heaven – they were public health workers after all). When they got to the Pearly Gates, God was waiting for them. The very first question they asked God was, “Will the United States ever implement a single-payer healthcare system and increase its investment in public health?” And God replied, “Yes, but not in my lifetime.”

The reality of our existence is that there will always be problems to be solved and challenges to be addressed. Some of those issues will be recurrent and, in our rapidly evolving world, many will be new. But all will require our attention, our persistence, and our patience because we will never achieve the utopia toward which we are all working. But it’s the work toward that goal that’s important.

Camus ended his essay about Sisyphus by saying, “I leave Sisyphus at the foot of the mountain! One always finds one's burden again. But Sisyphus teaches the higher fidelity that negates the gods and raises rocks. He too concludes that all is well. This universe henceforth without a master seems to him neither sterile nor futile. Each atom of that stone, each mineral flake of that night filled mountain, in itself forms a world. The struggle itself toward the heights is enough to fill a man's heart. One must imagine Sisyphus happy.”

Camus imaged Sisyphus happy and fulfilled because he was focused on the greater good, the higher fidelity. He was comfortable with the fact that his role in the larger scheme of life was to “struggle toward the heights.” That’s what drove the brave mythical Greek to continue his work day after day.

In our reality, every atom, every mineral flake of our public health work is important and necessary even if it often seems repetitious and futile. That’s why I hope that we can embrace the “struggle itself toward the heights” of assuring the conditions in which all people can be healthy as the higher fidelity vision that fills our hearts and keeps us pushing the public health rock up the hill. I’ll embrace that image of a happy Sisyphus as I optimistically continue to do the higher fidelity work. I hope you will too.

Rock on.


Monday, May 2, 2016

When learners become leaders for health equity

“The physician’s function is fast becoming social and preventive, rather than individual and curative…Directly or indirectly, disease has been found to depend largely on unpropitious environments…(which) are matters for ‘social regulation,’ and doctors have the duty to promote social conditions that conduce to physical well-being.” Abraham Flexner, 1910

While working at the Minneapolis Health Department in the 1980s and early 1990s, I staffed an evening pediatric clinic for Southeast Asian refugees at the Hennepin County Medical Center (HCMC) with Sherry Muret-Wagstaff, a wonderful nurse practitioner. In addition to caring for multiple medical issues, our interdisciplinary team addressed the myriad economic, social, and cultural issues confronting our patients and impacting their health. Occasionally, our clinic team would be augmented by a medical student interested in refugee or global health.

In 1989, in the midst of a major measles outbreak, medical student Joia Mukherjee joined our team. Even though she was in the early stages of her medical education, she had a remarkably clear understanding that health was much broader than just clinical care and she helped us identify and address the barriers to measles immunizations for our patients. It was obvious that she had a social justice perspective and a passion for addressing the conditions that impact health. At that time, I wondered how she would use her talents but was confident they would be used well.

I hadn’t seen Joia since our work on the measles outbreak until this weekend when she was a featured speaker at the “Reimagining Social Medicine” conference at the University of Minnesota. She is now the Medical Director of Partners in Health, a multi-faceted international medical non-profit found by Dr. Paul Farmer. The title of her presentation was “Disrupting the Status Quo: Moving Towards Health Equity and the Role of Social Medicine.” Watching Joia at Northrop Auditorium, it was evident that her understanding about what creates health has become even clearer and that her passion for social justice has grown.

She underscored the fact that “We cannot educate the victims of social inequality out of their problems. We need collective action on many levels.” Using the story of “Stone Soup” as the vehicle, she helped the audience understand that “medical care is just the carrots.” Much more is needed to make a rich and healthy soup; including (among many other ingredients) the potatoes of economic development, the meat of peace and safety, the celery of an equitable justice system, the beans of good sanitation, the salt of education, and the water of social cohesion. All in the pot of community. Her story was a vivid illumination of the Triple Aim of Health Equity and a reminder that it took an entire community to make the Stone Soup.

Even though Joia dislikes the term “social determinants of health” because that “sounds so fixed and unchangeable,” she did acknowledge that these conditions are impacted by the distribution of money, power, social policies, and politics and that they can be changed, though not easily. She underscored for the audience “that people with privilege and power have the obligation to speak the truth because the poor and dispossessed have a difficult time being heard when they speak the truth.”

Dr Mukherjee graciously acknowledged that her time with us at HCMC was an “important cornerstone in her formation” in Social Medicine. However, as one of her teachers, it was evident that she had progressed far beyond whatever we provided for her.

Joia ended her talk with an acapella version of “Give Light and People Will Find a Way.” As she led the audience in singing “Listen deeply, Walk together, Seek justice, Be brave, and People Will Find a Way,” I had tears in my eyes. The learner had become a powerful and inspirational leader. That gives me hope that there are more leaders in our midst learning from us every day and we will find a way to achieve health equity.


Wednesday, March 30, 2016

National Doctors' Day

Today is National Doctors’ Day, “a day to celebrate the contribution of physicians who serve our country by caring for its' citizens.” Surveys show that Americans love their own physicians and appreciate the great care they receive even as they acknowledge that our medical system doesn't always work as well as it should. Because clinical care accounts for only about 10% of our health yet absorbs 95% of our health resources, some critics have concluded that our clinical care system (personified in physicians) is more of a deterrent than a contributor to our overall health. Fortunately, that view is in the minority because a high quality healthcare system is essential in maximizing the health and well-being of our society. Without excellent clinical care people would be dying sooner than they should, injuries and pain would be debilitating, and quality of life would be diminished.  Certainly, our healthcare system has some major flaws but our work should be to diminish its deficiencies and increase its effectiveness.
However, medical care alone can’t make us healthy. We need a broader approach to health which focuses on creating the conditions in which people can be healthy.  That task is the responsibility of everyone in our society as we work to create the policies, systems, and economic and social environments that give everyone the opportunity to be healthy. Included in that approach is building a robust and high quality public health system that can respond to the needs of our rapidly changing society. And that public health system needs to be integrated with our clinical care systems so that we have a continuum of protection, prevention, promotion, treatment, and rehabilitation services. And who better to help with that integration than physicians who can bridge the divide between treatment and prevention? 
Even though many believe that the idea of the “integration of medical care and public health” is a new concept, those who know the history of medical care and public health realize that a better term would be “re-integration” because at its foundation, health care has always been about both treatment and prevention. The oath created by Hippocrates, the Father of Medicine, that many physicians take as they enter the field of medicine states: “I swear by Apollo, the healer, Asclepius, Hygeia, and Panacea…” Asclepius is the god of medicine, Hygeia the goddess of public health, and Panacea the goddess of universal health. Thus, physicians take an oath to heal, treat, and prevent for the betterment of all. I can’t imagine a better and more time-tested statement of integration than this.
More recently, “Medscape,” an on-line resource for physicians, listed the most influential physicians of all time.  Hippocrates was on that list. So were the following:
  • John Snow, the founding father of epidemiology, who identified the source of cholera which led to a better understanding of disease transmission,
  • Louis Pasteur who was influential in understanding the “germ theory” of disease, developing pasteurization, and the development of vaccines,
  • Edward Jenner, the first person to deliberately use vaccination to control and eventually eliminate an infectious disease,
  • Robert Koch who discovered the cause of tuberculosis, cholera, and anthrax and designed a way to establish a causative relationship between a microbe and a disease,
  • Jonas Salk who created the first polio vaccine,
  • Benjamin Spock who underscored the importance of parenting and child development,
  • Cicely D. Williams who highlighted the importance of nutrition and education in the prevention of childhood diseases,
  • David L. Sackett who advocated for evidence-based and data-driven medicine,
  • Elizabeth Blackwell, the first woman in the U.S. to become a physician and who confronted discrimination throughout her life and helped train subsequent generations of women in the practice of medicine,
  • George Papanicolaou who developed a screening test for cervical cancer,
  • Ibn Sina/Avicenna who founded the field of preventive medicine, and
  • Ignaz Semmelweis who used vigorous statistical methodologies to demonstrate how the simple act of handwashing dramatically lowered death rates after childbirth.
All of these physicians embraced public health principles in their practice and impacted the health of people far beyond those they saw in a clinical setting. They were giants in their field because they embraced a broader vision of what a physician could and should do to help their individual patients and all of humanity. They modeled what Rudolf Virchow, the father of social medicine, said about becoming a physician: “Medical education does not exist to teach individuals how to make a living, but to empower them to protect the health of the public.”
Virchow was also prescient in his statements about health equity and health in all policies. “Medicine is a social science, and politics is nothing else but medicine on a large scale.”  The physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction.”  I think Virchow would have fit in well at MDH.
Finally, Charles Nathaniel Hewitt, the physician who founded the Minnesota Department of Health, spoke succinctly about the need for the integration of medicine and public health. “Prevention first, cure if you must; capacity to do in both directions.”
Without diminishing the contributions of doctors who focus on treatment of injuries and diseases, my heroes in medicine are those who took Dr. Hewitt’s admonition to heart and who embraced both treatment and prevention in protecting and improving health. Those are the colleagues I will commemorate and celebrate today on “National Doctors’ Day” because they have worked hard “to serve our country by caring for its' citizens.” Please join me in celebrating the physicians who are with us every day on the frontline of public health!

Friday, March 25, 2016

World TB Day and Health Equity Postulates

Today is World TB Day – an event that occurs every March 24th to commemorate the day in 1882 when Prussian Physician Robert Heinrich Herman Koch discovered the bacillus that causes TB. For this discovery he won the 1905 Nobel Prize.
Probably as important as his work on tuberculosis are Koch's Postulates, four criteria used to establish a causative relationship between a micro-organism and a disease. The postulates embody the four criteria required to establish that an organism is the cause of a disease. According to the Koch Postulates, to be determined as the cause of a disease, an organism must be:
  • Found in all cases of the disease examined.
  • Isolated from a diseased host and prepared and maintained in a pure culture.
  • Capable of producing the original infection, even after several generations in culture.
  • Retrievable from an inoculated diseased experimental host and identified in culture as being identical to the original causative agent.
By using his postulates, Koch's pupils found the organisms responsible for diphtheria, typhoid, pneumonia, gonorrhea, meningitis, leprosy, bubonic plague, tetanus, and syphilis, among others. Koch’s Postulates have had a huge impact on health care and society.
As I thought about Koch’s Postulates and how they verified links between an infectious agents and diseases, I realized that we lack similar postulates for verifying links between some of our current health issues and their causative agents. Specifically, we lack the consensus criteria that could be used to evaluate the policies, systems, and activities that lead to health disparities and inequities.
To correct that deficiency, I will riff off of Robert Koch’s ideas and posit some Health Inequity Postulates. To establish that a policy, system, or activity is the cause of a health inequity, it must be:
  • Found to systematically disadvantage some populations while advantaging others.
  • Present in an affected/disadvantaged community and maintained by the political, social, and economic culture.
  • Capable of producing inequities generation after generation.
  • Identified as associated with disparate and negative outcomes in community after community regardless of time or geography.
In creating this list of postulates it became obvious that health inequities are much more complex than infectious diseases and require more than four postulates to determine causal links. I also realized that unlike infectious agents that cause disease, policies, systems, and activities can have both positive and negative impacts on factors related to health equity.
Given that our departmental efforts have focused on Advancing Health Equity, here are some Health Equity Postulates for consideration. To establish that a policy, system, or activity is advancing health equity it must:
  • Use the improvement of the health of everyone within a population or community as the ultimate measure of success.
  • Focus on the health of communities.
  • Embrace community engagement and ownership.
  • Be built on partnerships and shared power.
  • Recognize individual rights and responsibilities and societal responsibilities.
  • Include recognition of historical and cultural backgrounds and influences.
  • Be based on sound science not ideology.
  • Incorporate the physical, emotional, spiritual, environmental, social, and economic determinants of health.
  • Have both a short-term and long-term perspective.
  • Be socially responsible.
  • Be socially just – it must help meet the basic needs of everyone and no one benefits at the expense of others.

In accepting his Nobel Prize, Robert Koch stated: “If my efforts have led to greater success than usual, this is due, I believe, to the fact that during my wanderings in the field of medicine, I have strayed onto paths where the gold was still lying by the wayside. It takes a little luck to be able to distinguish gold from dross, but that is all.”
What I’ve outlined is just a start to what needs to be a more comprehensive list of Health Equity Postulates. I’d be interested in any postulates that you might add to that list. What gold is lying for us to discover along our path to health equity?


Monday, March 14, 2016

Colonialism and the Health of the Public

Having an unscheduled hour during my annual visit with members of our Congressional delegation, I stopped at the U.S. Capitol Visitor Center. In the House of Representatives section of the center, the point was made that its existence was in response to the fact that colonial Americans had been upset about taxation without representation. When ruled by Great Britain, they were angered about how wealth was being appropriated and removed from their communities. They wanted to be involved in decisions that affected them. Yet, that wasn’t happening in colonial America because Great Britain held all the power. And that differential in power was negatively impacting their lives and their communities.
I suddenly realized that the word colony is not just a romantic and neutral historical term – it is actually an emotionally charged economic and political term. Colonialism is about the acquisition, exploitation, and expansion of power in a conquered territory. It’s about unequal relationships between a colonial power and the colony.
Since many of today’s health disparities are due to policies developed in circumstances of unequal power, I began to wonder if the principles of colonialism still exist in the United States. Immediately, the idea of “data colonialism” came to mind. This was a term that was introduced to me by the director of the Minneapolis Urban Coalition 30 years ago. He argued that too often data were mined and removed from the community leaving the community with nothing. Data are a resource that too often benefit the researcher and not the community. He was an early advocate for community-led research and community-owned data in advancing health equity.
At that point, I remembered the Health Impact Assessment (HIA) on Payday Lending that was going to be released on Sunday, March 13. I had read the draft report several weeks earlier and was struck by the devastating impacts of payday lending on low-income communities, particularly communities of color and American Indians. As I studied the displays in the Visitor Center, I realized that colonialism is at the core of payday lending. Payday lending takes resources out of a community and the community is left impoverished. And the poverty is not just about economics – poorer health is also a consequence. Payday lending is a public health issue constructed on the mentality of colonialism.
A payday loan is a short-term loan from an institution that is licensed only to lend but not to accept deposits like banks or credit unions. Payday loan repayment plus interest and fees is required in full, typically about two weeks after the loan is secured.
There were virtually no payday loan stores in the United States until bank deregulation in the 1990s. Before deregulation, locally and community controlled banking systems, such as credit unions and savings and loans helped meet needs of the public. After deregulation, these institutions could no longer compete with the larger, more diversified, and better-funded financial institutions. Today, there are essentially two forms of banking: regulated and insured mainstream banks (few of which are located in low-income communities) and less regulated alternative financial institutions, such as payday lenders and check-cashing outlets, for the poor. The payday lending industry nationally has grown from about $8 billion in 1999 to around $50 billion in 2004.
In Minnesota in 2014 there were 72 payday lenders with the vast majority located in low-income communities. Statewide, these institutions made more than 385,000 loans to about 50,000 borrowers with loans totaling almost $150 million. Most payday loans are made by two national companies. The average loan amount in Minnesota is $390, with borrowers averaging 10 loan transactions a year (new loans are taken out to pay the high interest of previous loans) with an average annual percentage rate (APR) of 252%. Between 1999 and 2014, payday loan fees and interest drained more than $110 million from communities statewide – more than $13 million in 2012 alone.
The HIA notes that “Payday loans contribute to racial/ethnic health inequities by decreasing income, increasing poverty, and making it nearly impossible to build wealth for low- and moderate-income people and people of color…they exacerbate financial insecurity for those who already lack adequate income, are fighting poverty and debt, and are not able to build wealth…Income, poverty, and wealth are key determinants of health and well-being.” Payday lending is a public health issue.
As I left the Capitol Visitor Center, thoughts of colonialism were swirling around in my mind. I wondered how history would have changed if colonialism had not been the basis of economic policy decisions 240 years ago; would a revolution have been averted? I also thought about the policies of today that sustain various forms of colonialism and the impact they have on the disparities that are affecting our communities. I wondered if policies to eliminate credit colonialism manifested in payday lending would help move us toward health equity. I believe the response is yes and that provided a different perspective to my subsequent visits with policy makers.