Monday, June 23, 2014

Do you have a library card?

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

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

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

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

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

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

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

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

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

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

I ask you the same question.


Monday, June 16, 2014

Advancing Health Equity by sharing data

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

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

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


Tuesday, June 3, 2014

Open Streets – North Minneapolis Greenway Experience

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

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

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

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

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

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

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

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

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

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


Tuesday, May 27, 2014

Memorial Day 2014

May 26, 2014

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

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

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

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

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

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

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

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

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

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

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

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

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


Monday, May 12, 2014

“The sparrow is sorry for the peacock at the burden of his tail.”

One of the challenges of my job is the frequent opportunity to provide an opening welcome or keynote address at a health-related conference, participate in a panel discussion on some health topic, or attend an event highlighting the work of an individual or organization.  The challenge is that I’m often speaking to an audience that knows a lot more about the topic than I do.  The opportunity is the chance to broaden the horizons of a specialized audience by providing a broader public health context for an issue or challenging the attendees with an alternative narrative about what creates health.  
Last week typified those challenges and opportunities.  While monitoring and testifying at hearings related to therapeutic cannabis, I had the opportunity to:
  • provide opening remarks at the “Perinatal Hospital Leadership Summit” that was focused on supporting breast feeding,
  • speak on a panel at a “Forum on Science, Democracy and A Healthy Food Policy” convened by the Union of Concerned Scientists,
  • participate in a press conference on school-based and school-linked mental health services,
  • join in a panel interacting with Elmo at an event highlighting the work of Sesame Street in addressing the issues of children of incarcerated parents, and
  • attend the “150th Anniversary Celebration” of the founding of the Mayo Clinic.

In looking back at the week I recognized that the events that focused on some of our public health challenges (obesity, food insecurity, behavioral health, and Adverse Childhood Experiences) were bracketed and overshadowed by events celebrating the role of medical care in improving our health.  That’s when I recognized the insight of Rabindranath Tagore (born May 6, 1861), a Bengali poet, novelist, composer, and the first non-European to win the Nobel Prize in Literature, when he said, “The sparrow is sorry for the peacock at the burden of his tail.”
Minnesota is an overall healthy state.  We are ranked number 3 in the United Health Foundation’s State Health Rankings.  We have the lowest infant mortality rate and the highest male and second highest female longevity in the country.  The Commonwealth Fund just ranked Minnesota as number 1 in the country in “health care access, quality, cost, and outcomes.”  Our birth weight specific infant survival and many 5-year cancer survival rates are also among the best in the country.  On an overall population level Minnesota is doing well and the medical care provided in Minnesota is of the highest quality.  Minnesota has a lot to be proud of. 
But like the peacock, we are burdened by our visible successes.  While we focus on our noteworthy medical accomplishments, we often ignore the fact that most of Minnesota’s good health status is due to previous investments in public health.  Also overlooked are the health disparities in Minnesota that are some of the greatest in the country.  Disparities in infant mortality rates and in years of unhealthy life after age 65 are just two of the many disparities that are greater in Minnesota than in most other states.  As we are discovering, overall health and health disparities are not determined by just medical care but mostly by social, educational, and economic factors – the social determinants of health. 
To effectively address these determinants, we must move beyond the common narrative that health is created by good medical care and individual choices to a new narrative that health is created in communities by people in many sectors addressing the social determinants of health.  But creating that new narrative is difficult.  Our public health stories of preventing diseases don’t have the emotional impact of stories depicting daring surgeries or advanced technologies that bring people back from the brink of death.  Few of our stories about collaborative efforts to improve community health contain individual heroes who serve as role models for the next generation.  Seldom are our stories told by a person who can say, with tear-filled eyes, that he/she is alive today because of the work done to address social inequities.  We are burdened by the peacock’s medical care tail while we need the sparrow’s public health perspective. 
The peacock is a beautiful bird but its ability to fly is limited.  While it is charismatic in the space it occupies, its range of influence is restricted.  The sparrow is plain in comparison but has the ability to cover a great deal of space quickly and easily.  Medical care will continue to garner most of the attention and accolades in our society.  Yet, it is becoming increasingly clear that a broader and more inclusive public health approach will be necessary if we are to effectively create a healthy world for all.  As we work to create that healthy world, we shouldn’t feel sorry for the successes of our medical care system.  We should celebrate and support them because they are necessary.  However, we need to find ways to raise the visibility of our public health system that expands the horizons of what is needed to create a healthy and equitable world.  Despite the struggles that public health has endured over the last few decades, I have faith that public health’s future is bright because as Rabindranath Tagore also said:  “Faith is the bird that feels the light when the dawn is still dark.”  Do you feel the light?  I do.

Monday, March 31, 2014

Take Me Out to the Chaos!

Research in nonlinear dynamics has demonstrated that cells in healthy hearts seem to behave in a random, complex and unpredictable fashion. Contrary to conventional wisdom, it is this variability, or chaos, that keeps healthy hearts beating normally. Loss of complexity and variability leads to simple and fragile rhythms that put a heart at high risk for sudden cardiac arrest.  

“It is this variability that gives a living, dynamic system, such as the heart, the robustness it requires to cope with change.”
-Ary L. Goldberger, MD – cardiologist, Harvard University

Winter, Baseball, Health, and Chaos
The lack of variability this winter (cold, cold, cold, and more cold) made me ponder the benefits of chaos. A little more variety and unpredictability in the weather would have been welcomed by most Minnesotans. The foot of snow on the ground outside my window the day before Opening Day of the Major League Baseball season helped me finally understand why people wanted an open-air baseball stadium in Minnesota – it assures variability, unpredictability, and chaos.  Same, same, same, is not as much fun. This made me wonder if our health care system is also influenced by the dynamics of chaos.  The more I thought about it, the more I became convinced that baseball and our health care system are prime examples of the power of chaos theory. Let me explain.

My childhood summers were filled with baseball – collecting baseball cards, keeping track of batting averages, listening to Milwaukee Braves games, and playing the game as often as I could. Even though I played baseball almost every day, no two days were alike. Baseball brought me new adventures, new insights, and new challenges almost every day. Baseball was the heart of my summer.

After finishing my morning chores, I would jump on my bike and head to one of the many local ball diamonds. With my baseball glove hooked to the handlebars, a ball in my pocket, a bat in my hand, and a blessing from my mom to “play hard and have a good time,” I would stop by the houses of my friends to recruit participants for the day’s game.

Sometimes only two or three people would be available. At other times 15 or 20 would play.  Regardless of the number, we’d always have a game and we’d always follow an unwritten rule that no one would sit on the bench.  his meant we made up new rules to accommodate the number and skill level of players available. Except for the fact that we used bats, balls, and gloves, our games often bore little resemblance to the official version of baseball advanced by Abner Doubleday. Each day we found new, creative, and unconventional ways to play the game that all of us loved. Each day was wonderfully satisfying and we always looked forward to the next game.

As I got older and became more involved in “organized” baseball, the pick-up games became less frequent – not because of lack of time but because “real” baseball began to put limits on what we could do. In hopes of becoming “better” players we began to pay more attention to the rules that the Little League coaches taught us and work on the “weaknesses in our game” that they had noticed.  The game became a more serious undertaking. Soon the afternoon pick-up games stopped completely and our only baseball time was team practices or games. Since the number of people on the team roster was limited, many of the neighborhood players who hadn't made the team hung up their gloves and moved on to other things. In the process, my circle of friends became smaller and baseball lost much of its variability and spontaneity.

It appears that my experience may not be unique because fewer children are playing baseball today than at any time during the last 50 years. Some of this decline may be the result of increased activity options available to children, but I believe a major reason is that baseball has lost the spontaneity and dynamism that could have kept it fun, robust, and inclusive. Youth baseball has become adult-directed and tied to a set of confining rules so that the variability and innovation needed to survive in our ever-changing world has been curtailed. Baseball has become less chaotic and interesting and increasingly irrelevant to most American children. While baseball still claims to be America’s pastime, that status is now in doubt.

In many ways our health care system parallels baseball. Over the last several decades there has been an increased emphasis on uniformity in health care. Consolidation of health care clinics, providers, and systems has occurred while standardization of disease management protocols has become the norm. Definitions and measures of success have also been standardized and policies have been put in place to facilitate progress toward the desired and defined outcomes. Evidence-based practices are touted as the ideal, leaving little tolerance for spontaneity, individuality, creativity, and variability.

Like baseball’s development system which continues to produce some superstar players, this standardization of health care has also provided some tremendous benefits.  The quality, safety, and value of services have increased and overall health outcomes have improved.  These efforts have helped create one of the best medical care systems in the world and they need to be maintained and expanded.

However, as our society becomes increasingly diverse and complex, we are seeing that the things that most affect health are beyond the scope of “traditional” medical care. The diseases and disabilities affecting society today are influenced mostly by socio-economic and environmental conditions and lifestyle choices rather than health care. Income, economic policies, education, housing, community livability, and social capital are the real determinants of health today. Yet, our health care system with its traditional focus on preventing and treating disease rather than creating health has limited capacity and ability to address or influence these factors. While health care continues to be important, we are learning that its impact on overall health has limitations.

To maximize health, we need a broader approach to health that identifies, embraces, and supports the opportunities to create health in our communities. It needs a bit of disruptive, chaotic innovation that will stimulate complex, diverse, flexible, and dynamic approaches to health. To me, public health’s role in the 21st Century is to bring a bit of chaos (in the non-linear dynamics sense) to our health system.

If we continue to invest most of our resources in disease treatment and management and not in creating health, our health care system will, like baseball, risk becoming somewhat irrelevant – a casualty of its own inflexibility.  Our health system, like a healthy heart, must maintain a high level of variability and chaos. It can only do that by embracing a broader public health context that allows the flexibility to deal with not only the medical determinants of health but the social and environmental determinants as well.

Although we probably can’t do much about the current state of baseball, public health is in a unique position to help stimulate changes in how we create health. By encouraging and supporting creativity, diversity, innovation, risk-taking, and inclusivity in discussions about the social determinants of health, we can maintain a healthy and necessary level of chaos. Changing the current culture and modifying the rules of the health care will be a challenging, chaotic, and rewarding process – one that will most likely go into extra innings. Do you want to play?


Monday, March 17, 2014

Wages are a public health issue

When people think about minimum wage, they most often think about the impact on their bank account and their job. But policies that impact employment and income are actually about health – the health of individuals, families, and communities.

When 19th Century industrialization drove workers from farms and home workshops into urban areas and factory work, our economic system changed dramatically. This change was particularly devastating for poor families and children. Working conditions were unregulated and often unsafe, leading to tens of thousands of work-related deaths. Millions of children were forced to work long hours in hazardous conditions at low wages because their poor families desperately needed the income to supplement the parents' low wages. Factory owners benefitted from child labor because children were more manageable, cheaper, and less likely to strike. The reality for children was poor health and loss of educational opportunities.

These horrid conditions persisted for decades until progressive 20th Century laws restricted child labor, improved working conditions, and established a minimum wage. These laws significantly reduced fatalities and improved overall health. Families at the lower end of the socio-economic scale benefited the most. Low-income communities saw improvements in life expectancy and lifetime earning capacity.

Even though Minnesotans no longer work in sweatshops or send children into dangerous mines, how we work and what we earn continues to impact our health and that of our communities. Studies show that income is the strongest and most consistent predictor of health and disease. People with higher incomes are healthier and live longer than people with lower incomes. Lower incomes are consistently associated with higher rates of disabilities and chronic physical and mental conditions. Poverty also leads to faster disease progression, more complications, and poorer survival rates. The vast majority of diseases are much more common among the poor and near-poor at all ages. Recent data show Minnesotans making less than $20,000 a year were more than twice as likely to have diabetes compared to those making $75,000 or more a year.

Children are particularly vulnerable to the health impacts of poverty, and the more years a child spends in poverty, the more negative outcomes accrue. Poor children are more likely to experience injuries, violence, inadequate health care, poor nutrition, and insecure housing. These conditions have a powerfully negative affect on health and development. Children from poor families are less likely to live in a neighborhood with healthy food options, safe places to play, good schools, libraries, or other quality public services that help set them on the path to a successful, healthy life.

The relationship between health and income is not just about individual access to medical care, but how income affects a range of opportunities for health. Communities with residents with higher incomes are likely to have better recreational amenities, housing stock, food access, and schools, and tend to be safer – all of which impact health. Income is also associated with other factors that create the opportunity to be healthy, such as employment opportunities, reduced environmental contamination, and greater transportation options.

Health improves with increasing income, and the impacts of a rise in income are greatest for those at the lowest end of the wage scale. Moving from the lowest income level to the next lowest provides the largest percentage increase in life expectancy and health status. In other words, a family living on minimum wage realizes greater health benefits from an increase, in that low salary, than a middle-class family receiving the same raise. Increasing the minimum wage is a sound public health investment for Minnesota. The health of Minnesota’s lowest wage earners will improve along with that of their families and communities.

We all benefit from and have a role in creating healthier communities. It’s time for us to come together to implement a minimum wage that further enhances the health benefits of employment and lifts more than 350,000 Minnesotans out of poverty. As Health Commissioner and a physician, I prescribe an increase in the minimum wage to improve the lives and health of vulnerable Minnesota children and families. It will be a great investment in the health of individuals, families, communities, and our state.


P.S.  Check out our White Paper on Income and Health -