Monday, November 23, 2015

Challenge of Diversity and Vision of Equity: 1994 - 2015

Last Friday I had the honor of speaking at a celebration of 12 years of service of Sharon Sayles Belton as a member of the Hennepin Health Services board. In addition to that service, Sharon served as a Minneapolis City Council member for 10 years and in 1994 was sworn in as Mayor of Minneapolis, the first woman and first African-American to hold that position. In my remarks I quoted from her January 1994 inaugural address. At this time, when Minneapolis and Minnesota are struggling with inequities and racial tensions, I think it’s appropriate for us to consider what Mayor Sayles Belton said in that address 21 years ago. It certainly harmonizes with our Triple Aim of Health Equity, our new Strategic Plan, and our vision of health equity – where all communities are thriving and all people have what they need to be healthy. Here are her words and challenge for all of us:

“We are living in an era in which change takes place with astonishing speed…an era challenged by complexity, by an increasingly diverse population, and by ever-closer personal, social and business ties with people and cultures from all over the world.

“Today, as we stand at this crossroad and consider which paths to pursue…our community will not be served by clinging stubbornly to old ways of thinking and acting. That is why it is important on this day…that we take time to search out and study the maps and landmarks of our past and present that can serve us reliably as we move through change into the future. …

“First we must look within ourselves, to the things that we value and believe in….I believe we share community values, values that transcend race, economic status, individual need and ambition; values that constitute the framework of our society and community life. …

“We value our children, and know that our future lies in their hands.

“We value strong families, and know that only they can provide our children a safe and protective environment, and teach them the values of respect, education, responsibility and hard work.

“We value the entire community's role in the lives of our children, because it takes "a whole village"--or city--to raise a child. That means it takes community systems that work--schools that truly educate, neighbors that provide safety, health care for every child.

“These are our community values…based on an assumption of our own intrinsic goodness and that of our neighbor, and on the hope that each one of us can and must make the world a little bit better. …

“Americans like to say we are strong because we are founded on a tradition of tolerance--that we are nurtured by diversity. Living peacefully and creatively with diversity is the great American experiment.

“Minneapolis, like our state and our nation, has become increasingly diverse. We are a multiracial, multicultural, multilingual city. We are a kaleidoscope of skin colors, a tapestry of ethnic traditions, a treasury of spiritual beliefs, and a forge of ideas, perspectives and talents igniting in dialogue.

“Diversity fuels our creativity, makes us stronger and more resourceful, and serves, if we let it, as a pilot light for the virtues of humility, generosity, and peacemaking.

“But diversity can breed distrust, tension, and even violence. While it is our unique strength, it is also our unique challenge. That is why it is important, at this time in our city's history, to continue the traditions of tolerance and understanding that have guided us in our best moments. We must explore our diversity, embrace it, and harness it in the name of the common good. We must invent new ways of making decisions, based on consensus and cooperation….

“Our city is important. It is our family, our neighbors, our shops, our leisure, our financial base. It is the trees that shade us, the lakes that delight us, the water we drink and the air we breathe. We are its stewards. Each one of us bears responsibility for its health and prosperity.

“If we face escalating violence, we cannot turn to the police to resolve the problem single-handedly. The entire community must participate in the hard work of articulating and demanding compliance with our shared values.

“If we face a shortage of jobs, we cannot ask the business community to create employment without the support of schools, health and social services, transportation, day care, and government itself. …

“And if our land and our lakes,…are poisoned and slowly dying from pollution, then industry leaders and homeowners alike must become better caretakers, to ensure that these resources will survive, to sustain and be enjoyed by our children, and our children's children.

“We are a vibrant community, a brilliant and diverse family, living in a beautiful green and blue--and sometimes snowy white--city on the rich Midwestern prairie, blessed with abundant natural and human resources. We are blessed with everything we need. If we fail to remain true to our values, to our traditions, and to each other, and thereby fail to rise to the occasion of our own survival, it will only be because we lack the courage.

“Therefore…I ask every elected official, every city worker, and every citizen of this city to make a resolution--no, an oath--to this city:
  • to find common ground, and to profess privately and publicly our common values--in spite of our differences;
  • to commit ourselves--in spite of our doubts,
  • to listen--in spite of our certainties,
  • to persist--in spite of our failures, and,
  • in spite of our fears,-- to allow ourselves -- to be guided by our basic humanity.”
This address is a great articulation of public health – what we do collectively to assure the conditions in which people can be healthy.

Monday, November 16, 2015

Believing is Seeing: Advancing Health Equity in Minnesota and Mississippi

Last Friday (November 13) I traveled south to give the keynote address to the Mississippi Perinatal Quality Collaborative annual meeting. From the many opportunities I have to speak, I accepted this invitation because it offered the potential for collaborative learning between two states on opposite ends of the geographic, political, social, economic, and health continua. (Having the invitation come from Mary Currier, one of my favorite state health officials, was also a factor.) Even though the “M” states on the ends of the Mississippi River are miles apart in so many ways, there are many shared concerns including under investment in public health, persistent health disparities, and a growing recognition of the need to address the social determinants of health if each state is to become healthier.
Because November 13 happened to be an important day in Mississippi literary history – the date in 1942 when Eudora Welty won her first O. Henry Memorial Prize for her short story “The Wide Net” and when William Faulkner published “The Mansion” in 1959 – I used the work of these famous Mississippi authors to frame my talk about the Triple Aim of Health Equity. As I’ve discussed before, the Triple Aim of Health Equity includes the following:
  • Expand the understanding of what creates health.
  • Implement a "Health in All Policies" approach with health equity as the goal.
  • Strengthen the capacity of communities to create their own healthy future.
In “The Wide Net,” Welty tells a story contrasting the needs of the individual with the claims of the community. This resonates with the aim of changing the narrative about what creates health from one of solely individual responsibility to one of shared individual and community responsibility and the aim of strengthening community capacity. “The Mansion” deals with the changing economic and political landscape and the impact of racial and social tensions on individual and community well-being. It highlights how the policies and culture of society can lead to inequities and discord in communities. It’s a powerful example of the importance of the health in all policies aim.
These southern stories helped me underscore the imperative of public health to go beyond the dominant narrative that health is determined solely by medical care and personal choices to a focus on the more accurate narrative that it’s the social, economic, and environmental conditions in our communities that have the greatest impact on health. They also helped reinforce the point that many of the inequities in our society are the result of policies that regularly and systematically disadvantage populations of color and American Indians.
While making that argument, I had a personal epiphany that explained why I was in Mississippi on this particular day. Coming from Minnesota “Where the women are strong, the men are good looking, and all our children are above average,” I was particularly struck by one line uttered by V. K. Ratliff in “The Mansion” – “what ain't believed ain't seen.” It challenged my Lake Wobegon mindset. Because of our excellent overall statistics, Minnesotans may have difficulty believing that problems exist that threaten our status as a prosperous and healthy state; clouding our ability to see the need for significant change. Perhaps:
  • “What ain't believed” in a state with a history of investing in the “commons” is that our current investment strategies no longer benefit everyone – so the fact that not everyone is experiencing the good life in Minnesota “ain't seen.”
  • “What ain't believed” is that health care alone can’t make or keep us healthy – so the need to support state and local public heath activities “ain't seen.”
  • “What ain't believed” is that programs and services won’t fix our health and social problems – so the need to focus on policy, system, and environmental change strategies “ain't seen.”
  • “What ain't believed” is that structural discrimination still exists – so that the real causes of health, educational, and economic disparities “ain't seen.”
From my brief conversations with the audience in Jackson it seems to me that the people in Mississippi don’t suffer from the “ain't believed ain't seen” dilemma. They fully recognize the circumstances leading to their low rankings. They believe that they have significant health problems and they see them clearly. Because of that, they may actually be farther along in the process of transforming public health than we are in Minnesota. This made me think of the quotation from Rabindranath Tagore, the first non-European to win the Nobel Prize in Literature: “The sparrow is sorry for the peacock at the burden of its tail.” I was humbled by the work being done in Mississippi.
My experience in Mississippi underscored the need for the Triple Aim of Health Equity and particularly reinforced the importance of changing the narrative about what creates health. To be healthy we need to understand the realities in which people live and the importance of safe and prosperous communities and good public policies. A public health narrative helps us see what needs to be done to “assure the conditions in which all people can be healthy.”
On my way to the airport, Commissioner Currier and I stopped to visit the home of Eudora Welty. As we walked through the historic house filled with books and letters and memories, I pondered this line from “The Wide Net” – “The excursion is the same when you go looking for your sorrow as when you go looking for your joy.” Despite our circumstances, all of us ultimately share the same path of life from birth to death. For some of us the excursion unfortunately contains more sorrow than joy. But none of us should be on that journey alone. To enhance our opportunities for joy, we need to be on the excursion together. That’s part of the responsibility of being a member of a community.
As health commissioners, even though we live and work in markedly different states, Mary Currier and I are also on the same excursion – trying to find ways to improve the health of everyone in our state. We may have different challenges, opportunities, and resources but we are looking for the same thing – ways to create a state where there is health equity, all communities are thriving, and all people have what they need to be healthy.

Wednesday, October 21, 2015

Public Health Healers

What matters is the presence of healers in all walks of life – the teacher, the doctor, the rabbi, the family member, the friend.
                        Margaret Mahoney (October 24, 1924 – December 22, 2011

While at the Carnegie Corporation in the late 1960s, Margaret Mahoney realized that effective health leaders of the future would need health policy, health services research, and public health expertise in addition to their clinical skills. That vision came to fruition as the Clinical Scholars Program (CSP) when Margaret Mahoney moved to the newly established Robert Wood Johnson Foundation in 1972. 

I was privileged to be a CSP fellow in the earliest years of the program – an experience that helped shape my professional career.

I’ve been thinking about the CSP and Margaret Mahoney as I prepare to attend and present at my first CSP annual meeting in 35 years. I re-read several of the essays written by Ms. Mahoney that focused on the key roles required to bring about social progress. These essays were titled: Doers. Inspirers. Communicators. Healers. Builders. Innovators. Trustees. Mentors. Leaders. Partners. Heroes. 

Given that many of my recent presentations start with the World Health Organization (WHO) definition of health, I was particularly interested in her essay on “Healers” since both “health” and “healing” come from the same Old English word root hal meaning whole. To be healthy is to be whole. To heal is to be made whole. Healers help to make things whole. 

As I read her essay on “Healers,” I became more convinced than ever that healing is the primary task of public health. Because being whole includes both personal integrity/well-being and communal belonging/social connectedness, our healing efforts as a public health agency must encompass not only individuals but also the communities in which they live and the systems that affect them. 

In order to be effective, I believe healers must possess some specific characteristics.

¨      Healers must be patient. Healing takes time and we must accept the natural course of healing.  It’s okay to try to hurry things along but as Shakespeare said:“What wound did ever heal but by degrees?” Healers must take a long-term view and accept long term responsibility for results.  Being a healer is a lifetime job.
¨      Healers must be risk takers. Sometimes healers need to confront and educate those in power who may not embrace a healthful vision for our society. Healers are not always popular or welcomed. 
¨      Healers must work together. Healers must be confident and self-assured but must also be integrated with other healers. No one has all the skills or energy that is needed to foster all the healing that needs to be done. Healers are more likely to be successful if they are organized and working together.
¨      Healers must be compassionate and forgiving. Blaming those who make unhealthy choices is misdirected. Choices are made in the context of people’s environments and we, as members of this community, have in many cases helped create those environments. We all share the responsibility of making this a healthier community.
¨      Healers must be passionate. To be a healer, one needs to be firmly committed to improving the health of people and the community. 

Healing in this sense resonates with the Institute of Medicine definition that public health is what we, as a society, do collectively to assure the conditions in which people can be healthy. To make our communities healthy or whole we need the entire community to be healers. We need to have healing become a community responsibility.

This means that we all need to become healers and take a broader view of health so that healing can include the body, mind, and spirit of individuals and the community.

Using the clinical lexicon, we must first make the right diagnoses if we are to become individual and community healers. We must be able to identify the healthy state and any divergence from it.  Recognizing that most of the things affecting our health and the health of our communities are not medical conditions but social and economic conditions, we need to begin to make the right diagnoses related to things like violence, incarceration, discrimination, working conditions, structural racism, and community values. 

As I thought about healing, I realized that health and health equity require all of us to develop the capacity and skills to be healers. As Margaret Mahoney said: “Whether the healer is helping an individual or a community – family, neighborhood, group, or indeed the nation – the objective is to heal the rifts that lead one person or one group to misunderstand, even disdain, another. The goal is to recover friendships, rebuild self-esteem, and cement understanding.”  Healing is the only way to achieve health equity and optimal health for all. We all have a responsibility to be healers and we must take that responsibility seriously. 


Monday, September 21, 2015

C. Arden Miller, M.D. – Mentor and Role Model

When I arrived at the University of North Carolina - Chapel Hill in 1978 as a Robert Wood Johnson Clinical Scholar, I was planning to be a primary care doc in a rural community. I had chosen UNC because of its history of great health services research on rural health issues and the existence of the state’s premier rural-focused Area Health Education Center (AHEC) program. The Clinical Scholars Program (CSP) also offered me the opportunity to staff pediatric and internal medicine clinics in a couple of rural communities. It seemed like the perfect setting to move forward on the professional course I had chosen.
A perquisite of the program was the opportunity to earn an advanced degree in a health-related field. Since I knew next to nothing about public health at the time and recognized that some knowledge of epidemiology, biostatistics and health administration might be helpful, I decided to pursue a master’s degree in public health. The CSP program director suggested I meet with C. Arden Miller, Chair of the School of Public Health’s Maternal and Child Health Program. It was a recommendation that radically changed the trajectory of my career.
Dr. Miller took me under his wing and during the next two years taught me not just the principles and practices of public health but the importance, power, and potential of public health in protecting and improving the health of individuals and communities. He also led me to an understanding that epidemiology is the scientific mind of public health while maternal and child health is the social justice heart and soul of the field. He helped to dramatically change the way I looked at what is needed to create health, particularly for families and children.
During this time, Dr. Miller’s research activities were focused on assessing the impact of state and local governmental public health agencies. His findings opened my eyes to the potential and opportunities embodied in a governmental public health career. That epiphany and some direct help from Dr. Miller led to my first job in public health as the director of the Maternal and Child Health program at the Minneapolis Health Department.
Beyond the obvious impacts Dr. Miller had on my career, I have recently come to recognize some of his more subtle but profound influences. When I first met him in 1978, I wondered why a physician, who had been medical school dean and a university provost and vice chancellor, would give that up to be a just a teacher in maternal and child health. Where was the status, power, and influence in that? By his actions on many important health issues, he answered my question about power and influence. He demonstrated that physicians can influence health in so many ways other than treating individual patients. In fact, he showed that a physician working on policy, system, and environmental change could save more lives and improve the health of more people than any physician in a clinical setting.
With those same actions he also answered my ego-inspired inquiry about status. He demonstrated with great humility that no physician working on public health issues could do it alone. Public health is a team effort and physicians, as critical as they might be, are just one of the many essential team members. The credit for any advance in improving the health of communities must be shared with all of the people involved in making that happen. That’s why he never talked about his numerous accomplishments (for a partial listing see: C. Arden Miller: Advocate for Children's Health) but openly reveled in the success of all of his students - physicians and non-physicians alike.
Dr. Miller was a mentor and role model for me and for countless others. He made significant impacts on public health research and practice, effectively led organizations, and advocated tirelessly for the health of mothers and children. He did all of that with humility, dignity and class that inspired everyone who knew him.
I mention all of this because on Saturday I travelled to Chapel Hill for the memorial service of C. Arden Miller, MD. The event was attended by many former students, faculty, colleagues, family, and friends who were impacted by this remarkable individual and public health giant.
As I sat listening to the stories about Dr. Miller (some of which humorously revealed several of his not-so-perfect characteristics), I reflected on the impact he had on my career. I can honestly say that if it wasn’t for Dr. Miller, I would not be Commissioner of Health and would not be celebrating my 35th year of rewarding public health practice.
Two years ago I was able to visit Dr. Miller and thank him for all that he contributed to my personal and professional life. Many of the people at the memorial service had not had that opportunity and felt sad about that.
Knowing I’m not unique, the event made me wonder how many current public health workers have taken the opportunity to thank the people who have helped them in their careers. It also made me think about the future public health leaders among us and question whether we are effectively mentoring them to take on the public health challenges of tomorrow. As Arden Miller demonstrated, that might be the most important public health work we can do.


Monday, August 10, 2015

The Real Narrative of Peter Rabbit

A recent survey conducted by the people who are developing "Raising of America," a video series on child well-being, asked “Why do children struggle?” The most frequent response was “Parents don’t know how to parent” followed closely by “Children don’t work hard enough.” In our society, which values the autonomy of the individual, these responses are predictable because they spring from the “pull yourself up by the bootstraps” narrative that health and prosperity are due mostly to the choices that individuals make. These responses parallel what I’m hearing as I travel the state asking “What needs to be done to create a healthier Minnesota?” The most common responses I get are “Parents need to learn how to parent” and “People just need to be responsible for the choices that they make.” 

That focus on individual responsibility was on my mind as I traveled to address a collaborative of state health departments addressing infant mortality. My presentation was on July 28, the birthday of Beatrix Potter (author of "Peter Rabbit"), which inspired me to look at how children’s poems, stories, and fairy tales help shape our view of life.

Starting with "Mother Goose Nursery Rhymes" (Humpty Dumpty, Little Boy Blue, Three Little Kittens, Little Bo Peep, The Old Lady Who Lived in a Shoe) the message is clear; the choices one makes have consequences – usually negative consequences from bad choices. If Humpty, that silly old egg, hadn't been on the wall in the first place the king's horses and men wouldn't have had to go to all that trouble. 

"Aesop’s Fables" (Town Mouse and City Mouse, Hare & Tortoise, Ant and Grasshopper) reinforce that narrative. The fairy tales by the Brothers Grimm, Andersen, and others (Hansel and Gretel, The Little Mermaid, The Red Shoes, The Three Little Pigs, Santa Claus) offer a similar message but often expand the narrative to show how individual action can conquer life’s challenges. The sensible pig who built his house of bricks saved the day for his foolish friends who chose to make their domiciles from cheaper but unsafe building materials.

Given the pervasive message of individual responsibility in children’s literature, it’s not surprising why that narrative persists as the dominant one in our society.

One of the approaches necessary to advance health equity is to expand the understanding about what creates health. That means changing the narrative that health is not just about medical care and personal choices but also about the physical, social, and economic environment in which people live, work, and play. With that in mind, I tried in my speech to change the narrative of a children’s story to see how it might help change the narrative about what creates health. In honor of Beatrix Potter, I used "Peter Rabbit."

My speech, like the story, started with: Once upon a time there were four little rabbits, and their names were Flopsy, Mopsy, Cottontail, and Peter. They lived with their mother in a sandbank, underneath the root of a very big fir tree. One morning old Mrs. Rabbit said, "I'm going to the bakery to get some brown bread. You may go into the fields or down the lane, but don't go into Mr. McGregor's garden. Your father had an accident there; he was put in a pie by Mrs. McGregor." Flopsy, Mopsy, and Cottontail, were good little bunnies... but Peter, who was very naughty, ran straight to Mr. McGregor's garden and squeezed under the gate!

As the tale unfolds, it becomes clear that naughty Peter, despite the admonitions of his caring mother, made a bad choice by going into Mr. McGregor’s garden. His choice nearly cost him his life. The moral of the story is obvious, bad choices may have life-threatening consequences. 

But what would the moral be if the context of the story was known? You see, the Rabbits’ home under the root of the fir tree was not a great place to live. It was near a polluted creek that often flooded and inundated the Rabbits' house. The sandy soil in the neighborhood was not conducive to growing anything but weeds so food was scarce. Messrs. Fox, Eagle, and Badger roamed the sandbank and bullied the neighborhood. The Rabbits lived in fear of them.

Across the lane was Mr. McGregor’s Garden. It had great soil and moisture so a multitude of fruits and vegetables grew in abundance. Many outsiders envied the garden but it had an almost impermeable fence which kept out undesirables making it a safe and secure place for those who lived there. The garden had been in the McGregor family for generations so Mr. and Mrs. McGregor had the systems in place to make sure it continued to be a place that met their needs. They countenanced no disruptions. 

Driven by hunger and the desperate need to feed his growing family, Mr. Rabbit had managed to get into the garden. But, the systems put in place by the McGregors quickly identified his intrusion and his capture was inevitable. Within hours he was served up in a crust to satisfy the appetites of the McGregors.

Peter knew that story well. His mother mentioned it almost every day. Peter missed his father but also felt some of the same pressures that motivated his dad. He didn’t see that he had many choices if he was going to help his mother and sisters. Staying in the neighborhood meant fighting with the Fox, Eagle, and Badger over the meager resources available there. He didn’t like those odds. Brown bread from the bakery wouldn’t sustain him or his family for very long so he decided going into Mr. McGregor’s garden was the best option he had.

You know the rest of the story – at least up to the point when Peter is put to bed by his mother. Who knows what happens after that? I’d like a “happily ever after” ending but I’m not optimistic about the ultimate end of the story. Unless there is an improvement in the conditions in which the Rabbit family lives, I don’t see Peter or his well-behaved sisters doing well regardless of the choices they make. 

I’m not sure if the audience at the infant mortality conference made the connection between my story and what needs to be done to improve the lives of infants and their families. I hope they did. One thing for certain is that remembering the impact of the stories I read to my children years ago and my brief in-flight analysis of children’s literature convinced me of the truth of Plato’s statement that, “Those who tell the stories rule society.”

Now, go tell or read a story to your children, grandchildren, neighborhood children, or those who need more stories in their lives. But, be sure you include the context and the conditions in which the story characters live so that you and the children, understand that the community and its physical, social, and economic conditions are important in shaping the choices they make and determining what ultimately happens to them.


Monday, July 20, 2015

Make the Health Desert Bloom

Forty years ago this month I moved to Salt Lake City to continue my medical training. It was an exhilarating time in health care. Major advances in medical technology seemed to occur every week. The first clinical CAT (computerize axial tomography) scanners came online just as I started my residencies. That advance was bracketed by the “Babybird” respirator, infant incubators, MRIs, ultrasound, fiber optics, the Jarvik artificial heart, lithium batteries, lasers, and many others. These new technologies allowed clinicians to diagnose and treat conditions in ways unimaginable ten years earlier; saving smaller and smaller babies and more seriously ill children and adults than ever before.

During this time, our medical care system was transformed. The new medical technologies fostered the development and expansion of newborn intensive care units, tertiary care hospitals, implantable pacemakers, medical transports, in vitro fertilization, and new micro surgical techniques to name just a few. They accelerated the trend toward specialization within the medical profession. We had great hopes and expectations that a technology-enhanced clinical care system would lead to a new level of health in our country.

Last week I returned to Salt Lake City for the “State Health Departments’ Senior Deputies and Legislative Liaisons Meeting” conducted by ASTHO (Association of State and Territorial Health Officials). As I entered the city, I was struck by how much it had changed in forty years. The Wasatch Mountains and the Great Salt Lake appeared the same but, due greatly to the influence of the 2002 Winter Olympics, there were more hotels, light rail, and one could now purchase alcohol in restaurants. There was also a large homeless population – something non-existent in SLC forty years ago. But the biggest change for me was the focus of the meeting presentations and attendee conversations. They were not talking about the promise and potential of our medical care system to improve health; they were talking about its failures and limitations.

With forty years of hindsight it is evident that, despite all its benefits, technology has not made us healthier when compared with similar countries. In almost every health category, including infant mortality, longevity, and health disparities, the U.S. has fallen farther and farther behind other OECD (Organization for Economic Co-operation and Development, i.e. industrialized) countries. And we have achieved those poorer outcomes at a tremendous cost – both human and financial. Until 1975, the percentage of the U.S. GDP (gross domestic product) spent on health care paralleled that of other OECD countries. Since then, our skyrocketing costs have significantly outpaced every other country.

Our supersized investments in medical care have been mostly at the expense of investments in public health and human services. The U.S. has the lowest percentage of GDP spent on human services among the 28 OECD countries which spend more than 15% of their GDP on the combination of medical care and human services. Yet, it is these investments in public health and human services that are proving to be the most effective in improving health. Moreover, the huge investments in high-tech medical care has also lead to lost opportunity costs by stifling investments in education, housing, transportation and other social determinants of health.

As I sat in the room listening to how we need to create a new 21st century approach to protecting and improving health, I thought back to the Mormon and Utah history I learned during my three years in that unique state. On July 24, 1847, Brigham Young, sick with Rocky Mountain Spotted Fever, saw in the distance the Salt Lake Valley for the first time. Remembering an earlier vision about leading his followers to a place where they could "make the desert blossom like a rose," he proclaimed from the back of his wagon, "It is enough. This is the right place. Drive on." The Latter Day Saints did just that, they drove into the valley and helped make Young’s vision a reality.

The comments and questions from the senior deputies and legislative liaisons from state health departments throughout the country, made me aware that they were in one respect in the same place, both literally and figuratively, as Brigham Young. They understood that we’ve got enough data to know what creates health; that we’ve invested enough in the health care path we’ve taken over the last 40 years; that we know what needs to change to improve our health status; and that we don’t have to look further for the time and place to start. The question they had was how to instigate those changes? How do we invest in and implement a “health in all policies” approach that addresses the physical, emotional, environmental, and social determinants of health?

From what I heard last week in Salt Lake City and what I’m observing throughout Minnesota and the rest of the country, people are answering those questions. There is a growing consensus that, relative to our investment in health care, “it is enough.” There is a recognition that change needs to occur in the states because “this is the right place.”

The place and time are right to make our health deserts bloom so let’s “drive on” to create the policies, systems, programs, and conditions in which all people can be healthy. It’s a great time for you and me to be in public health and help shape the vision and the direction for all 21st century health pioneers.


Monday, July 6, 2015

Health is Community

Every year I have the opportunity to provide the closing keynote address at the Minnesota Rural Health Conference. Not wanting to be repetitious, I continually look for new perspectives on rural health that might be helpful to conference attendees. As I began to prepare this year’s remarks, I was made aware of a book of essays by Wendell Berry, a poet, writer, and farmer from Henry County, Kentucky. Knowing that his writings deal with healthy rural communities, sustainable agriculture, appropriate use of technology, connection to place, and the interconnectedness of life, I thought he might provide some inspiration. 

I wasn’t disappointed. 

In his essay “Health is Membership” Berry wrote that “…the community in the fullest sense is the smallest unit of health…to speak of the health of an isolated individual is a contradiction in terms.” That statement both stunned and energized me. Public health is based on data and measurement of health and this statement challenges how we currently think about, define, and appraise health. Although we are learning how individual health is profoundly affected by the environment in which people live, work, and play, we struggle to find ways to measure and assess that influence and appropriately improve it. The question is why?

You don’t have to go further than the guiding mantra of today’s health care reform, the “Triple Aim,” to find the answer. The “Triple Aim of Health Care” is: better care for individuals, lower per capita costs, and better health for populations. The focus is entirely on individuals. Even the population health aim looks at populations as the summation of individually-focused data and interventions. There is no direct or implied acknowledgement of the importance of community, which reinforces the common narrative that health is due solely to high quality health care and good personal choices. 

The “Triple Aim” reinforces an industrial model of health care that rewards efficiency and assumes bigger is better. It focuses on the care of each individual and assumes that a person can be healthy independent of outside factors. It strives for standardization and evidence-based, best practices although only certain kinds of evidence are acceptable. To best treat individuals with specific disease conditions, health care has become increasingly specialized and technology dependent. This model, effective as it is in providing excellent care to some individuals, discounts the importance of communities.

With that perspective, I had to conclude that the “Triple Aim of Health Care” is potentially detrimental to health – particularly rural health and health equity – and made that the premise of my speech. Knowing that my audience would be mostly health care providers, I made note to emphasize that health care is not detrimental to health rather it’s the health care systems put in place by the values represented by the “Triple Aim.” Health care is an important and necessary contributor to health but how it’s organized and funded is not necessarily best for the health of communities and health equity. In other words, what’s good for our health care system may not be good for communities or health equity. 

The “Triple Aim” reinforces the notion that health is the responsibility of the health care system. It crowns our health care system as the benevolent dictator of health in our country. All of health is viewed through a health care lens further reinforcing the narrative that health is solely about health care. It allows the health care system to dictate where health investments are made. That’s why public health and social services are underfunded in the United States compared to other countries and why other sectors that influence health are also under-resourced due to the overly-resourced health care system.

Knowing that people would not want to leave the conference on a negative note, I decided to offer an alternative triple aim for consideration – the Triple Aim of Community Health and Health Equity:
  • Expand our understanding about what creates health
  • Implement a Health in All Policies approach with health equity as the goal
  • Strengthen the capacity of communities to create their own healthy future

The value underlying these three components is community connectedness – the social capital and social cohesion that’s essential for individual and community health. 

The Triple Aim of Community Health and Health Equity is built on a community health model, not an efficiency model. It recognizes that health is created in communities by the social, economic, and environmental conditions in which people live, work, and play. It acknowledges that every sector of the community (including health care) impacts the community’s health. Most importantly, it recognizes the need for communities to possess the power to address the conditions that impact their health. 

To build healthy communities, the health care system should not be in charge of health nor should the public health system. The community needs to be in charge of health. Health care and public health are crucial to creating healthy communities but are only two of multiple partners who need to be at the program and policy tables where decisions are made about how to invest in health for current community members and for generations to come.

I made the above points in my speech and it was met with polite applause. No one commented or challenged me or even asked a question during the Q and A session so I was left wondering how the speech was received. That was partially answered when three different people approached me after the session and said, “We’ve been waiting for this speech for twenty years. Our present system isn’t working for rural communities. You explained why and you gave us a framework to change that.” 

As a farmer, Wendell Berry knows that the seeds he plants determines the crop he harvests. The seed in his essay that “health is membership” blossomed into my understanding that health and health equity is community. Who knows what crop will spring from my speech? If something grows, I hope it’s a crop of social connectedness that shows us that community really is the smallest and most basic unit of health.