Monday, July 31, 2017

Making A Way Out Of No Way


On my last trip to Washington, D.C. I was unexpectedly provided an opportunity to visit the recently opened National Museum of African American History and Culture (NMAAHC). My guide was Alice Bonner, a museum docent with a background in journalism and theater, which provided a unique perspective to my tour. She enthusiastically greeted me and was clearly pleased at the opportunity to share her passion for African American history and culture in a building too long in coming. It was also obvious that she understood the relevance of that history to contemporary society and its role in shaping our future when the first thing she pointed out was that “this building is located at the corner of 14th Street and Constitution Avenue. The 14th amendment to the U. S. Constitution gave citizenship to freed slaves and provided them equal protection under the law. The fact that the 14th Amendment is exactly in the middle of our 27 constitutional amendments and that this building is centrally located on the National Mall should remind us of the central importance of citizenship to the future well-being of our country.”

We began the tour at the lowest underground level of the museum and steadily worked our way up through three levels encompassing four centuries of struggle and oppression; from slavery to emancipation, from Jim Crow segregation to the Civil Rights movement, and from Martin Luther King, Jr’s assassination to our current situation of a society built around structural racism. Given my time constraints, Ms. Bonner suggested that we move quickly through these levels because “they depict some pretty dark and depressing times and events. Even though you need to understand what happened and why, the pain and sadness can be overwhelming. I want you to leave here with some optimism and hope.”

That optimism and hope came when we reached the above ground levels of the museum. The highest level joyously celebrates the numerous contributions of African Americans to our country and the world. Providing a transition to that level is one which explores themes of agency, creativity, and resilience of African Americans who challenged racial oppression and discrimination by “Making A Way Out Of No Way.” The exhibits in this section highlight the determination of a people, despite overwhelming adversity, to create strategies and specific actions that challenged the racial status quo in America. The unifying lesson emanating from each display is the importance of a sense of community for survival and how powerful a community can be in stimulating change on an individual as well as community, national and global levels. In the process, “Making A Way Out Of No Way” offers hope for the future and an example of what is needed if our society as a whole is to survive and thrive.

After thanking and saying goodbye to Ms. Bonner, I reflected on my visit and was struck by the powerful way the NMAAHC chronicles the magnitude of the centuries-long and on-going fight for social justice and how it clearly displays the formidable forces persistently in opposition. The museum also demonstrates that the most powerful and only way to effectively counter those oppositional forces is to create and nurture a sense of community.

Likewise, the core value of public health is social justice which strives for health equity and optimal health for all. Like all struggles for social justice, health equity can only be achieved in communities where there is social cohesion and where everyone has a sense of belonging and bears some responsibility for the community’s well-being as well as the power to help make needed changes. The work of public health is to create that kind of community everywhere, for everyone. Those of us who have some responsibility for our nation’s public health can learn from the struggles of our African American neighbors and adopt some of the strategies they modeled to advance social justice. Only then will we be able to effectively assure the conditions in which everyone everywhere can be healthy.

I hope Ms. Bonner somehow knows that as I left the NMAAHC, I was filled with optimism and hope.


Thursday, July 6, 2017

Life, Liberty, and the Pursuit of Social Justice

“We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.” Declaration of Independence, adopted in Philadelphia, July 4, 1776.

“…one Nation under God, indivisible, with liberty and justice for all. The Pledge of Allegiance, adopted by Congress in 1942.

As we celebrate Independence Day, think about Crispus Attucks, the first person to die in the American Revolution. He was a person of color who was part of a crowd in Boston standing up to British soldiers sent to quell the American resistance. The mob threw snowballs; the soldiers fired guns. The soldiers were put on trial for murder and defended by future U.S. president John Adams. His words describing Attucks have a modern tone, “This was the behaviour of Attucks;-to whose mad behaviour, in all probability, the dreadful carnage of that night, is chiefly to be ascribed.” At the end of the Boston Massacre trial six soldiers were found not guilty of murder. Two were convicted of manslaughter and given the penalty of thumb tattoos.

Justice was a central issue at the founding of our country and remains so today.

Public health is based on the principle of social justice – a recognition of the shared nature of our individual and societal welfare and a belief in the collective responsibility to assure that all people have their basic human needs met and no one unfairly benefits to the detriment of others. This foundational principle of public health is embedded in the stated American value that we celebrate every July 4th “that all men are created equal.” 

Despite our lofty democratic and public health visions of a socially just America, we are far from achieving that goal. Our societal shortcomings are seen in the disparities and inequities in health and economic status, educational achievement, and environmental quality that disproportionately impact populations of color, American Indians, the LGBTQ community, and people with disabilities.

A lack of social justice breeds social isolation, fear, alienation, and mistrust which impacts all parts of our society. I thought of those consequences of injustice as I watched and listened to the recordings of the shooting of Philando Castile and reflected on the “not guilty” verdict in the Yanez trial. I realized that if we are to learn from this event and move toward a more socially just society, our perspective can’t solely be a legal one. We must also focus on the emotional, ethical, and moral issues that connect us as human beings and which hold the potential to unify us as a community.

That human connection was palpable as I listened to the voice of the innocent 4-year-old child who had just witnessed a fatal shooting. Hearing the fear in her voice as she worried about her mother’s safety and recognizing her stress and anxiety as she took on the role of protecting her mother brought tears to the eyes of this pediatrician and pain to the soul of this grandfather. It made me sad and angry because I knew that this was an avoidable catastrophic adverse childhood experience (ACE) that threatens this child’s immediate well-being and her long-term health. All I could do at the time was cry and send prayers. But there is much more we can do – much more that we must do to create a safe, inclusive, and socially just society.

“Trauma-informed care” is one strategy available to address childhood trauma, but in public health we must go beyond care to the prevention of ACEs. We must address the precipitators of events like this shooting; what I call “Adverse Societal Conditions” (ASCs) –– the racism, sexism, classism, homophobia, and intolerance of diversity that have been a part of America since its founding.

We know how ACEs impact an individual, but we must recognize the evidence that ASCs affect everyone. Not just African-Americans who fear for their life every time they are stopped by the police. Not just transgender people who are bullied for trying to make peace with their identity. Not just Muslim women who are harassed and attacked for wearing a hijab. Not just immigrants who are systematically labeled and derided as terrorists, rapists, and criminals. Everyone! Including affluent, educated, white, and politically powerful individuals.

Just as “trauma informed care” helps heal the wounds of ACEs, we need an approach to heal the wounds of ASCs – the social isolation, fear, alienation, and mistrust of diversity that is too common in our society. The path to that healing might be contained in the origin of the word “heal,” from the Old English word “hal” which is also the root for health, whole, and holy. If we are to become a healthy society, we must heal our societal wounds and become whole. That is our sacred duty.

Our focus on Advancing Health Equity has been a small step in this healing process. The Triple Aim of Health Equity is centered on the value of “social cohesion” and creating a sense of belonging. It’s a step in making the community whole that can lead to better health. Building on that belief, our 2017 Statewide Health Assessment focuses on that notion of “belonging.” My hope is that this assessment will frame the action steps necessary to build social cohesion and make our community whole and healthy.

Because of societal injustices we are all less safe, less secure, and less whole. We will never heal, we will never be healthy, until we can become whole. Our sacred public health work is to help create a socially just society that advances health equity. That is also part of our civic responsibility to build community and strengthen democracy so “that government of the people, by the people, for the people, (all the people) shall not perish from the earth.”

Happy Independence Day.

Tuesday, May 30, 2017

Laws and Sausages

“Laws are like sausages, it is better not to see them being made.” Attributed to Otto von Bismarck

The chaotic ending of the 2017 regular and special sessions of the Minnesota legislature prompted multiple references to sausage making. Most comments reflected the sentiment in the attributed Bismarck quotation. As someone with Germanic ancestry (where sausages are a staple of everyday life), a Minnesota citizen (where laws help shape our everyday life), and a state agency head (where I can actually observe how laws are made), I say baloney!

Even though I recognize this quotation as a “tongue in cheek” statement, the actions of the last few weeks make me wonder if others actually take it literally – that laws should be made outside of the view of the public. We need to reframe the discussion; laws are like sausages and it’s absolutely essential for our health and the long-term well-being of our society to see what’s in them and how they are made.

Sausage making is a traditional food preservation technique going back thousands of years. It is also a conservation technique that helped assure that no vital nutrients were lost or wasted. Sausages helped sustain societies through cold, tough times and fortified them as they grew and expanded. They also embodied a great deal of cultural variety and helped add flavor to an often mundane existence.

When times were good, choice cuts of meat were used to make sausages. When times were tough, less desirable parts of animals were included along with other fillers and, with various spices and preparation techniques, made to be palatable, even tasty. Because sausages were crucial to people’s survival, it was recognized early on that consumers needed to know what went into sausages and how they were made. Given the sausage-making process, it was too easy for unskilled or unscrupulous butchers to create tainted products that frequently led to illness and death. This need was graphically reinforced even into the 20th century when the 1906 book “The Jungle” by Upton Sinclair highlighted the unsanitary and unsafe working conditions in the meat packing industry. This book led to the passage of the Meat Inspection Act and the Pure Food and Drug Act, which established the Food and Drug Administration.

Today, sausages are produced according to recipes; the ingredients are specified, carefully measured, and accurately identified on a label. Inspectors from the United States Department of Agriculture regularly inspect plants that make sausages for public consumption. For our health, well-being, and long-term survival it’s important to know how sausages are made.

Laws have been around at least as long as sausages (probably longer) and are even more essential to the long-term survival and prosperity of a community. Ideally, they add stability, fairness, security, and opportunity to a society. They help communities thrive during good times and sustain themselves during tough times. They help make best use of resources and help people optimally grow and develop. But that only happens when the lawmaking recipe includes openness to scrutiny, assurance that the voices of community members are part of the process, and lawmakers being accountable to their constituents. If that transparency and participation is absent, the needs of the wealthy are often prioritized over those of the poor, the community good is subjugated to the needs of some individuals, and long-term investments are delayed to meet short-term objectives. If we fail to inspect and monitor the process, a great deal of pork can get into laws leading to legitimate beefs by those left out. (Sorry about that.)

Laws are like sausages but for our health, well-being, and long-term prosperity it’s important to know how both our sausages and laws are made. We should never turn our eyes away from either and risk our health and the health of our democracy.

Now I’m going to go out and grill some well-inspected bratwurst – I think there’s a law that says you have to do that on Memorial Day.


Monday, April 3, 2017

Public Health Week 2017 – The Best of Times

In April 1859 the first of 31 weekly installments of Charles Dickens’s "The Tale of Two Cities" was published in a literary periodical titled "All the Year Round." The novel starts with the famous sentence: “It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us, we were all going direct to Heaven, we were all going direct the other way—in short, the period was so far like the present period…”

I don’t know if Dr. Martin Luther King, Jr. had that sentence in mind when he gave his “I’ve Been to the Mountaintop” speech in Memphis 109 years later on April 3, 1968, but his words underscored the theme. With rhetoric that presaged his assassination the following day (which would lead to some of darkest days in United States history) Dr. King clearly stated that these were the best of times. “Something is happening in our world. … if I were standing at the beginning of time… and the Almighty said to me, …’which age would you like to live in?’ I would take my mental flight (through Egypt, Greece, Roman Empire, Renaissance, Wittenberg with Martin Luther, Emancipation Proclamation, etc.)… But I wouldn't stop there. Strangely enough, I would turn to the Almighty, and say, ‘If you allow me to live just a few years in the second half of the 20th century, I will be happy.’”

He explained that “…the reason I'm happy to live in this period is that we have been forced to a point where we are going to have to grapple with the problems that men have been trying to grapple with through history, but the demands didn't force them to do it ... (and) let us keep the issues where they are. The issue is injustice.”

April 3, 2017, the 49th anniversary of that speech, is also the first day of National Public Health Week. For those of us in public health, this truly is the best of times and the worst of times, the age of wisdom and the age of foolishness, the season of light and the season of darkness, and the spring of hope and the winter of despair. We are living longer than ever before but that progress has already been reversed in some sub-groups. Fewer babies are dying than ever before but we are falling farther behind other countries in this crucial health indicator. Tobacco use is falling while our weight is rising. Our air and water quality is generally improving but regulations are being promoted that threaten the quality of our environment and our health. And while the overall health of our society is quite good, an increasing number of our fellow citizens don’t share in our wellness. In fact, it’s these inequities that portend the worst of times to come. As Dr. King said, “The issue is injustice.”

The theme for Public Health Week is “Telling the Story of Public Health.” Our story of public health is an amazing one. It celebrates successes and it identifies the problems and challenges that exist. It honors the people who help make this world safer and healthier and it keeps us focused on the social justice and equity issues that serve as the foundation for a healthy society. The Story of Public health is based on social justice and health equity brought to life: it is the public manifestation of social justice.

For public health, as Dickens said, these are the best of times and the worst of times. As Dr. King said, there is no better time to be alive because we have the opportunity to grapple with problems that have plagued society throughout history. And, as Senator Robert La Follette, Sr, one of my public health heroes reminded us, “There never was a higher call to greater service than this protracted fight for social justice.”

Thank you to all the public health workers who grapple to make these the best of times, even at the worst of times.


Monday, February 27, 2017

Science and Social Responsibility

On the edge of the National Mall in Washington, D.C. stands a building housing the National Academies of Science, an organization founded by Abraham Lincoln in 1863 to advance scientific knowledge for the purpose of improving people’s lives. Near the main entrance to the building is a memorial to Albert Einstein, one of history’s pre-eminent scientists. The memorial centers on a Robert Berks sculpture of Einstein that contains several engraved quotations by and about Einstein.

Given the current political and social climate, one statement by Einstein particularly struck me when I visited the memorial on Presidents Day: “As long as I have any choice in the matter, I shall live only in a country where civil liberty, tolerance, and equality of all citizens before the law prevail.” I wonder if this brilliant, Jewish, immigrant, scientist who changed the course of history, would have made the choice to live in the United States today. And how many like him are making that decision today?

Another Einstein quotation also spoke to today’s environment: “The right to search for truth implies also a duty; one must not conceal any part of what one has recognized to be true.” I wish he would have added the logical next sentence which would be that there is also a duty to use the truth in decisions, policies, and plans that impact the well-being of humanity. If he had, perhaps this 2002 statement by the Institute of Medicine (part of the National Academies of Science) would have been more influential in shaping current health and social policies: “The health of populations and individuals is shaped by a wide range of factors in the social, economic, natural, built, and political environments…(and we must) take into account the potential effects of social connectedness, economic inequality, social norms, and public policies on health-related behaviors and on health status…Health care services and biomedical technologies can generally only address the immediate causes of disease … and do so on an individual basis. Preventive approaches (like policies on education, housing, living wage, or clean air) that focus on populations are likely to have broader impact.”

This disconnect between knowledge and actions was on my mind when I left the Einstein Memorial for the memorials to a couple of presidents (the real reason I was at the National Mall on Presidents Day). These presidents led the nation during some of the darkest times in American history – Abraham Lincoln, who led our country through a civil war in which 700,000 people died while freeing more than 4 million slaves, and Franklin Roosevelt, who led our country through the Great Depression and a global conflict against fascism and genocide that claimed the lives of 70 million people.

These monuments reminded me that, as important as they are, data and truth aren’t the primary factors that influence policies and programs. Values, ideologies, history, culture, and dreams for the future are often the most powerful forces in guiding our actions. Fortunately, even during times of crisis and challenge the basic values and dreams of our democracy have endured and kept us moving forward. To help remind us of their importance and relevance, they are etched in stone on these two monuments. The Lincoln Memorial highlights those values with the words of Lincoln’s Gettysburg and Second Inaugural Addresses: “With malice toward none, with charity for all” – “a new nation, conceived in Liberty, and dedicated to the proposition that all men are created equal.”

The emphasis at the Franklin Roosevelt Memorial is on the "four essential human freedoms…freedom of speech and expression…freedom of every person to worship God in his own way…freedom from want...freedom from fear.” Roosevelt also underscored the importance of social cohesion and the need to focus on the conditions essential for a nation to thrive. This great leader reminded us of the need to embrace the value of the social justice, which is also at the core of public health. “The test of our progress is not whether we add more to the abundance of those who have much, it is whether we provide enough for those who have too little.”

Visiting these three memorials was a needed balm for today’s challenging environment and a great preparation for the public health meeting that brought me to Washington because they embody not only the heart and soul of our country’s values but the heart and soul of public health – science and social justice. In our civic endeavors we must work to assure that our country’s core values are embedded in all public policies. As public health workers, it is our solemn duty to discover truth and to share and use that truth to advance policies and programs that improve health and advance health equity.

Einstein was a good example of responsible civic and professional work. My hope is that the statement on the Einstein sculpture that describes this icon would also be applicable to all of us: “a scientist whose work led to a new understanding of the world and who believed his work was a solemn trust to be used for the common good.” That work is more important now than ever.


Monday, February 13, 2017

#BoldNorth Public Health

When talking with people about the work of public health, I often state that “if it’s not fun, it’s not public health.” That’s not to deny that the work of public health is serious, important, and sometimes challenging and difficult. On a daily basis Minnesota’s public health professionals address complex, life-threatening, and often traumatic situations that impact the health and well-being of everyone in our state; where the outcomes are sometimes distressing, disheartening, and devastating to individuals, families, and communities. When I talk about public health being “fun,” I am referring to the joy and satisfaction in the public health work that significantly impacts health and advances health equity and social justice.

But sometimes there really is boisterous fun in public health. Last week was one of those times. On Feb. 8, I helped kick off the 52 week run-up to next year’s Super Bowl which will be held in Minnesota. I did my part by hopping on a “fat tire” bike and pedaling with a group through the snow at Theodore Wirth Park while others snow-shoed, skied, or tubed down the hills. I can’t think of anything more fun than being outside with colleagues and friends in sunny 10 degree (my favorite temperature) weather and being physically active in the snow that gives Minnesota its identity, character and charm.

What made this event “fun” in public health parlance, was the fact that this was the first of 52 weekly events at which the Minnesota Super Bowl LII Legacy Fund Committee will make a health/wellness grant to a Minnesota community. With the theme of “Fuel, Fun, and Fundamentals,” the committee recognizes the importance of nutrition and physical activity to health and well-being and the need to build the community capacity to support those healthy behaviors throughout the state.

The first grant awarded was for $52,000 to the Loppet Foundation to build “The Trailhead: A Home for Year-Round Adventure.” The Trailhead will be a building at Wirth Park developed through a partnership of the Loppet Foundation and the Minneapolis Park and Recreation Board to advance equity in outdoor recreation. Since 2002, the Loppet Foundation has engaged more than 12,000 students, including more than 9,000 from nearby North Minneapolis, in outdoor activities including mountain biking, cross country skiing, trail running, paddling and orienteering. The Trailhead will enhance those efforts.

The kick-off event included the presence of dozens of children from the North Minneapolis’ Lucy Laney Elementary School, who spent the afternoon tubing and enjoying the snow; healthy food from the Breaking Bread CafĂ© subsidiary of Appetite For Change, a North Minneapolis community-based nonprofit whose mission is to “use food as a tool to build health, wealth, and social change;” and fat tire bicycling instruction from Anthony Taylor, one of the founders of the Major Taylor Bicycling Club that advocates for increased biking in the African American community.

The event also highlighted how our “health in all policies” and “community engagement” efforts are paying dividends. In partnership with the Department of Health, the Department of Education, the National Dairy Council/NFL’s Fuel Up to Play 60, and others, the Super Bowl Legacy Grant Committee has worked to ensure all of Minnesota is included in these grants. With its presence in every Minnesota county, our Statewide Health Improvement Partnership (SHIP), under the leadership of Chris Tholkes, was able to help communities make the most of this Super Bowl grant opportunity. MDH alerted SHIP grantees of the opportunity and SHIP staff convened local stakeholders from existing leadership teams – such as mayors, city administrators, county commissioners and community nonprofit partners – to identify potential health and wellness capital investment opportunities. The outcome of that work is that communities throughout the state will not only be receiving grants but also be better positioned to use the resources to meaningfully address health and wellness needs in their communities. The presence of SHIP in communities throughout the state was the perfect platform for developing this effort to create better health.

People rarely think of the Super Bowl as a healthy activity. Tons of Buffalo wings and oceans of beer consumed by millions of Americans watching professional athletes risk concussions and other serious injuries hardly screams public health. However, the Legacy Fund Committee under the overall Super Bowl LII theme of “Bold North” has implemented a bold initiative to use the hype of the big game to encourage healthy community activities statewide. Their unique capital project investments with the Loppet Foundation and 51 other partners across Minnesota will benefit the health of our state long after the Lombardi trophy is awarded (to the Vikings/Packers?). This initiative also presents an opportunity to challenge public health workers to implement and support bold and innovative policies and system changes that create better health for all. We just need to make sure that Bold North Public Health embraces the fun that brings joy and satisfaction to the important public health work that we do every day in creating a healthy state. Go Team!


Tuesday, January 17, 2017

MLK and the values of public health

The 2017 World Economic Forum begins on January 17 in Davos, Switzerland. The forum brings together influential people from the political, financial and business sectors from around the globe to discuss “the big issues facing the international economy.” This year’s theme is “Responsible and Responsive Leadership.”

In anticipation of the forum, Oxfam International, “a global movement of people working together to end the injustice of poverty,” issued a report stating that just eight men in our world own as much wealth as 3.6 billion people – and that this incredible the gap is growing every year. Winnie Byanyima, executive director of Oxfam International commented: "It is obscene for so much wealth to be held in the hands of so few when 1 in 10 people survive on less than $2 a day. Inequality is trapping hundreds of millions in poverty; it is fracturing our societies and undermining democracy."

This Oxfam report was released on the day we honor and celebrate the work of Dr. Martin Luther King, Jr. and echoes many of Dr. King’s core messages from 50 years ago. Sadly, the situation seems to have only gotten worse since 1967 when he stated:

“I am convinced that if we are to get on the right side of the world revolution, we as a nation must undergo a radical revolution of values. We must rapidly begin the shift from a thing-oriented society to a person-oriented society. … A true revolution of values will soon look uneasily on the glaring contrast of poverty and wealth with righteous indignation. … America, the richest and most powerful nation in the world, can well lead the way in this revolution of values. There is nothing, except a tragic death wish, to prevent us from reordering our priorities.”

This reordering has not yet happened. However, I believe the work being done to advance public health values through the Triple Aim of Health Equity with its focus on policy, system and environmental change strategies is exactly what Dr. King was advocating when he said:

“A true revolution of values will soon cause us to question the fairness and justice of many of our past and present policies. On the one hand, we are called to play the Good Samaritan on life’s roadside, but that will be only an initial act. One day we must come to see that the whole Jericho road must be transformed so that men and women will not be constantly beaten and robbed as they make their journey on life’s highway. True compassion is more than flinging a coin to a beggar. It comes to see that an edifice which produces beggars needs restructuring.

The role of public health is to facilitate that restructuring. As the Institute of Medicine stated, it is the job of public health “to assure the conditions in which (all) people can be healthy.” With the spirit of Martin Luther King, Jr. in mind, it is our job to transform the Jericho road and WE shall…