Monday, January 26, 2015

Beyond Insurance: Creating the Conditions for Health for Everyone

(I was invited to speak today at a church service and attend a post-service forum about what they could do to make health care more accessible and affordable. I was unable to stay for the forum so I’m not sure what they decided to do. However, I thought you might be interested in some of my comments to the congregation as preparation for their discussion.)

When I was a junior in high school and was debating what career path I should take, I came across the book The Other America by Michael Harrington. The book started with this passage:

“There is a familiar America. It is celebrated in speeches and advertised on television and in magazines. It has the highest mass standard of living the world has ever known… but, there is another America. In it dwells somewhere between 40,000,000 and 50,000,000 citizens of this land. They are poor. … tens of millions of Americans are, at this very moment, maimed in body and spirit, existing at levels beneath those necessary for human decency. … They are without adequate housing and education and medical care.”

It was that book and the picture that it painted about the disparities and inequities that existed in our country that prompted me to choose a career in medicine; thinking that being a physician and working in underserved areas would be an effective way to address those disparities.

Sadly, after more than 40 years as a physician, what was written in 1962 is as accurate and as relevant today as it was then. “There are millions of Americans maimed in body and spirit existing at levels beneath those necessary for human decency, without adequate housing, education, and medical care.”

The persistence of the health problems in our country is certainly not because we haven’t worked on the issues or spent money on them. Despite talking about health reform every year for the last four decades and spending more money on health care than any other country in the world, we are far from the healthiest population on the planet.

Fortunately, I was not the only one affected by Michael Harrington’s book The Other America. It was read by John F. Kennedy and it formed the basis of his social and economic agenda that ultimately led to the Johnson era Great Society programs and the War on Poverty.

I mention that today because it’s exactly 50 years ago this month that the 89th congress was convened, arguably the most productive congress in history. It was a congress that addressed the inequities in our society in ways not seen since then. This is the congress that passed, among other things:

  • Medicare and Medicaid
  • The Voting Rights Act (a year after the Civil Rights Act)
  • Job Corps
  • Peace Corps
  • School lunch program
  • Food stamps
  • Head Start
  • Neighborhood health centers
  • Older Americans Act
  • Elementary & Higher Education Act
  • Housing & Urban Development Act
  • Vocational Rehabilitation Act
  • The Freedom of Information Act
  • Cigarette labeling and advertising act
  • Public Works and Economic Development Act
  • National Foundation on the Arts and the Humanities Act
  • Immigration and Nationality Act
  • Motor Vehicle Air Pollution Control Act
  • Highway Beautification Act
  • National Traffic and Motor Vehicle Safety Act
  • National Historic Preservation Act
  • National Wildlife Refuge System Act
  • Department of Transportation Act
  • many more 
People argue about whether or not the Great Society programs and the War on Poverty worked. From my public health perspective, they were a resounding success. Poverty rates declined, especially for the elderly. We had a more balanced investment in health and social services and what we spent on health care remained in-line with what other developed countries were spending. And our overall health status improved and health disparities were reduced.

The activities that emanated from this national effort reflected what I discovered in my first three months of medical practice – that medical care alone will not make us healthy. I learned quickly that even if I spent every day of my medical career treating dozens of people with diseases, injuries, and disabilities, the overall health of the community would not improve. The unhealthy physical, social, and economic environment in which my patients lived overwhelmed whatever care I could provide. I learned that access to high quality medical care is necessary, but not sufficient, to create a healthy society.

While understanding that medical care is of crucial importance, the policy makers in the 89th congress recognized that it is the policies, systems, and the socioeconomic and physical environments that play the biggest role in determining health. That’s why they not only invested in medical care through Medicare and Medicaid, but also invested in economic development, education, housing, transportation, environmental protection, and a whole lot more. They also empowered communities to become engaged in the decision-making process that developed and implemented programs and initiatives. In addition, they understood that health is not solely under the purview of the health care sector – that every sector is necessary to create a healthy society. In the public health parlance of today, they took a health in all policies approach. They invested in the public good. They invested in the commons. They invested in communities.

We need to learn from that experience because our research now demonstrates the wisdom of that approach in that socioeconomic conditions have been shown to account for more than 50% of our health while medical care contributes about 10%.

We also now know that it’s the disparities in education, income, wealth, housing, and access to a variety of services that lead to health disparities and that those disparities affect the overall health of the community – even those at the top of the socioeconomic ladder. We also recognize that these disparities don’t happen by accident. They are the result of policies that systematically disadvantage some groups, particularly low income populations and people of color and American Indians. That’s why it’s not surprising that the Great Society efforts to improve the health of all Americans were linked with the Civil Rights movement. A socially just society leads to better health for everyone. That’s why the Minnesota Department of Health has made advancing health equity the central focus of our efforts to create a healthier Minnesota.

Unfortunately, the Great Society programs were affected by the Vietnam War which stressed our budget and undermined our trust in government. In the early 1980s a variety of factors led to the dismantling or reduction in support for some of those Great Society programs.

That was also the time when the conversation about what creates health was being systematically recrafted. What emerged was the narrative that health is determined by personal choices and access to medical care. The narrative was that if people simply had health insurance that provided access to high quality health care and they made good choices about diet, exercise, and drug use, they would be healthy.

Looking back, it was at that point that we began to disinvest in the public good and abandoned our community-oriented approach to health and increased our investment in medical care. It was also when our health status (compared to other countries) began to decline, when disparities began to increase, when homelessness and hunger began to reappear, and when our health care costs began to rise astronomically.

That narrative about the primacy of medical care and individual responsibility remains dominant today. It’s that narrative that drives our health policy and it distracts us from what really creates health.

The truth is that health care accounts for only about 10% of our health and personal behaviors account for less than 30% and many of those are often outside the control of the individual. It’s hard to choose healthy food when you are poor and live in a food desert. It’s difficult to be physically active when your neighborhood is unsafe or you are working three jobs just to survive.

Well over 50% of our health is determined by the physical and socioeconomic environment in which we live, learn, work, play, and pray. Despite that, over 95% of our rapidly increasing health expenditures go toward clinical care which obviates the investments in the social and economic conditions necessary to create health for everyone. Without these investments in the community good, which will help prevent the development of disease and disability, the costs of health care will continue to rise.

While it’s important to work for universal access to high quality, culturally appropriate health care, the health of our society cannot be improved solely by those efforts. Certainly, having universal access to a single-payer system would help. But, in fact, our myopic focus solely on health care, health insurance, and medical financing mechanisms, actually interferes with what needs to be done to effectively improve our health. It limits the scope of the needed discussions around health and it limits the discussion to experts in the field of health care. What really is required is the active involvement of all people from all sectors of our society who recognize and understand the broader determinants of health and are willing to work to create a society that is more socially responsible and socially just.

That’s where you come in. As individuals and as a community, you can help change the narrative about what creates health. You can attest to the fact that it’s the policies and systems that create the conditions that support or undermine health. And it’s not just the official health policies that are crucial but the education, housing, transportation, environmental, and economic policies. You can make the case that many in our society don’t have the opportunity to make healthy choices because they are limited by their income, their education, their neighborhood, or their mobility. You can work toward policies that assure a livable wage, paid parental and sick leave, safe and stable housing, effective transportation, incarceration justice, educational achievement, and much more. You can bring an equity lens, a social justice lens, to those conversations recognizing that as Paul Wellstone said, “We all do better, when we all do better.” And you can hold policy makers and public officials like me accountable for the decisions that affect our communities.  

Public health is defined as what we, as a society, do collectively to assure the conditions in which all people can be healthy. That definition doesn't say anything about doctors or nurses or hospitals or clinics. It doesn't even mention health departments. It includes all of us as a society. All of us are responsible for creating the conditions in which people can be healthy. It’s our job, not someone else’s. All of us are part of the collective effort necessary to build a socially just society.

What better place to start that work than here? What better time than now?


Tuesday, January 13, 2015

Inauguration 2015

Like every other commissioner in attendance, I listened closely to Governor Dayton’s 2015 Inaugural Address for any reference to issues related to my agency.  Although I didn’t hear specific references to health or the Minnesota Department of Health (MDH), I was pleased with what I heard – a speech constructed around principles, goals, and initiatives that should gratify anyone concerned about the long-term health of the public. 

The speech began with an emphasis on economic security and education – two of the greatest determinants of health – and concluded with a call for “community” recognizing that “what binds us together is much more important than what pulls us apart.  What helps one region usually benefits our entire state.”  It was the Governor’s take on the Institute of Medicine definition of public health as all of us working “collectively to assure the conditions in which people can be healthy.”

In between, the Governor underscored issues that are core to public health: inequities (“inequities in wealth and income are at record highs”) and the need to strike a balance between spending on current needs and investing in the future welfare of our state (“Spending is for now…Investing is for the future…to produce future benefits and rewards. Wise financial management requires understanding this difference and striking a proper balance between them.”)  That echoed what public health workers have been saying about balancing investments in treatment and prevention, medical care and public health.  He tied all these themes together by recommending “that our top priority be to invest in a better future – by investing it in excellent education…and making that educational excellence available to everyone.”

The Governor emphasized education because“…an excellent education unlocks the door to unprecedented opportunities.  Our future success – the health of our families, the vitality of our communities, and the prosperity of our state – will depend upon our making those excellent educations available to all Minnesotans…education is the key to our survival.  That certainly underscored the MDH vision for advancing health equity – that everyone have equal opportunities to be healthy. 

In concluding his speech with a call for community, Governor Dayton urged that we should cast “Minnesota modesty aside – we should be proud because we so often are the best…(having) earned (that) through smart minds, good ideas, and hard work; through all of us pulling together and making our state – despite lacking the advantages of ocean beaches, or Rocky Mountains, or fossil fuel riches – into a place (that is) unique and extraordinary.  A state upon which we proudly emblazon our motto: ‘L’Etoile du Nord,’ ‘The Star of the North,’ and bequeath it even brighter to future generations.”

As I stood with the rest of the crowd applauding, I thought “that was a great public health speech;” a speech that should challenge all of us for the next four years in creating a legacy of health and equity for our children, grandchildren, and great grandchildren.  Perhaps we even have the opportunity to create another “Minnesota Miracle” – one appropriate for the 21st century. 


Tuesday, December 23, 2014

Moving Beyond Checkmate

It was 60 years ago this month that I learned how to play chess.  Although chess has brought me some enjoyment over the years, the process of learning the game brought me some much more important life lessons.  

As the 1954 December holidays approached, the demand for the new board game “Scrabble” was exceeding supply so, when my last-minute-shopper parents got to the local department store on December 24th, none were to be found.  Looking around at the mostly empty shelves in hopes of finding an overlooked “Scrabble” game, my mother noticed a few chess sets.  On the boxes was the inscription “Chess, the Game of Kings.”  My mom thought “If it’s good enough for kings, it should be good enough for my children.”  

Neither of my parents had ever played chess so on that night before Christmas while the rest of the family was nestled snugly in bed, my mother read the rules and taught herself to play chess.  The next day when the hubbub of present opening was over and the dinner dishes had been washed and put away, my mom took my two older brothers and me aside and taught us how to play chess.  

My brothers learned the game very quickly and soon were teaching their friends how to play.  For the next couple of weeks we had a steady stream of neighborhood kids coming over to play chess.  Because of the fun they were having, many of the kids used their Christmas money to purchase chess sets while their new “Scrabble” games sat idle – at least for a while.

I learned a bit more slowly but within a week I had mastered the basic concepts of the game.  When I was finally able to call “checkmate” on my mom, she smiled and said that I was now good enough to play with the older kids and teach the younger siblings how to play when they were ready – which I dutifully did.

Over the next 51 years of her life, I never saw my mother play another game of chess.  I suspect that once she was confident that all of her children would learn how to play chess she felt it more important to move on to teaching them other things.  

About the same time that my mother was teaching me to play chess, Geoffrey Vickers was educating people about public health’s role in the “continuous redefining of the unacceptable.”  I frequently use that definition when I talk about public health.  While that definition highlights the importance of focusing on the problems we face in our society, I now realize that it provides a one-sided view of public health and its goal to protect and improve the health of all people.  As I look back to Christmas 1954, it’s evident that my mother was giving me a perspective that could balance and complement that of Vickers.  Although she was focusing on a relatively small population (her family), she knew what they needed to optimally grow and prosper.  In addition to addressing deficits, she was modeling another necessary component of the definition of public health as the “continuous redefining of the opportunities.” 

Public health needs to function as the conscience of our health system by continuously defining what’s unacceptable.  Public health also needs to lead the way to eliminating those unacceptable conditions/situations.  But of equal (if not greater) importance is the need for public health to identify the opportunities for all of us, as a society, to optimally grow and prosper.  Geoffrey Vickers and my mother helped me see and understand that continuum. Together they taught that once we checkmate today’s public health problems, we need move on to the next challenge and opportunity.  


Monday, December 1, 2014

Who will be stirring the public health pot?

In 1997 I played hooky from the morning sessions of the American College Health Association annual meeting in New Orleans to get a different view of the Crescent City than I was getting from inside the convention center. I remember that it was a moderately hot and humid day in a city not known for its moderation. I also remember that it was raining intermittently and that one of the rain showers forced me to seek shelter in a near-by French Quarter building – the Jackson Brewery which no longer housed a brewery but rather a spate of trendy boutiques and gift shops.

Since shopping is not one of my favorite pastimes, I looked for a place to pass the time while waiting for the rain to stop. On the far end of the building I noticed a sign for the New Orleans School of Cooking. The sign announced that there was still space available in a class that was just about to begin. Without a second thought, I signed up.

Within minutes I was in a “teaching kitchen” surrounded by a jumble of aromas and jars and bottles of colorful spices and cooking ingredients. The teacher/chef informed the “class” that we would be making Cajun Gumbo, Creole Jambalaya, Bread Pudding with Whiskey Sauce, and Pecan Pralines. Since the class would end at lunchtime, we would have the opportunity to eat the results of our cooking. Given that the class was taking place in an old brewery, the teacher/chef thought a few glasses of beer for the students would be appropriate. He thought it might even help with the cooking – or at least make the class more enjoyable. None of the students objected.

Over the next three hours we mixed, seasoned, stirred, sautéed, boiled, baked, tasted, sipped, and laughed. Using the “be’s right” method (cook it until it “be’s right”), I learned the importance of cooking something “until it looks pretty.” I was introduced to the Louisiana “Holy Trinity” of vegetables: onions, bell peppers, and celery. I discovered that rice is a staple in the New Orleans diet because it is the only grain that can grow in wet climates. In the process I was also given a lesson about the geographic, historical, social, and cultural influences that have shaped Louisiana and its cuisine.

The class went quickly and all of the recipes worked perfectly. As we sat around the table enjoying the results of our efforts, the teacher ended the class with this observation: “A regional cuisine is the product of geography and history. Geography determines what goes into the pot and history determines who stirs it. The geography remains relatively constant but the history is ever changing and evolving; so is the cuisine.”

I thought of that experience a couple of weeks ago when I was back in the Big Easy for the annual meeting of the American Public Health Association; my first trip back since 1997. Much had changed in 17 years. One noticeable difference was that, as health commissioner, my time at this meeting was tightly scheduled and I had very little free time to explore the city. There was no time to play hooky because in the course of a couple of days I had to give three presentations, participate in several meetings on issues related to MDH initiatives, and “meet and greet” people at a couple of receptions while trying to earn a few CME credits. No need for pity though; I was still able find time in the two evenings I was there to visit a couple of noted New Orleans restaurants and sample the local cuisine. It was during these outings that I noticed the more global changes that have occurred in NOLA.

In 2005 Hurricane Katrina devastated the city. Physically and economically, most of the tourist areas have bounced back but the recovery of the rest of the city is uneven. While some neighborhoods are struggling to recover, other neighborhoods are rapidly gentrifying. But the most notable change is the demographics. Many who left after the storm have yet to return. Many who came to help with the clean-up and rebuilding have stayed. The racial and ethnic make-up of the city has changed dramatically on both ends of the socio-economic spectrum. You can see it among the cab drivers, the airport and hotel workers, the wait staff, and on the streets outside of the French Quarter. You can also see it in the clientele of trendy restaurants.

I could even taste the demographic change in the food that was served; it had more of an Asian and “Tex-Mex” flavor than I had noted in 1997. As I looked at the menu that listed “Vietnamese Blackened Catfish Tacos,” I thought of the statement by the teacher/chef from the New Orleans School of Cooking; “Geography determines what goes into the pot and history determines who stirs it.” It was obvious that New Orleans and its cuisine were evolving because of its changing history.

But New Orleans is not alone. It struck me that Minnesota is also evolving. Despite climate change, Minnesota is still dramatically influenced by the geography that has remained relatively unchanged, a geography that definitely contributes to what goes into our pot – not just our culinary pot but all parts of our socio-economic and public health pots. Conversely, the history that determines who stirs our pot is changing in a much more dynamic way. The changing demographics of our state guarantee that the people stirring the public health pot in the future will be markedly different than in the past. Just as the New Orleans diet evolved from the blend of French, Spanish, Mexican, Indian, Cajun, Creole, Asian, and African influences, our socio-economic and public health systems will evolve from the influences of the new and varied residents who now and in the future will make Minnesota home. Our history and who stirs the multiple Minnesota pots is changing. And like New Orleans cuisine, Minnesota society will be constantly evolving. As health commissioner, I can’t wait to sample and taste our future public health system’s complex and robust flavor.


Thursday, November 13, 2014

Veterans Day 2014

November 11, 2014

When I tell people that I’m a Veteran, their first response is usually “I didn’t know you were in the military.” That statement is then routinely followed by the question, “In what branch of the military and during what era did you serve?” When I tell them I wasn’t in the military they are really perplexed until I explain that I served in the United States Public Health Service Commissioned Corps, one of the seven “uniformed services” that also include:  the United States Army, Marine Corps, Navy, Air Force, Coast Guard, and the National Oceanic and Atmospheric Administration Commissioned Officer Corps. Besides a uniform, the common bond between these organizations is their mission to protect the health and well-being of the people of the United States and to partner with other countries to address the threats to peace, health, and safety throughout the world.

The U.S. response to the Ebola crisis in Liberia, Sierra Leone, and Guinea is a great example of how this broad mission gets advanced in a non-combat manner by several of the uniformed services. Military and public health personnel are partnering to fight an infectious disease that poses a threat to people in the U.S. and throughout the world. That threat is not only to health but to economic, social, and governmental systems that, if disrupted, could destabilize communities and countries and lead to new and broader conflicts. That’s why all of the uniformed services are vital to our health and security. This also underscores the “Health in All Policies” approach needed for health and security in that the uniformed services are part of different governmental departments:  Defense, Homeland Security, Health and Human Services, and Commerce. Our response to Ebola highlights the various ways one can serve his/her country.

On this Veterans Day we appropriately honor our military veterans for their efforts and sacrifices during times of conflict and war. Even though World War I, which began 100 years ago, was to be “the war to end all wars,” U.S. troops have been activated numerous times since then to address conflicts that threaten peace in our world. We categorize the era in which Veterans have served in terms of these conflicts, World War II, Korea, Vietnam, Persian Gulf, Bosnia, etc. This is a reminder that our military needs to always be ready to serve.

Similarly, the public health issues that threaten peace and stability are continuously changing and/or resurfacing so public health has to continually be prepared and ready to serve. That’s why we should also honor the service of public health workers who fought different wars in different eras like:

Infectious disease eras: smallpox, TB, cholera, yellow fever, measles, polio, HIV, Ebola, etc.
Vaccine and antibiotic eras including the emerging antibiotic resistance era.
Environmental eras: contaminated air, food, water, and climate change
Chronic disease eras:  diabetes, heart disease, dementias
Disparity eras:  poverty, education, opportunity, structural inequities, etc.
And many others and more to come.

I recognize that not everyone working in public health is or has been part of the Commissioned Corps of the U.S. Public Health Service (PHS). Yet, the work of all public health workers is essential. That’s why when I honor PHS Veterans, I also honor all public health workers who are doing just what PHS Veterans have done since 1889  – working diligently, passionately, and collaboratively to assure the conditions in which everyone can be healthy. We are all a vital part of that public health team.

While it may not be as well recognized as the tunes of the military services, on this Veterans Day, let’s end with the official march of the U.S. Public Health Service:

The mission of our service is known the world around
In research and in treatment no equal can be found
In the silent war against disease no truce is ever seen
We serve on the land and the sea for humanity
The Public Health Service Team


Monday, October 6, 2014

13 Ways of looking at Ebola

Last Thursday was the birthday of Wallace Stevens. I quoted verse V from his poem “13 Ways of Looking at a Blackbird” as part of my presentation to the 350 people assembled at a meeting of Health Care Home providers and advocates.   

I do not know which to prefer,
The beauty of inflections
Or the beauty of innuendoes,
The blackbird whistling
Or just after.

I used this verse to make the point that I prefer the approach that Minnesota has traditionally taken to improve the health of its residents – investment in the “public good” and the “commons.” To me, it’s those investments of decades ago that are paying the dividends of a healthy state today. I made the case that we have to continue that tradition of investing in the “commons” (the social determinants of health), if we are going to keep Minnesota a healthy state for our grandchildren and great grandchildren.

Immediately after my talk I had to participate in a conference call discussing how to respond to the news that a case of Ebola had been diagnosed in an individual in Texas. As we discussed the issue, it was evident that responding to Ebola in its global and local contexts will be difficult and complex. I then thought about the talk that I had just given and realized effectively addressing Ebola will require looking at it in at least 13 ways – probably more. 

With apologies to Wallace Stevens, here are my 13 Ways of Looking at Ebola. 

Among twenty bad diseases
The eye of the world
Was only on the movement of Ebola.

I was of many minds,
Like a world
Watching three countries devastated by Ebola.

Ebola whirled in the autumn winds.
A major part of the world-wide fear.

People and the environment
Are one.
People and the environment and Ebola
Are one.

I do not know what I most fear,
The risk of infections
Or the damage of insinuations,
Ebola identified
Or just after. 

Interference filled the digital screens
With indecipherable static.
The shadow of Ebola
Flickered, in and out.
Embedded in the shadow
An unfathomable threat.

O all you of America,
Why do you imagine vultures?
Do you not see how Ebola
Cannot walk when under the feet
Of public health about you?

I know effective care
And proactive, inescapable containment
And I know, too,
That Ebola can be controlled
By what we know.

When Ebola spread like never before,
It marked the effect
Of many circles of inequity.

At the sight of Ebola
Flying in an interconnected world
Even the bawds of isolationism
Should cry out sharply. 

He rode over the landscape
In a self-confident state.
Once Ebola pierced his equanimity
He finally understood
The need to equip the world
With social justice.

Public health is moving
Ebola must be our teacher.

The darkness gave way to light
The storm was abating
The sun began to shine
And Ebola sat contained
For the present.


Monday, September 15, 2014

Science, Esthetics, Public Health, and the Social Determinants of Health

The closing session of the 2014 ASTHO (Association of State and Territorial Health Officials) Annual Meeting was entitled “The Intersection of Public Health and Clinical Medicine:  Addressing Social Determinants of Health.”  I was asked to give a Minnesota perspective on what needs to be done to assure “that all systems integrate to further address the social determinants of health.” 
As I prepared for the session, I reviewed the World Health Organization (WHO) definition of Social Determinants of Health:  “the conditions in which people are born, grow, live, work and age.  These circumstances are shaped by the distribution of money, power and resources at global, national and local levels.”  The WHO goes on to say that “social determinants usually identified as influencing health and health equity include those such as housing, employment and education.”  While clinical medicine is commonly viewed as a ‘downstream’ determinant of health, there is a growing realization that healthcare systems themselves are a social determinant of health because of their impact on the broader socio-political environment.  According to the WHO, ”when appropriately designed and managed, health systems can address…the circumstances of socially disadvantaged and marginalized populations…and they may be influential in building societal and political support for health equity.”
Health systems in Minnesota recognize the impact that social determinants of health have on the health of the population they serve and most, if not all, understand that they have a responsibility to help address those determinants.  The increasing focus on total cost of care and population health indicators underscores that responsibility.  How that gets realized is a work in progress.  Health Care Homes and the development of Accountable Care Organizations (ACOs) are part of that work.
Minnesota’s public health agencies also recognize the need to effectively engage with health care systems in order to use the strengths of both systems to affect the social determinants of health.  The work being done through the Statewide Health Improvement Program (SHIP) demonstrates that local public health agencies can serve as the backbone for magnifying the collective impact of community-based health equity efforts.  Embedding ACOs in a community context and using the Community Leadership Teams and the ‘policy, systems, and environment’ approach of SHIP in the development and implementation of the Accountable Communities of Health holds promise for effectively addressing the social determinants of health at a local level. (
Because this session was held on September 11th, a day when an act of violence changed the course of our history, and because “peace” is at the top of the WHO list of determinants of health, I felt compelled to add some comments about peace to my presentation. 
2001 was not the only year when acts of war occurred on September 11.  On 9/11 Scotsman William Wallace defeated the English in 1297, the French conquered Milan in 1499, Imperial troops under Eugene of Savoy defeated the Turks in 1695, Anglo-Dutch-Austrian forces defeated the French in 1709, the U.S. fleet destroyed a squadron of British ships in the Battle of Lake Champlain in 1814, and Mexican troops captured San Antonio in 1842 to name just a few battles and wars.  Most striking to me was that the groundbreaking ceremony for the Pentagon occurred on September 11, 1941 – exactly 60 years before an attempt was made to violently destroy it. 
I included these historical references near the end of my presentation and closed with a quotation from Isidor Isaac Rabi, a Polish-born American physicist, a 1944 Nobel laureate recognized for his discovery of nuclear magnetic resonance, and a participant in the Manhattan Project.  He died on September 11, 1988.  He said:  “Science is an expression of the human spirit, which reaches every sphere of human culture.  It gives an aim and meaning to existence as well as a knowledge, understanding, love, and admiration for the world.  It gives a deeper meaning to morality and another dimension to esthetics.”
Given that public health is both a science and an art, this quotation provides those of us in public health a way to approach peace and all the other social determinants of health.  The quotation begins with ‘Science’ and ends with ‘esthetics’ (“a set of principles underlying and guiding the work of a particular artist or artistic movement.”)  By including both science and esthetics, public health gives us a better understanding, love, and admiration of the world while providing a set of principles based on social justice that can guide the work of all sectors to create a better, peace-filled world for all.