Tuesday, May 26, 2015

For Want of a Nail in Public Health

In preparation for this summer’s “Pitch the Commissioner (PTC)” tour around Minnesota, I managed to find some time between rain showers this weekend to pitch a few horseshoes. Although the PTC events are non-competitive, I wanted to practice in hopes of not embarrassing myself in front of county commissioners, local public health officials, state senators and representatives, health care providers, and community activists who usually attend these functions. I discovered the 40 feet between stakes seems to be getting longer each year.

As I pitched shoe after shoe, an old proverb my mother frequently cited while I was growing up kept looping through my mind:

For want of a nail the shoe was lost.
For want of a shoe the horse was lost.
For want of a horse the rider was lost.
For want of a rider the message was lost
For want of a message the battle was lost.
For want of a battle the kingdom was lost.
And all for the want of a horseshoe nail.

I was hoping this proverb might be a sign that I would “nail” a few ringers but my errant throws quickly dispelled that notion. Obviously, the message was not about horseshoes but prevention. The more I pitched and the more I thought about the proverb the more I appreciated the appropriateness of the horseshoe metaphor in public health.

Getting a ringer in horseshoes requires the shoe to end up in the center of the pit. That means the shoe can’t be too far left or right and it can’t be too long or too short. Given the presence of those parameters, the shoe must also have the right orientation to encircle the stake.

Similarly, to achieve good health, among other things, there needs to be a balance between treatment and prevention and between innovation and regulation. With those conditions in place, optimal health also requires good choices by an individual.

The game of horseshoes is governed by rules that assure the match is played fairly. To provide equitable opportunity for everyone to compete, the rules allow a shorter pitching distance to accommodate age, gender, and disability. While not in the rules, it’s assumed that everyone who wants to play horseshoes has access to a horseshoe pitching venue. In Minnesota that assumption is accurate because most pitches are in parks or public spaces; free and open to everyone.

The rules and assumptions related to health in our society are not as accommodating and equitable as in horseshoes. As our 2014 Advancing Health Equity report notes, “…the opportunity to be healthy is not equally available everywhere or for everyone in the state.” Whether it’s housing, transportation, health care, education, food, or employment (the determinants of health), the opportunities to be healthy are too often governed by one’s race, income, education, sexual orientation, and geography. Unlike horseshoes, few accommodations are made to allow everyone equal opportunity to be health winners.

Having taken that metaphor as far as I could, my mind went back to the proverb my mother taught me. I began to wonder how each component in that verse linked with public health. It then struck me that the horseshoe could represent the principle of social justice upon which public health stands. And social justice is held in place by the nail of the narrative that what creates health is investment in the public good (the commons) and the social, economic, and environmental circumstances in which people live. Sadly, this public health narrative has been displaced by the currently dominant narrative which states that rugged individualism and market forces are preeminent in determining health and prosperity; a narrative that has brought us great disparities and inequities and limited the opportunities for many to be optimally healthy.

With that in mind, each pitch of a horseshoe brought forward a different line for the old proverb.

For want of a public health narrative social justice was lost.
For want of social justice equity was lost.
For want of equity opportunity was lost.
For want of opportunity hope was lost.
For want of hope health was lost.
For want of health the community was lost.
All for the want of a public health narrative.

Our job is to create and sustain (nail down) a public health narrative about what really creates health and then pitch that to as many people as possible. The “ringer” will be health equity and optimal health for all.


Wednesday, March 18, 2015

Revisiting Lifeboats, Torpedoes, and Social Policies

Today I was part of a press conference that focused on the health benefits of paid leave – family leave and sick leave.  The event was prompted by last week’s release of our White Paper on Paid Leave and Health. As I was presenting our recent findings, I thought back to last year at about this same time when we released our White Paper on Income and Health. That report helped add a health frame to the policy discussions that ultimately led to an increase in Minnesota’s minimum wage.  My hope is that our recent report will also help bring a health perspective to another important public health and public policy issue. 

Given that the press conference relating to a significant social policy was held on St. Patrick’s Day, I decided to reprise a blog that I wrote at this time last year.  It’s as appropriate now as it was then.  Just replace Minimum Wage and Income and Health with Paid Leave.

On the south coast of County Cork, Ireland is the sheltered seaport town of Cobh. The town is best known as the final port of call of the RMS Titanic which sank on April 15, 1912 with a death toll of 1,517. Another maritime disaster that is part of Cobh’s history is the sinking of the RMS Lusitania on May 7, 1915. The Lusitania was torpedoed by a German U-boat ten miles off the shore of Cobh with a loss of 1,198 lives.

Less well known is the fact that for over a hundred years Cobh was the single most important emigration center in Ireland. Between 1845 and 1851 over 1.5 million adults and children emigrated from Ireland. Ultimately, over 6 million Irish people emigrated, with over 2.5 million departing from Cobh.

I visited Cobh 6 years ago and this quaint town resurfaced in my mind this weekend when I purchased some corned beef in preparation for St. Patrick’s Day. I remembered that as I walked along the docks of Cobh, the specter of those three traumatic events was everywhere. Wherever I looked, whatever I read, and with whomever I talked, these historical events which occurred 100 + years ago were still vivid in people’s minds.

The more engrossed I became in the stories of Cobh, the more I realized that the unifying lesson in all of these events was the role of policy decisions in causing these tragedies. Different individual or societal decisions could have prevented or significantly reduced the loss of lives and the human trauma caused by these events.

On the Titanic the number of lifeboats was inadequate for the number of passengers. The ship had been designed for more lifeboats but a decision was made to fit it with a lower number that met the minimum requirements of an outdated law that based lifeboat numbers on tonnage not on number of passengers. Plans were to add more only if the law required them.

In early 1915 a policy decision was made by the German military to do whatever was necessary to gain control of the waters of the Atlantic Ocean. This decision led to the torpedoing of the passenger ship Lusitania and the eventual US entry into World War I – a war that killed or injured over 37 million people.

The policy decisions that led to the starvation and mass emigration of the Irish were more subtle and indirect but just as lethal as the iceberg and the torpedo that sunk the Titanic and the Lusitania. Decades of state-sponsored discrimination promoted laws that influenced all aspects of Irish life including the restriction of education, the practice of religion, and the use of Gaelic by the Irish people. It also fostered passage of the “penal laws” that affected land ownership and led to total dependence on the potato for sustenance. These prejudicial policies inevitably caused the 1.5 million deaths and mass emigration precipitated by the potato famine that plagued Ireland for decades.

In each of these situations, conscious policy decisions led to catastrophic results that negatively affected the life and health of large numbers of people. Yet, none of these policy decisions was related to health care. They were policies emanating from consideration of business and political needs or the maintenance of a social and economic order that favored those in power.

I relate this story about Cobh not just for historical interest but because the impact of policies on health continues to play out every day. The discussion around minimum wage, one of the 2014 legislative session’s major policy issues, is a good example. The debate has centered mostly on the business, economic, and political ramifications of increasing the minimum wage. Yet, our recent report on “Income and Health” points out the fact that minimum wage is a public health issue – as income increases, health improves. Even though minimum wage is not being heard in health committees, policy makers need to be aware of the individual and community health implications of this policy decision.

Similarly, last month MDH submitted a report to the legislature entitled “Advancing Health Equity in Minnesota.” The report notes that “(w)hen groups face serious social, economic and environmental disadvantages, such as structural racism and a widespread lack of economic and educational opportunities, health inequities are the result.” The report underscores the fact that health is determined by much more than just health care. In fact, the majority of the health of individuals and communities is influenced by the “non-health” sectors. When health is not considered, policy decisions in these sectors often establish barriers that inhibit equal opportunities for health for all. These policies particularly affect“(t)hose with less money, and populations of color and American Indians, (who) consistently have less opportunity for health and experience worse health outcomes.”

Certainly, “health care policies” need to be part of the policy milieu that influences health. However, the example of Cobh demonstrates that business, occupational, educational, transportation, economic, and social policies can have an even larger impact on the survival and health of individuals and communities.

As the state’s lead public health agency, MDH has a responsibility to help create the conditions in which all Minnesotans can be healthy and that responsibility goes far beyond just dealing with issues in the clinical care and public health arenas. To be true to the vision of advancing health and health equity, MDH and all public health professionals need to be actively involved in assessing and monitoring policies at the local, state, and national levels that could have a health impact and advocating for decisions that will ultimately benefit the health of all Minnesotans and every community in our state.

The history of Cobh reminds us that policy decisions are important to the health of the public. There is health in all policies.


Tuesday, March 3, 2015

Zooks and Yooks

March 2, 2015

Every March I go to Washington D. C. to meet with federal agency heads and visit with the Minnesota congressional delegation. Today, my arrival in D.C. coincided with the arrival of Israeli Prime Minister Benjamin Netanyahu. Because of that coincidence, getting to my hotel took longer than usual as the cab had to navigate around police barricades and groups of protesters. That extra time in the taxi allowed me to ponder the polarization that’s so prevalent in our society. On almost every issue – from the Affordable Care Act through immigration reform to funding of Homeland Security and research on zoonotic diseases – the protagonists and antagonists appear to be acting like each other has an infectious disease that requires as much separation as possible. Sparked by the Prime Minister’s scheduled appearance before a joint session of Congress tomorrow, that polarization was blatantly evident throughout our nation’s capital today. 

Although the rhetoric is less intense and the issues not as prominent, Minnesota certainly hasn’t escaped from partisan polarization. 

With that thought in mind as I watched the green light turn red for the third time without the cab moving, I remembered that today was the birthday of Theodor Seuss Geisel. Not surprisingly, I immediately thought of one of my favorite Dr. Seuss books, The Butter Battle Book, which begins: 

On the last day of summer, ten hours before Fall…
my grandfather took me out to the wall.

For a while he stood silent. Then finally he said,
with a very sad shake of his very old head,
“As you know, on this side of the Wall we are Yooks.
On the far other side of this Wall live the Zooks.”

Then my grandfather said, “It’s high time that you knew
of the terribly horrible thing that Zooks do.
In every Zook house and in every Zook town
every Zook eats his bread with the butter side down!”

“But we Yooks, as you know, when we breakfast or sup,
spread our bread,” Grandpa said, “with the butter side up.
That’s the right, honest way!” Grandpa gritted his teeth.
“So you can’t trust a Zook who spreads bread underneath!

While the nuclear arms race was the basis of that story, Dr. Seuss could just as easily have used any of today’s controversies as his inspiration because, in Washington and throughout the country, people are using their Boom Blitzers, Blue Gooers, and Big-Boy Boomeroos to throw invectives at those who think differently than they do about myriad issues.  And what has it gotten us - a stalemate on most important issues and mutually assured destruction of anyone who tries to collaborate or compromise.  Health policy seems to be ground zero for many of these debates. 

Is it possible to get away from this brinksmanship and find a way to break down walls and collaboratively develop rational health policies?  Given the entrenched positions in Washington, it’s probably not possible there – at least not now.  Perhaps it can be done at the state level; especially in a state like Minnesota which has a history of coming together for the common good.  But who could help make that happen? 

I contend that it is our role as public health workers (some of whom are Yooks and some Zooks) to help make that happen.  Building on the fact that most people value health on both the individual and community level, we have the opportunity and responsibility to foster a conversation about what creates health.  We need to broaden that conversation beyond just the policy makers on one side of the aisle or the other and actively engage community members because everyone has a stake and responsibility in creating the conditions for health. 

The health of the public should not be a partisan issue – it is an issue that benefits everyone and everyone’s input is needed.  Our role in public health is to create the opportunity for all voices and perspectives on health issues to be heard and foster respectful and non-judgmental debate - essentials for the development of rational and effective approaches to creating health for everyone.  Now is the time to create that opportunity because, as was stated in Horton Hears a Who, another of my favorite Dr. Seuss stories: 

"This", cried the Mayor, "is your town's darkest hour!
The time for all Whos who have blood that is red
To come to the aid of their country!", he said.
"We've GOT to make noises in greater amounts!
So, open your mouth, lad! For every voice counts!"


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.