Tuesday, December 5, 2017

A Note to the Commissioner from MDH Staff

Yesterday, I received a note requesting that I send the following message to all MDH staff. It relates to the passing of my wife, Sally. I was initially hesitant to send it because my experience of losing a loved one, is no different than the personal losses that many of you have faced. But, as I considered the “bold request” from an MDH staff person, I realized it contained a message from my wife that’s important for all of us to hear. Because of that, I humbly share it with you. My wife was a remarkable woman who enriched my life and the lives of many who encountered her. May the light that she brought to the world continue to shine through all of us.


Dear Colleagues,

Usually these messages come from the Commissioner to the staff, but by its nature this one comes from an MDH staffer on behalf of the rest of us and goes to the Commissioner.

You may have seen the note last week indicating that Sally Ehlinger died. Most of us did not know her because she has been incapacitated the entire time that Dr Ehlinger has been at MDH. The Commissioner with the support of home care nurses, hospice care, family, and their friends, cared for his wife of 48 years as she faded away.

Her life was a vibrant one full of many accomplishments, especially her two daughters who describe her as a wonderful, inspiring mother. Mrs. (Dr.) Ehlinger not only taught physical education, but she earned a doctorate in the subject using her skills to train teachers, develop programs for individuals with disabilities and chronic illnesses, and do research. She was also an active volunteer in all the communities where the family lived.

Her nieces, nephews, godchildren and friends marvel at her joy and hospitality and always mention her commitment to serving fresh fruits and vegetables. At her table she led spirited conversations about justice, politics, and inequality and served as a feisty role model for many.

No wonder Governor Dayton described Sally Ehlinger as “clearly a very extraordinary woman.”

A noted rabbi says that it is a mitzvah (good deed) to comfort mourners and to generously support the work they care about in the world. WE, as MDH staff, are in a unique position not only to offer our condolences to Commissioner Ehlinger, but to continue to work in Sally Ehlinger’s name to: teach; develop programs for people with chronic illnesses and disabilities; make sure all Minnesotans have access to fresh fruits and vegetables; be responsible researchers; be active members of our communities; and eliminate inequalities and injustice in our state.

The Ehlingers were very active in their faith community. Not long before she began to slip away, Sally Ehlinger wrote these inspiring words as part of an Epiphany (Three Kings) service:

“The story of the “Three Wise People” – how often we’ve heard it! How did they feel when a new, dazzling star that they had been expecting actually appeared as promised? How did they experience the preparation and leave-taking for this journey? Were their friends and families uniformly supportive of this star chase?

Once they were on the long road, were they faith-filled and certain each step of the way? Or like us, did they have nagging doubts or fears about the wisdom of the mission? Might there have been spirited discussions about whether to turn right or left? Were they always kindly received in each of the dusty little stops they made on the journey, with their unusual dress and different ways? Regardless, their knowledge of the star and their very presence on this star quest offered a lesson in living faith to those in their homeland and those along the way.

Whatever else, they stuck together. Like them, we all need each other. We need each other’s ideas. We need each other’s strength, experience and wisdom. Let’s remind one another that where we are in our lives at this moment is exactly where we need to be. May we encourage one another to follow our individual and collective stars! May we heed the voice within when we are assailed by the doubts and fears that are a part of being human.

Never are we alone, nor could we be! May we continue to be bright, wise and warmly encouraging stars for one another on this long and challenging journey!”

Monday, November 27, 2017

The Existential Challenges of Climate Change and Health Equity

Climate change was the focus of the 2017 American Public Health Association (APHA) annual meeting. Dozens of sessions and hundreds of papers described and catalogued the impact of rising global temperatures on the health of people, animals, plants, and the physical environment. Beyond that, many presentations described how climate change is already destroying vulnerable communities, cultures, and societies along with the history, wisdom, knowledge, customs, traditions, and social order that they embody. There is a growing realization that the threat of climate change is an existential one – one that could irreversibly alter our existence, as we know it.

What wasn’t acknowledged is that equity is also an existential challenge – one that if not addressed in a responsive and inclusive fashion, could lead to conflict, social disruption, and the dissolution of the values and hopes that bind us together as a society. Inequities in opportunities, discrimination against minority populations, and the growing disparities in wealth and power are the forces that stress social and political structures and threaten to fracture them.

The existential challenges of climate change and equity are reciprocally related – climate change impacts equity and equity influences climate change. Climate change disproportionately affects indigenous peoples, populations of color, and the poor; making climate change a major force in worsening health and societal inequities. Conversely, the economic and social policies and systems that create and perpetuate health and social inequities also embody a disregard for the health of the environment. These policies and systems are the reason why climate change and health inequities exist. 

The APHA meeting convinced me that the tack MDH is taking to address health equity is also what is needed to prevent and mitigate the disastrous consequences of climate change. Advancing health equity also advances the creation of a livable planet for everyone. The Triple Aim of Health Equity provides the framework for essential actions .

Expand our understanding about what creates (a healthy planet). We need to expand the narrative about the causes of climate change – that it is not just about uncontrolled economic development and the burning of fossil fuels but how all of us live our lives and how we interact with each other and our environment. It is recognizing how the dominant public narrative of individual responsibility and free market economy shapes our economic and social policies in ways that are not climate friendly.

Implement a (climate) health in all policies approach with (health) equity as the goal. We must recognize that, like health equity, climate change is not the responsibility of just one sector of the economy, one governmental agency, or one country. Climate change prevention and mitigation require all sectors and all countries to be involved. Equity must be the goal of those actions otherwise, there will be climate winners and losers, which will perpetuate climate change and negatively affect all of us.

Strengthen the capacity of communities to create their own healthy future. We must acknowledge that having the authentic voice of communities in discussions of policies that affect climate is essential. Policies made without community involvement will not be effective or sustainable. Policy makers and public officials must also be accountable to the communities they serve which will facilitating the development of policies and systems that create healthy people and healthy environments everywhere for everyone.

At the core of the Triple Aim of Health Equity is social cohesion – the set of shared vision, values, and hopes that keep a society functioning in harmony. The breakdown in social cohesion is at the core of most of today’s problems and the barriers to solving them. Health is not about individual actions but about relationships – to one’s family, community, culture, society, and environment. Health – be it personal, community, or climate health – is dependent on relationships that build and support social cohesion. Moreover, social cohesion can only be achieved on a platform of social justice – the core value of public health.

Climate change and health equity are linked and, if we are successful in achieving health equity, we will be effective in preventing and mitigating the negative effects of climate change. The continued existence of our society is dependent upon our work to advance health equity.


Tuesday, November 21, 2017

Respect and Responsibility – What We Should Have Learned in Sixth Grade

Over the last year mass killings; police shootings; immigration bans; racial, religious, and LGBTQ discrimination (to name just a few) have tested and shaken the social fabric of our society. The current tsunami of sexual harassment allegations against people in positions of power and leadership are the most recent addition to the growing list of societal traumas. All of these events brought back memories of an episode in my life from 60 years ago. Although that decades-old event was not specifically about any one of these issues, it was in fact about all of them.  It was about power, leadership, social norms, and accountability – some of the principal issues behind all of these disturbing events. That grade school experience also points out how much better our society would be if we all had learned and internalized childhood lessons about how to treat people. 

Bobby was a sixth grade classmate of mine. He had some developmental and behavior issues that made him different from his classmates and the object of frequent teasing and ridicule. Sadly, I often joined the crowd in harassing Bobby. I thought it was funny and just part of the normal behavior of the “in crowd.”

My mother learned of my behavior and immediately sat me down for a “talking to.” Deep down I knew that what I had been doing was not right and that my “everyone was doing it” excuse would not fly, so I expected a severe scolding and some form of punishment.  Instead, I got a lovingly delivered lesson, possibly the most influential one I ever received. 

“Buck (my childhood nickname), you have been blessed with many gifts. You are smart, talented, healthy, and popular. (She was my mother after all.) You are very fortunate because things could have been much different.  The skills and abilities you have are not because of anything that you did.  They truly are gifts for which you should be grateful.  Your gifts are also very powerful and they will provide you many opportunities that others may never have.  However, they come with some responsibilities and those responsibilities last a lifetime.  Your gifts can be used for good or evil so you have to use them wisely.  I hope that you learn how to use them humbly, respectfully, and responsibly.

“You know as well as I that what you are doing to Bobby is not the best way to use your gifts. You may not be able to see it but you are hurting him in very painful ways. Because you are a leader in your class, he wants to be your friend so he will probably never say anything to you.  Only you can make the pain that you caused go away – by treating him with kindness and respect.

“But your responsibilities are even bigger than that. Your classmates look up to you and my guess is that if you start treating Bobby with more kindness, others will follow your example. Who knows, they may even stop teasing other kids who may be feeling what Bobby is feeling.  

“You should also be aware that Bobby too has some gifts. They are much different from yours but look for them because I think Bobby has some things that he can teach you.  

“Lastly, you know what I always say: ‘To whom much is given, much is expected.’ You have been given some special gifts and they will provide you some opportunities others might never have. I hope you take advantage of those opportunities – not just for your own benefit but for people like Bobby. I trust that you will use your gifts well.  Now go finish your homework and then go out and play.”

The next day I apologized to Bobby and began treating him differently. Eventually, he became a good friend. As my mother predicted, my other classmates also started to treat him with more respect.  Surprisingly, Bobby started to do better in school and ended up contributing a great deal to our class and to my education. 

My mother was a teacher but I think she was also a public health person because she put into practice Geoffrey Vickers’ definition of public health (“the constant redefining of the unacceptable”) and the Institute of Medicine’s definition (“assuring the conditions in which everyone can be healthy”). She certainly reminded me over and over again about what was acceptable behavior. She also drilled into me the responsibility of using my talents to help everyone thrive.

The parallels between my sixth grade experience and many recent traumatic events are clear. Many people who are in powerful positions due to their talents and skills are not using their power in a respectful or responsible way, but are acting in ways that are hurtful and painful to others. There also continues to exist a large “in crowd” with a social norm that encourages and allows abusive, hurtful, and disrespectful behaviors to occur. Too many people are acting like sixth grade boys. It is obvious that a large number of boys missed, ignored, or have forgotten a major lesson from their parents and respected elders.

However, it is never too late to learn that “to whom much is given, much is expected.” Respectful and responsible behaviors are the expectations – for everyone but especially for those entrusted with power and leadership.


Monday, November 20, 2017

Assessing Health Opportunities in Minnesota

Minnesota is a wonderful state with strikingly beautiful lakes, rivers, forests, and grasslands; vibrant urban, suburban and rural communities; numerous passionate and committed civic-minded people; many world-famous institutions; and a robust economy. Overall, Minnesota is a great place to live, work, play, pray and raise a family.

Minnesota is also grappling with unprecedented changes precipitated by events and policies at local, national and global levels. Unstable weather patterns, political polarization and shifting demographics challenge us to step up and meet the future as never before.

When we consider the averages, Minnesota compares quite well overall for health, economic opportunity, civic engagement and more. In areas where we do not do so well, we see some positive trends in the last five years—teen pregnancies are down in every population and high school graduation rates are up. However, we also see some major challenges. Deaths from opioid and alcohol overdoses, suicides and other diseases of disconnection and despair are rising fast, and inequities — in everything from infant mortality and educational achievement to employment, rates of home ownership and incarceration — stubbornly persist. These inequities challenge the notion that Minnesota is doing well: it is doing well for some, but not for everyone.

As public health workers, we cannot be content with averages that mask the real health of many people in both urban and rural Minnesota — especially people with disabilities, American Indians, African-Americans, Hmong, Somalis, people with Latino heritage, the LGBTQ community, elders, women and children.

The 2017 Minnesota Statewide Health Assessment, developed through a joint effort of the Healthy Minnesota Partnership and the Minnesota Department of Health, is a critical step in examining Minnesota’s inequities by race and ethnicity, gender, age, sexual orientation, geography and disability. With this information we can focus our attention and begin to work together for change. Collectively our strengths can equip us to meet the challenges of today and tomorrow head on — provided we make room at the table for all.

Some tragic and traumatic events in Minnesota over the last few years have underscored the importance of confronting one of the things that is pulling us apart – structural and individual racism linked with all forms of hate. Acts of violence, exclusion and discrimination, as well as unjust social and economic structures, certainly do not represent the values that guide the work of public health. I trust that they also do not reflect the vision and values of the vast majority of Minnesotans. In fact, our growing racial and ethnic diversity is deepening our knowledge and broadening our vision of how to live in a way that helps all of us thrive.

Minnesota is a headwater state—a place where things begin and flow outward—not just via the Mississippi River but also via public health. The 2017 Minnesota Statewide Health Assessment is a headwater document, a source for ideas and actions that can spring into being and stimulate change. This assessment allows us to look directly at our challenges and decide our response. I hope we all use these findings to channel our shared passion and commitment toward making sure Minnesota lives up to its image as a great place to call home—for everyone.

I encourage you to review the assessment at 2017 Minnesota Statewide Health Assessment (PDF).

Monday, October 2, 2017

Be Part of the Conversation: Our Stories, Our Communities, Our Health

The theme of the 2017 Minnesota Community Health Conference was “Be Part of the Conversation: Our Stories, Our Communities, Our Health.” As Commissioner of Health, I welcomed the 400+ attendees and then set the stage for the opening keynote address entitled “Telling Our Public Health Stories” with these words:

Once upon a time, long ago, in a New Mexico pueblo, a wise elder sitting among the people in a council ring began to speak:
“I will tell you something about stories,
They aren't just for entertainment.
Don't be fooled
They are all we have, you see,
all we have to fight off illness and death.
You don't have anything
if you don't have the stories.
The evil in the world is mighty
but evil can't stand up to our stories.
So they try to destroy the stories
let the stories be confused or forgotten
They would like that
They would be happy
Because we would be defenseless then.
You don't have anything
if you don't have the stories.”
(From Ceremony by Leslie Marmon Silko, a Native American from the Laguna pueblo in New Mexico.)

The wise ones then and the wise ones now recognize that stories are powerful tools. They are powerful because stories help change our perspective. The Laguna people start each story with the phrase, “Humma-hah,” meaning long ago. We often start our stories with “Once upon a time.” Just saying those words puts us in a different mindset, one where we suspend disbelief and become more open to new ideas, different ideologies, and foreign notions. Stories can get us to think and act in different ways.

Besides being interesting, enjoyable, and effective in transmitting information and ideas, stories are also powerful because they link people to a broader more expansive narrative that underlies, enriches, and adds substance to the stories. That underlying narrative generally embodies the values, principles, and beliefs that a community holds sacred. Stories create, reinforce, and strengthen the narrative, make it more powerful and influential, and help carry it beyond the moment.

Despite what we would like to think, data, information, and even experience are not the things that most shape our behavior. That distinction belongs to the narrative which forms and shapes our beliefs, perspectives, and sense of responsibility and possibilities from which our actions spring. Stories help create and strengthen that narrative which is why they have such incredible power.

In fact, stories are so powerful that Plato warned "Those who tell the stories rule society…so we need to carefully control who tells stories.”

Abraham Lincoln sounded a similar theme. He said, “Public sentiment is everything. With public sentiment, nothing can fail; without it nothing can succeed. Consequently, he who molds public sentiment goes deeper than he who enacts statutes or pronounces decisions. He who molds public sentiment makes statutes and decisions possible or impossible to be executed.”

Stories and their underlying narrative (public sentiment) are powerful public policy tools thus they are also public health tools.

As public health workers, it is crucial that we tell a variety of stories that help shape the overall narrative about what creates health. We should tell stories about bad things that don’t happen because of our past public health investments in protecting people and that those investments have given us a longer and healthier life. We need to tell stories about what bad things might happen if we don’t change our current resource investment strategies which prioritize treatment over prevention. We must especially tell stories about disparities that have been caused, not by the lack of medical care or because of poor personal choices, but by policy decisions that affect income, education, housing, economic development, and the quality of communities – policies that have destroyed opportunities and hope for too many people in too many communities.

Public health stories are seldom about heroic actions or ground breaking technologies. They’re not about individuals pulling themselves up by their bootstraps or about short term miracles. Public health stories are about the basic needs of individuals and communities, about the need for a long term vision and shared responsibility for health, and about protecting the “commons” – the public good. Public health stories are about inequities in opportunities to be healthy.

The narrative behind the public health stories is that health is created in communities by communities, and that health is determined mostly by socio-economic circumstances and environments that have been created by public and private policies. Too often, these policies systematically disadvantage some population groups and communities and limit the opportunities for populations affected by these policies to make healthy choices which stifles their opportunity to be healthy. That narrative is a social justice narrative.

And, the social justice narrative is really the public health narrative. Bill Foege, former director of the Center for Disease Control and Prevention (CDC) reinforced that notion when he said, “The philosophy behind science is to discover truth. The philosophy behind medicine is to use that truth for the benefit of your patient. The philosophy behind public health is social justice.”

Sadly, from my perspective, the dominant public narrative about what creates health (that health is determined by medical care and personal choices) is overpowering the social justice/public health narrative. That’s why we need to initiate and be part of the conversation about what creates health. That’s why all public health workers need to bring the health equity/public health perspective into those broader conversations. That’s why our stories need to be told in a way that expands our understanding about what creates health and helps create an alternative narrative that can guide the creation of policies, systems, and environments that allow everyone in every community to thrive.

That’s why you need to be part of the conversation that’s going to take place over the next two days – and beyond. Your stories are powerful. They are the best weapon “we have to fight off illness and death. You don't have anything if you don't have the stories.”

The stories I heard over the two days of the conference filled me with hope and convinced me that there are a lot of great public health story tellers in our midst. As they become a more integral “Part of the Conversation,” I’m anxious to see what impact their stories will have on “Our Health and Our Communities” in our state, our country, and the world. Living happily ever after may be how fairy tales end but I hope our real life stories end with everyone living equitably ever after.


Wednesday, September 6, 2017

The Work of Public Health

The Work of Public Health – Labor Day 2017

“A summary of the problems in our culture is that we made three bad philosophical bets along the way: we chose (Thomas ) Hobbs when we should have chosen (Émile) Durkheim, we learned to think of ourselves as individuals when we are really relationships – too individualistic and not communitarian; we chose (René) Descartes when we should have chosen Augustine (of Hippo), we think of ourselves as primarily cognitive feeling creatures when we’re primarily emotional longing creatures; and we chose (Jeremy) Bentham when we should have chosen (Viktor) Frankl, we think our lives are organized around pleasure and pain but really our secret and deepest desires are purpose and meaning.” -David Brooks, 2017 Aspen Ideas Festival Lecture

In the late 1970s and 1980s American society made some philosophical choices that altered the course of our collective history. The field of public health and the health of our society were particularly affected by those choices.

We had just lived through two tumultuous and chaotic decades. We had experienced the Vietnam War, the War on Poverty, culture wars, the Great Society Program, and movements for civil rights, women’s rights, and environmental protection. We had seen the rise of Black Power, Flower Power, feminist power, and community power. We had witnessed the emergence of the idealistic, obstreperous, and numerically powerful Baby Boom generation.

Amidst the turmoil and conflict of those years were some dramatic and positive changes in our society including expansion of voting rights, acknowledgment of civil rights, drafting of environmental protection laws, decreased poverty among the aged, expanded healthcare access, improved health status, and narrowing of health disparities. Yet, all of these changes were disruptive and a direct challenge to the political, economic, and cultural status quo.

We became uncomfortable with the disorder within our country and longed for stability. This desire led us to a crossroads of philosophical directions for the future. In the health sector, seduced by the promise of scientific and technological miracles, we chose a biomedical rather than a public health perspective. That choice mirrored those in all other sectors. We chose boot straps individualism rather than interdependence and social cohesion. We chose competition and free market solutions rather than solutions based on social responsibility and social justice. We chose to demonize government rather than recognize its critical role. We chose to invest in technology and specialists rather than support generalists.  And we saw structural discrimination as a thing of the past rather than a challenge for the present and future.

These choices brought us unimaginable technological advances and great rewards for some. But those came at a very steep price both financially and socially. Despite healthcare costs far exceeding those of any other country, we’ve been steadily falling behind in the basic indicators of good health status – longevity and infant mortality. We have increasing disparities in all sectors of our society, particularly those that impact health – income, education, housing, incarceration, and environment. We have disintegrating urban and rural communities. We have a rise in the diseases of despair (drug and alcohol use, suicide, mental illness among others) that threaten the long-term health of our society. We have a changing climate that threatens our very existence. And we have a rise in fear, hate, and discrimination that is destroying our sense of community and social cohesion that will be essential in creating a livable future.

Like David Brooks, I believe we made some bad philosophical choices that have negatively impacted our society. But like the late 1970s and 1980s, we are at a crossroads.  We are in a time of turmoil and chaos and we again have the opportunity to choose the philosophical direction that we will take as a society. This time I hope we choose a direction that is more “communitarian” and one that gives our activities “purpose and meaning.”

I believe that our public health work is to collectively be the contemporary Durkheim, Augustine, and Frankl of public health. We must demonstrate that many of the choices that we’ve made are not socially, economically, or environmentally healthy for our country, our planet, or their inhabitants. Our greatest challenge is to build the public will to work collectively to assure the conditions in which all people can be healthy – conditions built on the philosophy of social responsibility, social cohesion, and social justice.


Tuesday, September 5, 2017

Health Equity and Social Cohesion

(The September/October issue of MetroDoctors (the journal of the Twin Cities Medical Society) is dedicated to “Striving for Health Equity.” The articles in this issue are accessible at: Twin Cities Medical Society: 2017 September/October Striving for Health Equity. A modified version of the article I contributed to the journal is included below. EE)

“The greatest epidemic today is not TB, HIV, or leprosy – it is being unwanted. … Being unwanted, unloved, uncared for, forgotten by everybody is a much greater hunger, a much greater poverty than (having) nothing to eat.” – Mother Teresa

The standard approaches of contemporary healthcare and public health have been insufficient to reduce the persistent and seemingly intractable health disparities in our society. This should challenge us in public health to rethink how we do our work. Given our current understanding of what determines health, we must expand our focus beyond clinical care and disparities to include the inequities in opportunities in our political, economic, educational, healthcare, and social systems that are at the core of health disparities and then work to change them.

We also must recognize that creating health and health equity is not just about the health of individuals but the health of communities. As poet/farmer Wendell Berry said, “…the community in the fullest sense is the smallest unit of health…to speak of the health of an isolated individual is a contradiction in terms.” Unfortunately, that’s not the common perspective. Most people focus on health as an individual issue which minimizes the importance of the community and social cohesion to health. Therefore, it is critical that we understand how the lack of community and social cohesion (a lack of belonging or “being unwanted” as Mother Theresa noted) is a health determinant that is at the root of many health disparities.

In its 2014 Advancing Health Equity Report to the Minnesota Legislature, the Minnesota Department of Health (MDH) made the case for addressing the root causes of health inequities and disparities by focusing on the social, economic, and environmental conditions that create health. In addition, recognizing that health disparities and inequities are particularly stark and persistent for populations of color and American Indians, MDH chose to lead this effort with a focus on racial equity, noting that race often compounds disparities and inequities linked to gender, sexual orientation, age, and disability. Advancing health equity is now at the core of the state’s Healthy Minnesota 2020: Statewide Health Improvement Framework and MDH’s strategic plan.

To more effectively advance health equity, MDH created the Triple Aim of Health Equity - a set of practices necessary for changing the work of public health. The components of the Triple Aim of Health Equity are based on a theory of change that builds the power and capacity to improve living conditions in every community. The Aims are:
Expand the understanding about what creates health,
Implement a health in all policies approach with health equity as the goal, and
Strengthen the capacity of communities to create their own healthy future.

With this framework, efforts are underway to expand the narrative about what creates health; that ill health is not just due to lack of access to healthcare and bad personal lifestyle choices but mostly due to the policies and systems that impact economic, educational, housing, physical, criminal justice, and transportation environments. The Triple Aim of Health Equity also recognizes that health is not solely the responsibility of the healthcare and public health sectors but is impacted by the policies in all other sectors of society. This recognition highlights the need for new and expanded partnerships to advance health equity. Finally, the Triple Aim of Health Equity acknowledges the importance and necessity of strengthening civic participation so the collective voice of community members can effectively impact decisions made by institutions and government at all levels.

All these efforts are centered around building social cohesion, a prerequisite for achieving health equity. Social cohesion is defined as community force that “works toward the well-being of all community members, fights exclusion and marginalization, creates a sense of belonging, and promotes trust.”

Among the constituent elements of social cohesion are:
social capital – the resources that result from people working together toward a common goal,
social mobility – the ability to move up in social or economic status, and
social inclusion – having connection to and ownership of community goals, having a sense of belonging – being wanted and needed.

According to John A. Powell, director of the Haas Institute for a Fair and Inclusive Society, that sense of “belonging means more than just being seen. Belonging means being able to participate in the design of political, social, and cultural structures. Belonging means the right to contribute and make demands upon society and institutions.”

Social cohesion can be developed only if all parts of the Triple Aim of Health Equity are being actualized.
Expanding the understanding about what creates a thriving and prosperous community is essential for building the social capital necessary for a socially cohesive society.
An inclusive, coordinated, and accountable decision-making process that incorporates the views of all stakeholders in all sectors of the community enhances social cohesion.
Strengthening community capacity by providing community members with the opportunity to share their perspectives and impact policy decisions is fundamental to creating social capital and a sustainable, socially cohesive society. The process of policy making is often as important for building social cohesion as the policies themselves.

Public health is defined by the Institute of Medicine as “what we, as a society, do collectively to assure the conditions in which (all) people can be healthy.” Those conditions are influenced by the policy decisions made at all levels of society. If we are to change the policies to improve health equity, we must constantly ask the basic question: what would our work be like if health equity was the starting point for all policy and programmatic decisions?

Our work would be different. Our work would be shaped by the Triple Aim of Health Equity; we would expand the understanding of what creates health, implement a health in all policies approach with health equity as the goal, and strengthen the capacity of communities to create their own healthy future – all with the objective of increasing social cohesion and belonging. Our work would be to build a proper community as described by Wendell Berry: “A proper community…is 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.” Our work would be to create socially cohesive communities where no individual or group is unwanted and where everyone has a sense of belonging and the opportunity to be healthy.