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 Café 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…


Monday, December 19, 2016

Housing Security Is Not a Fairy Tale

The importance of safe, stable and secure housing has been on my mind over the last few weeks – especially since the outside temperature has dropped far below zero. Being reminded at the last Interagency Council on Homelessness meeting that thousands of adults and children are homeless every night in Minnesota’s cities, suburbs and rural areas underscores the reality that housing is a major public health issue. But the initial trigger for my thinking about housing was the tragic fire in a warehouse in Oakland, California that killed 36 people followed a week later by the collapse of a building in Nigeria that killed 23 people. What haunts me is that each of these situations was/is preventable.

Housing instability in our country didn’t happen by accident; it was created by policy decisions about how our economy should function and the role of communities and government in assuring safe and stable housing. Unaffordable housing forces people to live in unsafe dwellings that frequently don’t meet fire and safety codes – codes that are often undermined or unenforced by an individual responsibility narrative that contends government involvement and regulation is the problem, not a solution.

As I pondered our current situation, a familiar fairy tale came to mind. Perhaps a reframing of the story of "The Three Little Pigs" could help challenge that narrative.

You all know the story of "The Three Little Pigs." One lived in a house of straw, another in a house of sticks, and the third in a house of bricks. The moral of the story is that the choices we make have consequences and that hard work pays off. The two little pigs who lived in the houses of straw and twigs are often depicted as frivolous creatures who made bad choices and didn’t work hard enough to build substantial dwellings that could withstand the attacks of the Big Bad Wolf (BBW). The third little pig, on the other hand, is depicted as a diligent worker which allowed him to live in a BBW-Safe house of bricks.

But what the story doesn’t tell is that the three little pigs lost their parents when they became homeless due to a home foreclosure and ultimately fell victim to a pack of BBWs. The three little orphaned and homeless pigs lived in constant fear of meeting the same fate as their parents. Together they did their best to escape the vengeance of the BBW, but after months of being pursued, they decided to split up and go to different towns in an attempt to ditch their nemesis.

The first little pig ended up in a town where there was no available housing and was told by the townspeople he would just have to fend for himself. He couldn’t find a job so he had few resources to use in building or renting a house. He diligently searched but the only affordable building materials that he could find were pieces of straw so he used those to build his home. He knew it wasn’t the safest home but it was comfortable and kept him from the elements.

The second little pig moved on to the next village where he found a decent paying job and soon earned enough, he thought, to rent a house. But as he searched, he realized housing was more expensive than he anticipated. He was nearing despair when he met a man who had just constructed a bunch of houses for the new folks in town. He hadn’t gotten approval from the city to build but he knew he would be able to rent them easily. To make them affordable he built them out of sticks. When the second little pig saw the house of sticks, he fell in love with it, paid the rent and moved in.

The third little pig ended up in another town. This town welcomed new arrivals and recognized their need for housing. The town also had a program to create affordable housing. They also required that every house constructed be made of bricks and have a sprinkler system, smoke and CO detectors, and plumbing and electrical systems that met the highest building code standards. The townspeople knew this was a sound 100 year investment that benefited everyone.

Although the third little pig was only able to find a minimum wage job, he discovered that he qualified for a low interest loan which allowed him to actually purchase a home that was just being built. He was pleased and thankful for this opportunity.

While all of this was going on the BBW continued to stalk the three little pigs and it wasn’t long before he came to the first little pig’s straw house.

"Little pig, little pig, let me come in."
"No, no, not by the hair on my chinny chin chin I won’t let you in."
"Then I'll huff, and I'll puff, and I'll blow your house down."
And he did.

You know the rest. The first little pig ran as fast as he could to the next town seeking shelter in the house of twigs with the second little pig. The BBW then blows down the house of sticks and moves on to the house of bricks where he is ultimately foiled. Supposedly everyone but the BBW lives happily ever after. But that’s not the case.

The truth is that the story about the three little pigs made the rounds to all the towns in the area. After hearing what happened, civic leaders decided to establish sustainable safe, secure and affordable housing initiatives for all homeless and new arrivals in their communities. They also began to make plans to end homelessness and enact strict building codes to protect all the residents of their town.

However, the builder of the stick houses knew that these building codes would put him out of business so he started to lobby the decision makers to back off on the codes. The builder was joined in this effort by the BBW and his friends who also didn’t like the codes and declared that it was better for the towns if these codes were voluntary because “the market” should dictate how houses should be constructed. They also argued that the resources used to help the homeless and newcomers be divided up and given back to business owners to help them create jobs that would ultimately solve the housing problems.

These arguments were countered by the three little pigs who contended that both ending homelessness and having safe and secure housing for everyone were not only the right thing to do but in the long-term best interest of the community and everyone who lived there.

As of today, some civic leaders are still debating the issues while the wolves and the builder and the three little pigs wait to see what happens.


Friday, November 4, 2016

Poetry and Public Health

I am fortunate to have the opportunity to speak often to groups of people with varied interests, backgrounds, and expertise. In just the last several weeks I’ve presented to county commissioners, urban planners, transportation engineers, hydrologists, air quality specialists, National Park supporters, American Indian tribal leaders, psychologists, and data analysts among others. While I tailor my presentations to the specific interests of each group, my basic message is always the same – “you have an important role to play in creating healthy communities and advancing health equity.”

That message emanates from the Institute of Medicine’s definition of public health: “what we do collectively to assure the conditions in which (all) people can be healthy.” From that starting place I use the Triple Aim of Heath Equity to frame how people in all sectors and disciplines could do their work to advance health equity and optimal health for all. The Triple Aim of Health Equity consists of three “simple rules” for addressing complex situations like health equity:
Expand the understanding about what creates health,
Implement a “Health in All Policies” approach with health equity as the goal, and
Strengthen the capacity of communities to create their own healthy future.

The aims are unified around the core value of social cohesion which recognizes that health, well-being, equity, and thriving communities can only be accomplished in partnership and by collective action – action that requires the efforts of all sectors and disciplines.

I had the Triple Aim of Health Equity in mind recently as I prepared to speak to a group of psychologists and social workers. While formulating my talking points, I remembered a lecture in one of my undergraduate psychology classes given by Harry Harlow, a psychologist at the University of Wisconsin who studied social behavior and development and was best known for his maternal separation and social isolation experiments with monkeys. In his talk Professor Harlow outlined how he had worked to transform the field of psychology so that the notions of love and affection were “deemed worthy of psychological study.”

As an English major who was taking a pre-med curriculum, I was particularly struck by one of his comments: “So far as love or affection is concerned, psychologists have failed in their mission. The little we know about love does not transcend simple observation, and the little we write about it has been written better by poets and novelists.” That statement reaffirmed my decision to major in English rather than the more customary pre-med disciplines of biology, chemistry, or mathematics. A mere 50 years later, his lecture about transforming a field and that particular statement encouraged me to quote a passage from the Romantic poet John Keats in my speech to the psychologists and social workers: “Many have original minds who do not think it -- they are led away by custom.” I used that passage to make the point that we often fall victim to the custom of following our usual and long-standing ways of doing things even when they are not achieving our aspirational goals. To illustrate, I noted that our reliance on our traditional medical care and public health practices are not moving us closer to the achievement of health equity and that a transformation of our work is necessary for that change to occur.

Coincidentally, two days later, as I was preparing to talk to a group of data analysts, I came across a statement by Karl Weierstrass, a 19th century German mathematician who (according to Wikipedia) is known as the "father of modern analysis" for his work that led to the modern theory of functions. He said: “It is true that a mathematician who is not somewhat of a poet, will never be a perfect mathematician.” That quotation made me wonder if “It is (also) true that a (public health worker) who is not a poet, will never be a perfect (public health worker).” It didn’t take long to realize the truth of that paraphrase.

In growing our understanding about what creates health, we’ve come to realize that health is determined by much more than just medical care and personal choices. It’s particularly influenced by the social and economic circumstances in which people live, work, worship, and play. And those circumstances/living conditions are dramatically affected by the presence or absence of music, art, theater, dance, and literature of all types.

Consider how poets and novelists have expanded and enhanced our view of relationships, physical and social environments, transportation, housing, agriculture, business, education, and the importance of community. Imagine how different the peace, civil rights, women’s rights, and environmental movements of the 1960s and 1970s would have been without the musical soundtrack laid by the Nobel Award winning lyrics of Bob Dylan and the powerful tunes of Motown. Ponder the emotions and the questions raised by a stimulating works of classical and modern art within and outside of galleries. Contemplate the expanded understanding of culture transmitted by dances and dancers from around the world. Reflect on the questions raised about our place in the world by theatrical works like “Death of a Salesman” and “A Raisin in the Sun.” Just envision the sterility and blandness of a world without the ability of people to creatively express their joys, sorrows, fears, hopes, and dreams.

Literature, art, music, dance, and theater significantly influence the conditions in which people live, work, worship, and play. Their influence underscores the need to include them in the transformation of the work we must do in public health to advance health equity and optimal health for all. Arts and poetry broaden our thinking and help us see the reality of other people’s existence. They also allow us to imagine how the lives of our fellow citizens can be improved. There is no doubt in my mind that “It is true that a public health worker who is not a poet, will never be a perfect public health worker.” Seeing the everyday impact of these creative forms of expression gives credence to the statement of physician and poet William Carlos Williams,

“It is difficult/ to get the news from poems/ yet men die miserably every day/ for lack/ of what is found there."


Monday, September 26, 2016

The Ark of Public Health

Midway through the 2016 annual meeting of the Association of State and Territorial Health Officials (ASTHO) being held in Minnesota, 180 attendees headed to the Mississippi River for an evening of socializing. Despite the dark clouds forming overhead, people were ready, after a day of discussing difficult public health issues, to venture from the conference hotel to spend time interacting informally with colleagues from around the country. Two by two, they filed across the gangplank of an old-fashioned paddle boat for a three-hour scenic and music-filled cruise from St. Paul to Minneapolis and back.

Two by two they came bringing the perspectives of red states and blue states, liberals and conservatives, moderates and progressives, reformists and libertarians, east and west coasts, northern and southern boarders, new professionals and seasoned veterans, executives and line staff, academicians and practitioners, federal and state/local agencies, policy makers and program implementers, racial and ethnic minorities and majorities, men and women, straight and LGBTQ, optimists and pessimists, lumpers and splitters, and a myriad of professionals dealing with issues from AIDS to Zika. Two by two came a menagerie of public health workers with one thing in common (in addition to a desire to have some fun) – a public health vision of how to protect and improve the health of everyone in our society.

One hour into the trip a lightning-created extravaganza rivaling the northern lights filled the sky. Despite its awe-inspiring beauty, the lightening presaged a huge storm. Before long, the deluge arrived forcing everyone into the deckhouse. Sheltered from the rain in a boat equipped to weather this “once in 500 years” storm, the party and the trip continued. Although this storm was not of “biblical proportions,” the analogy was not lost on many of the passengers – it was certainly not lost on me.

As I sat on the boat with my public health colleagues watching the lightening and rain, I reflected on the numerous challenges facing our world: climate change, war, terrorism, interpersonal violence, economic inequities, educational and health disparities, racism, homophobia, religious intolerance, antibiotic resistant organisms, new infectious diseases, burgeoning chronic diseases, and the aging of our society to name just a few. Yet, the approach that we’ve taken over the last several decades has been remarkably ineffective in addressing these issues. Something needs to change. Perhaps it’s time for a new approach – an approach based on the public health principles embraced by the people sequestered on the boat.

Our current approach is built on a worldview anchored on the principle of individualism. From this evolves our reliance on market justice and free market solutions where competition is embraced with its attendant winners and losers and disparities are considered to be due to an inability to effectively compete rather than discrimination. Not surprisingly, health is seen as an individual responsibility. This worldview has led to great technological advances, powerful corporations, and a global economy. It has also fostered the development of a large and expensive health care system to treat individuals when they become ill or disabled. It has also led to huge disparities in wealth and health and to the erosion of social cohesion. Investments in public health and human services have suffered with this approach.

An alternative worldview, one based on public health principles, might provide a better framework from which to address today’s problems. This worldview is community-based and anchored on a shared responsibility for improving health and well-being. It is based on the principles of social responsibility and social justice where cooperation and collective action are essential to improving the well-being of all members of society. Discrimination and disparities are acknowledged and not seen just as individual shortcomings but as societal failures to provide equitable opportunities to thrive. Although this worldview is not currently dominant, it was at other times in our past and it fostered significant benefits for our society. Perhaps it’s time to adopt this alternative worldview in plotting our course for the next 50 to 100 years.

Pondering this notion of worldview, I recalled this statement by Wendell Berry, a Kentucky farmer and poet: “We have lived by the assumption that what was good for us would be good for the world. We have been wrong. We must change our lives so that it will be possible to live by the contrary assumption, that what is good for the world will be good for us.” This mirrors what Minnesota Senator Paul Wellstone said: “We all do better when we all do better.” This is the philosophy behind public health.

To set aside the dominant worldview in this country and adopt a public health worldview will require a huge shift in societal attitudes. Yet, every day we are being flooded by seemingly intractable problems that are threatening and frightening everyone. Perhaps now is an opportune time to wash away our current approach and make the case for a fresh one, a public health approach, to our contemporary and approaching challenges.

The sky cleared and the rain ended just as the paddleboat docked. As people left the boat, there was a sense of cohesion, community, and optimism among the group. Maybe I was mistaken, but I sensed that this group of public health leaders felt energized and empowered to take on this challenge of creating a vibrant and equitable new world where everyone has the opportunity to be healthy. What better group than public health workers to lead this change two by two, four by four, eight by eight …


Wednesday, August 17, 2016

Creating the Good Life in Minnesota August 13, 1973 to August 13, 2016 - Reflections on Wendell Anderson (1933-2016)

(The funeral for Governor Wendell Anderson was held on 8/15/16. A version of this note was published in MinnPost on 8/10/16.)

As a young doctor driving from Pennsylvania to my National Health Service Corps assignment in Montana, I stopped to get gas in Alexandria, Minnesota. Although I had never considered Minnesota as a place to live, the iconic image of Wendell Anderson on the August 13, 1973 cover of Time magazine proclaiming “The Good Life in Minnesota” prompted me to purchase a copy, which I still have today.

The values behind that promise of the good life brought me permanently to Minnesota seven years after that Time article was published, kept me here for 36 years, and guide my efforts as commissioner of health.

Governor Anderson’s vision captured in that cover story remain relevant today. During the past six years, I have frequently referred to it in speeches and use it as the “North Star” for what we must do as Minnesotans to address our health challenges.

What stood out for the Time article’s author was Minnesota’s “civility and fairness, courtesy, honesty, a capacity for innovation, hard work, intellectual adventure and responsibility.” In support of that he mentioned there is “…a deep grain of sobriety and hard work, a near-worship for education and a high civil tradition in Minnesota life.”

Community leaders quoted in the article focused on the ability of Minnesotans, despite a great variety of opinions and immigrant backgrounds, to engage in political activity and form coalitions that could further the people’s will.

It was this latter point that most impressed the author. “Part of Minnesota’s secret lies in peoples’ extraordinary civic interest. The business community’s social conscience…is reflected in annual reports: most of them carry a section called ‘Social Concerns.’…Minnesotans tend to be participants in their communities, perhaps because for so long they were comparatively isolated and developed traditions of mutual reliance. Citizens’ lobbies are a real force.”

In the reception room after Governor Mark Dayton’s 2015 State of the State Address, I had a chance to talk with Governor Anderson about that 1973 article. I asked him, “What created the good life in Minnesota?” Without hesitation he responded, “The article accurately captured most of what we were doing. But two things stand out. First, we had a social conscience that led us to invest in the common good; things that benefit everyone, like education. Second, we cooperated. We didn’t always agree, but we cooperated and compromised. That’s an approach I wish was embraced today.”

Governor Anderson helped make some wise public investments 40-plus years ago that are still paying dividends today. I contend that Minnesota is a healthy state today mostly because of those investments. Governor Anderson helped set a tone of “civility and fairness; intellectual adventure and responsibility; a lot of mutual trust; social conscience; and extraordinary civic interest” that helped build a foundation which created “The Good Life in Minnesota.”

For the sake of those generations who follow us, our challenge is to build on that foundation to create an even Better Life in Minnesota. That will take a social conscience, a sense of the common good and a level of civic engagement that sometimes seems antiquated and in short supply these days. My hope is that the spirit of Wendell Anderson resurrects those values and helps us cooperatively build a better Minnesota – one that assures a good life for every Minnesotan.


Monday, June 27, 2016

Capitalism and Democracy: Shaping the American Enterprise and Our Health

One faces the future with one's past. Pearl S. Buck (born 6/26/1892)

The Smithsonian’s National Museum of American History has assembled a major exhibition on the “American Enterprise,” which “…chronicles the tumultuous interaction of capitalism and democracy that resulted in the continual remaking of American business—and American life.”

I visited the exhibit just after being part of a Congressional Briefing on health equity where I made the point that the dominant worldview in the United States has led to policies and systems that systematically disadvantage some population groups while advantaging others; contributing to health inequities. Using the Triple Aim of Health Equity as the framework, I challenged congressional leaders to embrace a worldview that is based on community good and social justice rather than on individual needs and market justice. It was with that mindset that I entered the “American Enterprise” exhibition.

From the first to the last display I saw contrasting and conflicting worldviews impacting not just our health but the evolution of American business and democracy. During the “Merchant Era” (1770 - 1850s) when there was abundant land and vast natural resources fueling economic opportunities, the population was mostly rural. During that time, Thomas Jefferson saw the future optimally tied to farming, not factory work, while Alexander Hamilton favored an economy based on industry.

Those differing perspectives have persisted throughout the development and evolution of our economy and society. In the “Corporate Era” (1860s – 1930s) industrialization and business expansion brought major economic growth and social change to the United States, including massive immigration, financial crises, and labor/management confrontations. Business and political leaders “disagreed over the power of big business and whether it endangered the balance between private gain and common good.”

Industrialist Andrew Carnegie argued that competition was good for the country, while Supreme Court Justice Louis Brandeis was concerned that the rights of common citizens would be abridged by the wealthy few. Likewise, President Theodore Roosevelt championed the government’s role in controlling the negative aspects of unbridled big business. In anticipation of a more interdependent world, President Woodrow Wilson suggested the ideal of social responsibility and social cohesion.

In the “Consumer Era” (1940s – 1970s) “production boomed and consumerism shaped the American marketplace. Innovations in technology, expansion of white-collar jobs, more credit, and new groups of consumers fueled prosperity. Business and political leaders claimed consumerism was more than shopping: it defined the benefits of capitalism. This era marked a high point of American productivity and a high standard of living. But it ended with many Americans questioning the promises of consumer capitalism.”

Contrasting worldviews became starker during this time. Economist John Kenneth Galbraith opined that an unregulated marketplace resulted in “private opulence and public squalor.” Philosopher Ayn Rand contended that individuals thrive best in a free and unregulated marketplace. Labor and civil rights leader A. Philip Randolph argued that equality of opportunity could not be left to the marketplace.

In the “Global Era” (1980s – present) the pace of change has rapidly accelerated. Computers, smart devices, and “big data” have affected all aspects of life. There is increased global interdependence expanding markets and opportunities for some while eliminating traditional stability, employment, and safeguards for others.

While some of the debate around the role of government and free enterprise has existed since the founding of our country, the debate now has global ramifications. Economist Milton Friedman advocated for a limited role for government in the American economy while Secretary of Labor Robert Reich argued that access to opportunity was the right of all American citizens.

After two hours in the “American Enterprise” I was acutely aware that the differing worldviews that have jousted with each other over our economy also impact health. Given that socio-economic conditions are the greatest determinants of health, that wasn’t a surprise but I had never seen it articulated so clearly. I also realized that there is no “best” or “perfect” worldview. Every worldview by itself is inadequate for developing the policies and systems needed for everyone to thrive. That’s why the debate that has been going on in this country for 240 years is so crucial. That’s also why it’s essential for those of us in public health, who have a worldview that embraces advancing health equity and optimal health for all, need to be engaged in the debate.  And that’s why the questions that we have framed around the Triple Aim of Health Equity need to be part of every conversation:

Who is at the decision/policy-making table, and who is not?
Who is being held accountable and to whom?
What are the health and equity implications of any decision?
Who is benefiting and who is left out?
What values/worldviews underlie the decision-making process?

As I headed back to my hotel, I wondered how this museum visit would influence the speech that I was to give in five days at the Minnesota Rural Health Conference. The tension between capitalism/economy and democracy/community seemed like a theme to be explored especially as it relates to rural communities. Those tensions reminded me of a statement in "Racism and the Economy" by farmer, poet, and essayist, Wendell Berry – a statement that ultimately framed my speech: “Cultivating Health Equity and Optimal Health for All In Resilient Rural Communities – How the Dominant Worldview of Society Impacts Health.”

“A proper community, we should remember also, is a commonwealth: a place, a resource, an economy. It answers the needs, practical as well as social and spiritual, of its members - among them the need to need one another. The answer to the present alignment of political power with wealth is the restoration of the identity of community and economy."