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.

Tuesday, February 16, 2016

Haunted By Waters

“Eventually, all things merge into one, and a river runs through it…I am haunted by waters.”
      Norman Maclean, author of "A River Runs Through It"

Minnesota is blessed by water. In this state of 10,000 lakes and multiple streams and rivers, water is all around us and runs through us. Water stimulated the lumber, flour, agriculture, and tourist industries that helped shape the culture, economy, and people of the state. Water has made us who we are. Water is such an integral part of our state that it’s reflected in our name which comes from the Dakota word Mnisota meaning land of sky-tinted or clear water.

Minnesota’s abundance of clean water has lulled much of the public into taking our water legacy for granted. In public health we have not done that because our origins as a discipline float back to Dr. John Snow who found the source of cholera in the water from London's Broad Street pump. This led to the development of water sanitation systems that would halt the epidemic and change public health practice. Since then, much of the improvement in our overall health and well-being has been linked to efforts to protect and improve our water. However, after touring the state and learning about our aging water infrastructure, like Norman Maclean, I’m haunted by waters.

My concern about waters has steadily increased in intensity – not just because I’ve spent recent weeks and months working with our drinking water team to rectify some inconsistencies in our water sampling and testing procedures. While these deficiencies are serious and concerning, they are being quickly addressed and corrected by our dedicated staff and I’m convinced that they haven’t posed a significant threat to the health and safety of Minnesotans. Why I am particularly haunted today is that the waters necessary for our survival and well-being are threatened like never before.

I am haunted by the fact that most of the lakes and streams in southwest Minnesota have been deemed unsuitable for swimming or fishing because of pollution. I am haunted by the increasing threat of nitrates in Minnesota’s drinking water. I am haunted by what we are learning about the major human, animal, and environmental health impacts of the drought (haunted by the lack of water) in California. And, I am haunted by the tragedy playing out in Flint, Michigan where the degradation of their drinking water will affect the health and future of thousands of children.

What most haunts me is that our waters, in each of these situations, are being degraded and threatened by an economic and political climate in which financial considerations often trump health concerns and individual rights are protected at the expense of the community good; the antithesis of a public health approach.

Safe drinking water is essential for health and access to it should be considered a basic human right. That doesn’t mean that each individual or organization has the right to use water in any way he/she/it would like. Because it’s a community resource, the use of water beyond basic human needs is a privilege not a right. (Think “water privileges” rather than “water rights.”) And with that privilege comes the responsibility to use our finite water resources in a way that sustains and enhances the “commons” or the communal good.

Water and its use underscores the foundational public health principle of social justice – everyone should have their basic/essential needs met and, in addressing those needs, no one should benefit at the expense of others. The problems facing our waters today are because we have not consistently followed that principle in our use of water. That needs to change if we hope to thrive as a community/society.

Every individual and all sectors of our society like industry, agriculture, transportation, defense, energy, etc., must recognize the need to be good stewards of our water resources. All must embrace water-use practices that add to the overall health of our waters and the overall health of our community. The needs of the community must trump personal desires and business needs. And there needs to be some publicly accountable oversight to assure that this happens.

No one sector alone can protect our waters; all must be involved. As Norman Maclean wrote, “all things merge into one, and a river runs through it.” It requires a “water in all policies” approach with healthy waters and social justice as the goal.

Minnesota's geography has blessed us with abundant waters. With that blessing comes the responsibility to protect the great waters that run through the veins of our state. Everyone (especially those of us in public health) should, like Dr. Snow, make the case to policy makers and our fellow citizens that contaminated water hurts us all and we ALL have a role in protecting the waters that run through us. Given the current threats, we should all be haunted by waters.


Monday, January 11, 2016

Injustice Made Clear Is Justice Reborn: The National Academies and Health Equity

Etched in the stone façade of the building in Washington D.C. that houses the National Academies of Sciences, Engineering, and Medicine are two quotations:

“Liberty is the great parent of science and of virtue; a nation will be great in both always in proportion as it is free.” Thomas Jefferson

“The right to search for truth implies also a duty; one must not conceal any part of what one has recognized to be true.” Albert Einstein

I pondered those words as I entered the National Academies’ building to do a presentation to the Institute of Medicine’s (IOM) “Committee on Community Based Solutions to Promote Health Equity in the United States.” While science and truth are mentioned in those quotations, it struck me that the focus of both was values – the values of liberty, rights, freedom, virtue, and duty. Those words gave me some hope for the eventual recommendations coming from the committee because health equity is about much more than just objective data; it is also about the aspirations we have for our society.

These façade-enhancing quotations also seemed to potentially give some credence to the core message in my presentation that public health, as articulated by Geoffrey Vickers, is about using data to continually redefine the unacceptable and move the unacceptable conditions in which people live “from the category of the given into the category of the intolerable.” Public health and the advancement of health equity is about the interaction of data and values.

Einstein was very clear in pointing out the bidirectional nature of the interaction between rights and duties – “one must not conceal any part of what one has recognized to be true.” Jefferson’s statement is more unidirectional – liberty is required for science and virtue. That gave me pause.

In Jefferson’s mind, science and virtue are siblings with liberty as their parent. We all know that the interactions of siblings are sometimes cooperative and sometimes competitive; ideally enhanced and mediated, when necessary, by parental influence. We also know that the experiences and perspectives of children often challenge and influence their parents. In this case, liberty and freedom are necessary for science and virtue to thrive; while science and virtue have the duty to influence the legacy of liberty. Implicit in these bidirectional interactions is the requirement to always search for truth and the duty to make those truths known.

As I entered the National Academies building for the IOM session on health equity, I was hoping for a broad discussion springing from the spirit of the quotations that met us as we entered. I was not disappointed. The presentations contained a great deal of data but those data were presented in the context of the values of our society and the aspiration that everyone has the opportunity to be healthy and to thrive. As I left the meeting, I was optimistic that the forthcoming recommendations of the experts on the committee will outline a path that assures the societal conditions in which everyone can be healthy.

Having some free time before my flight back to Minneapolis, I thought I’d take advantage of being in D.C. for a quick visit to a museum. Because it was just three blocks from the National Academies and being a site I had not visited before, I stopped at the Newseum, a museum dedicated to news reporting. Unexpectedly, it turned out to be a perfect capstone to the day’s discussions.

The main reason for the existence of the Newseum is to underscore how being able to freely share information, ideas, and opinions helps protect our liberty. The underlying message in every exhibit in the Newseum is the critical importance of the values embedded in the First Amendment to the Constitution which prohibits “…abridging the freedom of speech, or of the press.” That message resonated perfectly with the quotations of Jefferson and Einstein. It also resonated with the day’s focus on health equity.

The introductory exhibit in the Newseum put an exclamation point on the day. It told the story of Colonel John A. Cockerill, chief editor at the Pulitzer newspaper The World, sending Nellie Bly to report on the abuses occurring in a women’s insane asylum. According to Cockerill in his charge to Bly, “Injustice made clear is justice reborn.” Her investigative reporting which led to some needed policy changes in the prisons helped prove that point.

Since social justice is the core principle of public health, this statement also reflects the role of public health and advancing health equity. Working to make injustices clear helps us redefine what’s unacceptable and move injustices from the category of the given into the category of the intolerable. In that way, justice and equity can be reborn.


Monday, November 23, 2015

Challenge of Diversity and Vision of Equity: 1994 - 2015

Last Friday I had the honor of speaking at a celebration of 12 years of service of Sharon Sayles Belton as a member of the Hennepin Health Services board. In addition to that service, Sharon served as a Minneapolis City Council member for 10 years and in 1994 was sworn in as Mayor of Minneapolis, the first woman and first African-American to hold that position. In my remarks I quoted from her January 1994 inaugural address. At this time, when Minneapolis and Minnesota are struggling with inequities and racial tensions, I think it’s appropriate for us to consider what Mayor Sayles Belton said in that address 21 years ago. It certainly harmonizes with our Triple Aim of Health Equity, our new Strategic Plan, and our vision of health equity – where all communities are thriving and all people have what they need to be healthy. Here are her words and challenge for all of us:

“We are living in an era in which change takes place with astonishing speed…an era challenged by complexity, by an increasingly diverse population, and by ever-closer personal, social and business ties with people and cultures from all over the world.

“Today, as we stand at this crossroad and consider which paths to pursue…our community will not be served by clinging stubbornly to old ways of thinking and acting. That is why it is important on this day…that we take time to search out and study the maps and landmarks of our past and present that can serve us reliably as we move through change into the future. …

“First we must look within ourselves, to the things that we value and believe in….I believe we share community values, values that transcend race, economic status, individual need and ambition; values that constitute the framework of our society and community life. …

“We value our children, and know that our future lies in their hands.

“We value strong families, and know that only they can provide our children a safe and protective environment, and teach them the values of respect, education, responsibility and hard work.

“We value the entire community's role in the lives of our children, because it takes "a whole village"--or city--to raise a child. That means it takes community systems that work--schools that truly educate, neighbors that provide safety, health care for every child.

“These are our community values…based on an assumption of our own intrinsic goodness and that of our neighbor, and on the hope that each one of us can and must make the world a little bit better. …

“Americans like to say we are strong because we are founded on a tradition of tolerance--that we are nurtured by diversity. Living peacefully and creatively with diversity is the great American experiment.

“Minneapolis, like our state and our nation, has become increasingly diverse. We are a multiracial, multicultural, multilingual city. We are a kaleidoscope of skin colors, a tapestry of ethnic traditions, a treasury of spiritual beliefs, and a forge of ideas, perspectives and talents igniting in dialogue.

“Diversity fuels our creativity, makes us stronger and more resourceful, and serves, if we let it, as a pilot light for the virtues of humility, generosity, and peacemaking.

“But diversity can breed distrust, tension, and even violence. While it is our unique strength, it is also our unique challenge. That is why it is important, at this time in our city's history, to continue the traditions of tolerance and understanding that have guided us in our best moments. We must explore our diversity, embrace it, and harness it in the name of the common good. We must invent new ways of making decisions, based on consensus and cooperation….

“Our city is important. It is our family, our neighbors, our shops, our leisure, our financial base. It is the trees that shade us, the lakes that delight us, the water we drink and the air we breathe. We are its stewards. Each one of us bears responsibility for its health and prosperity.

“If we face escalating violence, we cannot turn to the police to resolve the problem single-handedly. The entire community must participate in the hard work of articulating and demanding compliance with our shared values.

“If we face a shortage of jobs, we cannot ask the business community to create employment without the support of schools, health and social services, transportation, day care, and government itself. …

“And if our land and our lakes,…are poisoned and slowly dying from pollution, then industry leaders and homeowners alike must become better caretakers, to ensure that these resources will survive, to sustain and be enjoyed by our children, and our children's children.

“We are a vibrant community, a brilliant and diverse family, living in a beautiful green and blue--and sometimes snowy white--city on the rich Midwestern prairie, blessed with abundant natural and human resources. We are blessed with everything we need. If we fail to remain true to our values, to our traditions, and to each other, and thereby fail to rise to the occasion of our own survival, it will only be because we lack the courage.

“Therefore…I ask every elected official, every city worker, and every citizen of this city to make a resolution--no, an oath--to this city:
  • to find common ground, and to profess privately and publicly our common values--in spite of our differences;
  • to commit ourselves--in spite of our doubts,
  • to listen--in spite of our certainties,
  • to persist--in spite of our failures, and,
  • in spite of our fears,-- to allow ourselves -- to be guided by our basic humanity.”
This address is a great articulation of public health – what we do collectively to assure the conditions in which people can be healthy.