Monday, August 11, 2014

Pitching Public Health

I was warming up for a run on August 9, 2001, when I heard Bob Kelleher from Minnesota Public Radio report on the World Horseshoe Tournament that was being held in Hibbing, Minn. Over 1,000 contestants from around the world were assembled for the two week-long event. I was only half listening to the story until a three-time world champion from California was interviewed. He claimed that “Horseshoes is a game of strength, stamina, and consistency.” Consistency made sense but I had never thought of horseshoes as a game of strength and stamina. That made me listen more closely, but what intrigued me most was that this participant was 77 years old and still competitive.

While I was still participating in running and cross country ski races at the time, I filed horseshoe pitching in the deep recesses of my brain as a “lifetime sport” that might be fun if my joints or other body parts ever rebelled at my long-distance running and skiing activities.  

My activities had already shifted to biking and walking before horseshoes resurfaced in my consciousness. That happened after I became commissioner. Initially, pitching horseshoes was in the context of the “bully pulpit” that I’m purported to have and the need to listen to community voices. Playing off the pun, I thought I could go around the state “pitching” public health to the citizens of Minnesota while they “pitched” their ideas and concerns to me. That horseshoe pitching also fit well with our Statewide Health Improvement Program’s (SHIP) efforts to get people to be more active was added value not to mention that it supported my mantra that “if it’s not fun, it’s not public health.”

The more I thought about doing “Pitch the Commissioner” events, the more I discovered about Minnesota as a horseshoe pitching hot spot in the US. There are more registered horseshoe pitchers in Minnesota than any other state and Minnesota is home to dozens of world champions. Also, everyone that I talk with remembers pitching horseshoes with their fathers (never their mothers) on the farm, at a cottage, at a family reunion, or at a picnic. It seems like horseshoes, in larger or smaller portions, is part of the Minnesota DNA, even for women who are increasingly involved in the sport.

I’m now in my third year of doing “Pitch the Commissioner” events. These events have allowed me to visit all parts of the state; meet with county commissioners, local health department staff, and other community members; observe some innovative and effective programs; participate in some health-related tours and activities; and marvel at the strategic plan of Dairy Queen. In the process, I’ve been able to hear the concerns and ideas about public health in Minnesota at a community level while discovering that horseshoes is a great (although not perfect) metaphor for public health.

To be successful in horseshoes, you first need access to a horseshoe pitch and to the horseshoes themselves. I've learned that not every community has a horseshoe pitch and that some pitches are in disrepair. When you are actually pitching, you don’t want the shoes to go too far to the left or right or too short or too long; you want them centered in the middle of the pit. Finally, you want the shoe to have the right orientation to encircle the stake so you can get a “ringer.”

Creating a healthy population is like playing horseshoes. Imagine the stake as an individual and the horseshoe pit as the community. The community needs to have some basic infrastructure that surrounds and embraces each individual community member.

Next, imagine that the trajectory to the right is treatment and to the left is prevention. To meet the needs of each community member you need the correct balance of each. Treatment and prevention are needed in proper proportion for health. Likewise, from a distance perspective there needs to be a balance between short-term and long-term goals. You need to address short-term issues while planning and working for long-term health.

Individual behaviors are the horseshoe itself. Individual behaviors need to have the right orientation to achieve the “ringer” of optimal health. If the community doesn't have the proper balance between treatment and prevention and between short-term and long-term needs, individual behaviors are somewhat irrelevant in maximizing health. However, with the proper balance, individual choices make a tremendous difference in one’s health score.  

Finally, the horseshoe pitch itself is a metaphor for the social determinants of health (income, wealth, economic opportunity, education, housing, transportation, etc.) which are the most influential factors in creating a healthy community. Before being able to play any game and be competitive one needs access to the game and the rules have to be fair. These are policy issues that are often outside the control of an individual. For horseshoes the issues are: Who owns the horseshoe pitch? Who controls it? How is it financially supported? Who gets to use it? Who are the decision makers about its use?  Where is it located? Can people get to it? What are its hours of operation? Who sets the rules for play? And do those rules provide the opportunity for everyone to be competitive?

The same questions have to be asked about the policy decisions made related to the social determinants of health. Who is at the decision-making table and who has the power to make the decisions that affect health? In horseshoes, if you can’t get into the pitch, where and how you throw the shoe doesn't matter. In health, without access to economic opportunities, safe and stable housing, and a good education, health care and individual choices are still important but less impactful than they could be in achieving good health.

In addition, once in the game, the rules have to provide equal opportunities for everyone to be successful. Knowing that throwing a 2-pound 10-ounce horseshoe 40 feet may exceed the physical capacity of some individuals, the rules in horseshoes allow men over 70 and women to pitch from 30 feet. That helps equalize the opportunity to be competitive. To create a healthy community, we also need to have some flexibility in the rules to assure the conditions that allow everyone the opportunity to be healthy.

At the risk of pushing this metaphor too far, I’ll make one last comparison. You don’t have to be good at horseshoes to enjoy the sport. I’m a great example of that. Just being on the pitch with people who are moving, conversing, and laughing engenders great satisfaction and joy. However, the more you participate, the better you become. Practice makes better.

Similarly, with our individual health and the health of our communities. One doesn't need to be an expert to get involved in building a healthy community. In fact, different levels of expertise and experience lead to richer conversations and innovative ideas. Just being involved makes a difference. And, like horseshoes, the more involved you are the better you become at helping to improve the conditions that create health.

This week I will be in St. Louis County where I will be pitching horseshoes and public health in the place that generated the idea for my “Pitch the Commissioner” tour. I may not get many actual ringers with my horseshoes while I’m on the pitch, but I’m confident that there will be many ideas and concerns that the community will pitch me that will be ringers for the health of our state.

Friday, August 8, 2014

Let’s Nurture Public Health with Some Purple Rain

At the beginning of this week I was in Washington D.C. for the “graduation” of the first cohort of the Aspen Institute’s Excellence in State Public Health Law (ESPHL) program. The ESPHL program brought together teams from 8 states to work on a variety of public health issues that could benefit from policy analysis and policy changes. With funding from the Robert Wood Johnson Foundation and technical assistance from policy experts from across the country, the teams looked at public health issues like children’s oral health, girls’ physical activity, breast-feeding, chronic disease prevention, strengthening local public health, and new primary care models.

Minnesota’s team, consisting of 4 legislators (Miller, Eaton, Allen, Zerwas), 3 commissioners (Dohman, Jesson, Ehlinger), and 1 utility infielder (Munson-Regala), was focused on reducing the devastation caused by the binge drinking of alcohol. After considering the evidence-based interventions like increasing the price of alcohol, decreasing the Blood Alcohol Content (BAC) for driving, and social host ordinances (among other approaches): polling Minnesotan’s about their views on those issues; and considering what is politically feasible at this time, the team decided to focus on ignition interlock systems for first-time offenders. We’ll see how that plays out over the next year.

The majority of the meeting was spent listening to the status reports from each team but the conference was launched and keynoted by Kathleen Sebelius, former Secretary of the U. S. Department of Health and Human Services. Her presentation highlighted many of the health problems faced by the United States but also acknowledged the public health opportunities afforded by the Affordable Care Act. A subtext of her comments was the recognition of the political polarization that has developed around health and health care reform which has slowed progress on many issues. 

With the perspective of Secretary Sebilius in the background I listened with interest as each team provided an update on what they leaned and what they accomplished during the course of this one-year ESPHL experience.  As I listened to each presentation, it was apparent that the core of the public health issues each state was addressing was really non-partisan; that, regardless of political persuasion, these were issues of concern for almost everyone. Certainly, the approaches to addressing these issues varied depending on one’s political persuasion but the goals were the same. 

When it was my turn to report on the progress of the Minnesota team, I was struck by the fact that I was presenting on the 30th anniversary of Prince Rogers Nelson’s album “Purple Rain” reaching number 1 on the charts. Given that many of the approaches to addressing public health issues vary markedly between “Red States” and “Blue States,” it dawned on me that most, if not all, of these issues should be purple issues – non-partisan issues that should be addressed in a non-partisan way.

With that in mind, I ended my presentation by quoting a verse from Purple Rain:

I know, I know, I know times are changing
It's time we all reach out
For something new, that means you too
You say you want a leader…
(So) let me guide you to the purple rain

My experience with the ESPHL program reinforced that most people want the same things for themselves, their kids, their grandkids, and their communities. They want people to have the opportunity to blossom and flourish.  While people have different opinions about how to achieve those things, the program also taught me that movement forward on the overarching goals is best achieved by combining a little red and a little blue and watering these public health seeds with purple rain.

Purple rain, purple rain
I only want to see you
Only want to see you
In the purple rain.


Monday, July 28, 2014

The Power of Stories and Narrative

Since most religions or faith-based organizations are concerned about physical and emotional health in addition to spiritual health, I occasionally get invited to speak at a church, mosque, meeting house, or synagogue. When my presentation is temporally related to their prayer service, I try to link my public health message with their theme of the day.

Today I was invited to speak at a local church whose readings revolved around parables, simple stories used to illustrate a moral or spiritual lesson. Since we’ve been working on the narrative about what creates health and because stories and parables help create and support a narrative, I saw this invitation as a good opportunity to talk specifically about the power of stories and narrative.  

Here is part of what I shared with the congregation.

Once upon a time, long ago, in a New Mexico pueblo, an elder sat among the people and 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 they 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.”
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 are hypnotic. 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 and adds substance to the stories. The underlying narrative generally embodies the values, principles, and beliefs that a community holds sacred. Stories reinforce and expand the narrative, make it more influential, and help carry it beyond the moment.

Even more powerful is the use of stories to create a narrative because it is known that it’s not data, information, or even experience that most shapes our behavior. That distinction belongs to narrative because a narrative shapes our beliefs, understandings, perceptions, and our sense of responsibility and possibilities. Stories and parables help create and expand a narrative. That is where the real power of stories lies.

Whether a story is fact or fiction, accurate or erroneous, or for children or adults is irrelevant in its relationship to the underlying narrative. Every story helps create or support a narrative. You can see why the Laguna elder stated, stories are not just about entertainment. They are all we have to fight off illness and death. That’s why stories are so powerful.

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 makes statutes and decisions possible or impossible to be executed.”

Stories and their underlying narrative, or public sentiment, are powerful public policy tools.

You hear lots of stories every day. Some recent ones you’ve probably heard are about the Israeli and Palestinian conflict. There is probably truth behind each of the stories yet the stories are often conflicting. That’s because the message of the story and how the story is told is influenced by the narrative that underlies the story; the narrative that reflects the perspective and core beliefs of the teller.

Similarly, the narrative influences the stories about the unaccompanied children showing up on our southern border, about the ACA, and about taxes, minimum wage, and jobs, to name just a few. Ask yourself, what’s the narrative behind those stories? What values, principles, and beliefs are they trying to convey?

As health commissioner, I hear a lot of stories about health. For example, at a recent celebration of major historical milestone of a large health care organization, I heard wonderful and very emotional stories about how people’s lives were saved by ground-breaking research, heroic surgical procedures, and a medical staff focused solely on the welfare of their patients. In fact, they now have a website devoted specifically to the telling of these stories.

A major medical device manufacturer has a similar website dedicated to personal stories about how technology has saved and improved the lives of many people from around the world.

All of these stories are true. And behind each of these stories is the narrative that it is the medical care system that is responsible for our health. Each story reinforces the narrative that, if everyone had access to and was able to use our medical care system, health would be assured.

Another set of stories that I hear takes a more negative and judgmental perspective. I hear stories about babies being born prematurely because their mothers smoked or used drugs. I hear stories about how obesity is increasing because people are making bad choices about what they eat and because they are spending too much time in front of one kind of screen or another. And I hear stories about kids not doing well in school because parents aren’t attentive to their needs or didn’t spend enough time reading to them when they were younger.

Again, these stories are probably true. And behind these stories is the narrative that a great deal of our health is determined by the choices that individuals make. If we just ate well, exercised, avoided drugs, and read to our kids, everything would be better.

Combined, these two narratives have formed the dominant public narrative that it is medical care and personal choices that create health.

I tell different stories. I tell stories about bad things that don’t happen because of our past investments in protecting people and that those investments have given us a longer and healthier life. I tell stories about what bad things might happen if we don’t change our current resource investment priorities. Mostly, I 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 opportunities, and the quality of communities.

My stories are not about heroic actions or ground breaking technologies. They’re not about individuals pulling themselves up by their bootstraps or about short term miracles. My stories are about the basic needs of individuals and communities; about a long term vision and responsibility, and about protecting the “commons” and the public good.

The narrative behind my 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 opportunity for disadvantaged populations to make healthy choices and limit their opportunity to be healthy. This is a social justice narrative.

Because social justice is about assuring that the basic needs of everyone are met and that no one benefits at the expense of someone else, the social justice narrative is also 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 (medical care and personal choices) is overpowering the social justice/public health narrative.

So what does this have to do with the parables in your readings today? I’m not a theologian so I’m not going to interpret those parables. Instead, I ask you to focus on the narrative behind the parables. What are the values, principles, and beliefs behind those stories and parables? What is the narrative that the parables create and support? How does that narrative help create health in your community? And, do these stories align with your narrative about how you should live your life?

I leave the answers to those questions up to you. But I certainly resonate with the narrative in a couple of your readings today. That narrative is about the wisdom to lead, it's about the needs of the community, it's about connections and all of us working together, it’s about social justice.

I like that narrative because that's the narrative needed to create health in our society and build the kind of society every faith-based group would love to see on this earth.

That’s my story and I’m sticking to it.


Monday, June 23, 2014

Do you have a library card?

Even though I’ve lived in Minnesota for over three decades and have been involved with myriad literacy and reading programs, I didn’t know that Minnesota had a state librarian until about a month ago. I knew we had a state demographer, a state economist, a state forester, and a state climatologist, but it took Elmo from Sesame Street to introduce me to Jennifer Nelson, Minnesota’s State Librarian. 

It was after an event at the Brookdale Library highlighting what Sesame Street was doing to address the needs of children of incarcerated parents that I had a chance to tour the library and hear about the roles that libraries play in protecting and creating health in our communities. I saw firsthand that libraries are much more than a place to just store and check out books. They are places where one can go for personal and professional development while, among numerous other things, also providing meeting spaces, enhancing cultural engagement, supporting literacy for all ages, encouraging community involvement, and improving the overall quality of life in a neighborhood. I learned that there are more libraries in the U.S., than McDonald’s restaurants. There are over 350 public libraries in Minnesota which are available to everyone regardless of socio-economic circumstances. And you can use them even if you don’t have a library card. The card is needed only if you check out something.

Recognizing the role that libraries play in public health in our state, I invited the State Librarian to be a guest on my cable TV show – A Public Health Journal. At last week’s taping we discussed the history of libraries, their current activities, and their changing role in our increasingly diverse and digital world. I learned that libraries remain crucial to the health of our state and are providing a broader range of services today than ever before. It was during that conversation that I also learned that the position of State Librarian is celebrating its 100th anniversary.

I end every episode of my show with a closing comment. Here is my closing for the show that featured the State Librarian: 

When I was a practicing pediatrician, I would ask three questions of every parent: does your child know how to swim, have you visited the state capitol, and do you and your child have a library card? 

You may wonder what those questions have to do with the health of a child. Knowing how to swim should be obvious, it is a life-saving skill. It fits in the same category as wearing your seat belt and bicycle helmet and looking both ways before crossing a street. It’s a personal behavior that protects you from harm.

Visiting the capitol on the other hand highlights the community aspects of health. We all live in a community and the health of our community affects our health. Only by actively participating in how our communities are built and governed will we be able to assure that our communities are healthy. Visiting the capitol underscores for children the importance of community engagement and that engaged communities are healthy communities.

The library card is about opportunities. It offers the opportunity for education and learning, for growth and development, for exploration and discovery. A library card provides opportunities to examine the past, explore the present, and create the future

More importantly, the library card is about dreams. It stimulates dreams about the future, about a child’s place in the world, about possibilities.

Kids need to know how to swim. They really should visit the capitol. But most of all they need to dream and have the opportunities for those dreams to come true. Do you and your child have a library card?

I ask you the same question.


Monday, June 16, 2014

Advancing Health Equity by sharing data

As part of our Advancing Health Equity agenda, the Minnesota Department of Health has been looking for ways to ensure that all people in Minnesota have the opportunity to be healthy. One way is to address the social determinants of health. Since income is probably the most influential social determinant of health, we welcomed the opportunity to submit a White Paper to the legislature on “Income and Health.” (PDF: 936KB/36 pages). That paper helped broaden the conversation around the minimum wage bill that was in front of our legislature. Our report showed that raising the income of the lowest paid workers had a significant impact on improving their health. People began to see minimum wage as a public health issue, not just a jobs issue. I believe our report helped move the discussion along at the Capitol that led to passage of a minimum wage bill in MN that increases the minimum wage to $9.50/hour and links it with inflation.

Our report has also been read by people in multiple community organizations and used in their efforts to enhance the economic stability of members of their community. One of those groups is Centro de Trabajadores Unidos en la Lucha (CTUL), a group representing the cleaning crews for the Target Corporation. They used the MDH report in negotiating with Target for improved, wages, benefits, and working conditions. Following those negotiations, Target announced last week that they are adopting a Responsible Contractor Policy, the first of its kind in the retail industry. Here is a link to the CTUL website:

To me, using data to define the context of what creates health and getting that information and analysis into the hands of the people/communities most impacted by existing policies, systems, and programs is one of the ways in which public health can help assure that everyone has the opportunity to be healthy. It can sometimes be difficult to see the impact of this kind of analysis on the health of individuals, but I think this is one circumstance where the application of work done at MDH will make a significant difference to folks at the bottom of wage scale and their families. Most people will not make the connection between public health and the CTUL/Target settlement but it will show up in the health statistics that we will see over the next decade – an outcome that should be a source of pride for all of us in public health.


Tuesday, June 3, 2014

Open Streets – North Minneapolis Greenway Experience

On Saturday, while participating in this summer’s first Open Streets event, lines from a couple Maya Angelou poems kept running through my mind. Given that Angelou had died just three days earlier and that I was biking with members of the Major Taylor Bicycle Club (an African-American bike club) through north Minneapolis, I wasn't surprised that verses from "Still I Rise" and "Million Man March" were rising into my consciousness and marching through my brain.  

Biking down Humboldt Avenue North and seeing the remnants of the house and tree damage caused by the tornado 3 years ago and the foreclosed homes and vacant lots caused by predatory lending of the last decade and years of community-level poverty, I could hear the poet clearly lament:

The night has been long,
The wound has been deep,
The pit has been dark,
And the walls have been steep. 
Million Man March

But the mood was not one of sadness or defeat. Instead, there was joy in the air and it was contagious as our group pedaled through the neighborhood. There were bikers everywhere. Those who weren't biking were laughing, waving, and enjoying the spectacle. Many of the vacant lots were slowly being reclaimed by sprouting vegetables – part of a network of community gardens. Schools and churches along the route were offering food and music. Dance groups were performing on temporary stages at several venues. Tents put up by community agencies lined the streets and offered education, information, connections, and water. And community members were beaming as they interacted with each other. Among this hubbub I could envision a triumphant smile on the face of Maya Angelou as she demanded:

I say, clap hands and let's come together in this meeting ground,
I say, clap hands and let's deal with each other with love,
I say, clap hands and let us get from the low road of indifference,
Clap hands, let us come together and reveal our hearts,
Let us come together and revise our spirits,
Let us come together and cleanse our souls

Clap hands, call the spirits back from the ledge,
Clap hands, let us invite joy into our conversation,
Million Man March

And there was joy in this Open Streets community-building conversation/event that couldn't be dampened even by the threat of rain. 

Our Advancing Health Equity report outlined many of the policies and structural inequities that have disadvantaged communities of color and American Indians in our state and it highlighted many of the health disparities that have resulted. It did one of the things that public health is supposed to do - redefine the unacceptable. What hasn't received as much attention is the more uplifting role of public health that the report suggested – assure the conditions in which people can be healthy. Engaging and empowering communities in creating opportunities to be healthy is one of the best ways to do that. Community engagement and empowerment is what I saw rising up last weekend in one of the poorest and most stressed neighborhoods in Minneapolis.

Out of the huts of history's shame
I rise
Up from a past that's rooted in pain
I rise
I'm a black ocean, leaping and wide,
Welling and swelling I bear in the tide.
Leaving behind nights of terror and fear
I rise
Into a daybreak that's wondrously clear
I rise
Bringing the gifts that my ancestors gave,
I am the dream and the hope of the slave.
I rise
I rise
I rise.         
Still I Rise

Despite the magnitude and seeming intractability of the disparities in our state, I am optimistic that we can achieve health equity. Community after community is showing us how to make that happen.  Health equity is on the rise.


Tuesday, May 27, 2014

Memorial Day 2014

May 26, 2014

Even though he was 25 years old when the United States entered World War II, my dad never served in the military. Instead, he used his machinist skills to help build tanks for the war effort. He was proud of his contributions but, like most men of his generation, he seldom talked about the war. “I did my part but the soldiers should get the attention and praise because they risked their lives” was about the extent of his conversation on the topic.

The wartime actions of my father resurfaced today (Memorial Day) when I paused to reflect on the lives lost in war in defense of our country and the values on which it is based. My dad won’t be honored in speeches today, but that’s OK. He would want it that way. He did the best with the skills and talents that he had and he was secure in the knowledge that he was a vital part of the war effort. That was recognition enough.

My mom was less reticent to talk about those war years. “Winning the war was truly a national effort. All of us contributed in whatever way we could. Your father had some unique skills that were best used here at home. Few people could do what he did. He certainly did his part in winning the war.” She would frequently use the occasion of these conversations with her children to reinforce her belief that any really big accomplishment is usually the result of a community effort and that the “behind the scenes” efforts are oftentimes the most important. It was in those chats that she would often quote a couple of verses from the poem Be the Best of Whatever You Are by Douglas Malloch:

We can't all be captains, we've got to be crew,
There's something for all of us here,
There's big work to do, and there's lesser to do,
And the task you must do is the near.

If you can't be a highway then just be a trail,
If you can't be the sun be a star;
It isn't by size that you win or you fail —
Be the best of whatever you are!

People in the public health field understand the importance of behind the scenes work. Like my dad’s behind the scenes efforts in winning the war, most people don’t recognize the behind the scenes reasons for losing most wars. Throughout history, the greatest number of casualties in wars has not been due to the conflict but infectious diseases. Over two-thirds of the deaths in the U.S. Civil War were due to infectious diseases – cholera, dysentery, yellow fever, etc.  And despite the homage given to cannons in Tchaikovsky’s 1812 Overture, Napoleon’s advance into Russia was not stopped by artillery but by typhus. As Charles Hewitt, the founder of the Minnesota Department of Health learned during the Civil War, the armies with the best public health infrastructure are usually victorious.  

Another “behind the scenes” fact is that civilians also suffer casualties because of war. And, as with troops, infectious diseases have been the major cause. It is estimated that one-fourth of the 4 million freed slaves died from infectious diseases in the wake of the Civil War. War disrupts the public health infrastructure that helps keep people safe and alive. That’s why the World Health Organization places “peace” at the top of the list of determinants of health.   

As my Memorial Day thoughts evolved, I began to more fully appreciate the fact that war and peace are public health issues. I also began to better understand what my mom meant when she stated during our war conversations that any really big accomplishment is usually the result of a community effort. Certainly the outcomes of the 20th century wars in which the U. S. participated – whether military victory, negotiated settlement, or withdrawal – were determined by community engagement and support (or lack thereof).  Getting into wars is often not a community decision, but getting out of wars, one way or another, most often is.  

But what about peace? Is that also a community effort? There is growing recognition that investing in public health is one way to assure peace. One example is that the State Department's Strategic Plan for International Affairs lists protecting human health and reducing the spread of infectious diseases as strategic U. S. goals. This doesn’t get much attention but, if accomplished, could dramatically change the war/peace dynamic in the world. It is this kind of “behind the scenes” efforts of public health that could really make the world a more peaceful and healthy place. But this will happen only if the community comes together to support local, state, national, and international public health efforts.  

Public health may never get the public accolades it deserves but that’s not the goal. The ultimate goal is to protect and improve health and create the conditions for peace. We can do that by following the poetic advice quoted by my mother:  

There's something for all of us here,
There's big work to do, and there's lesser to do,
And the task you must do is the near. 

If you can't be the sun be a star;
It isn't by size that you win or you fail —
Be the best of whatever you are!

On this Memorial Day I honor our soldiers and all the people behind the scenes in our many war efforts. I also honor all public health workers because they are doing some of the most important work in creating a peaceful world and they are doing it the best way that they can from behind the scenes.