Monday, August 11, 2014

Pitching Public Health

I was warming up for a run on August 9, 2001, when I heard Bob Kelleher from Minnesota Public Radio report on the World Horseshoe Tournament that was being held in Hibbing, Minn. Over 1,000 contestants from around the world were assembled for the two week-long event. I was only half listening to the story until a three-time world champion from California was interviewed. He claimed that “Horseshoes is a game of strength, stamina, and consistency.” Consistency made sense but I had never thought of horseshoes as a game of strength and stamina. That made me listen more closely, but what intrigued me most was that this participant was 77 years old and still competitive.

While I was still participating in running and cross country ski races at the time, I filed horseshoe pitching in the deep recesses of my brain as a “lifetime sport” that might be fun if my joints or other body parts ever rebelled at my long-distance running and skiing activities.  

My activities had already shifted to biking and walking before horseshoes resurfaced in my consciousness. That happened after I became commissioner. Initially, pitching horseshoes was in the context of the “bully pulpit” that I’m purported to have and the need to listen to community voices. Playing off the pun, I thought I could go around the state “pitching” public health to the citizens of Minnesota while they “pitched” their ideas and concerns to me. That horseshoe pitching also fit well with our Statewide Health Improvement Program’s (SHIP) efforts to get people to be more active was added value not to mention that it supported my mantra that “if it’s not fun, it’s not public health.”

The more I thought about doing “Pitch the Commissioner” events, the more I discovered about Minnesota as a horseshoe pitching hot spot in the US. There are more registered horseshoe pitchers in Minnesota than any other state and Minnesota is home to dozens of world champions. Also, everyone that I talk with remembers pitching horseshoes with their fathers (never their mothers) on the farm, at a cottage, at a family reunion, or at a picnic. It seems like horseshoes, in larger or smaller portions, is part of the Minnesota DNA, even for women who are increasingly involved in the sport.

I’m now in my third year of doing “Pitch the Commissioner” events. These events have allowed me to visit all parts of the state; meet with county commissioners, local health department staff, and other community members; observe some innovative and effective programs; participate in some health-related tours and activities; and marvel at the strategic plan of Dairy Queen. In the process, I’ve been able to hear the concerns and ideas about public health in Minnesota at a community level while discovering that horseshoes is a great (although not perfect) metaphor for public health.

To be successful in horseshoes, you first need access to a horseshoe pitch and to the horseshoes themselves. I've learned that not every community has a horseshoe pitch and that some pitches are in disrepair. When you are actually pitching, you don’t want the shoes to go too far to the left or right or too short or too long; you want them centered in the middle of the pit. Finally, you want the shoe to have the right orientation to encircle the stake so you can get a “ringer.”

Creating a healthy population is like playing horseshoes. Imagine the stake as an individual and the horseshoe pit as the community. The community needs to have some basic infrastructure that surrounds and embraces each individual community member.

Next, imagine that the trajectory to the right is treatment and to the left is prevention. To meet the needs of each community member you need the correct balance of each. Treatment and prevention are needed in proper proportion for health. Likewise, from a distance perspective there needs to be a balance between short-term and long-term goals. You need to address short-term issues while planning and working for long-term health.

Individual behaviors are the horseshoe itself. Individual behaviors need to have the right orientation to achieve the “ringer” of optimal health. If the community doesn't have the proper balance between treatment and prevention and between short-term and long-term needs, individual behaviors are somewhat irrelevant in maximizing health. However, with the proper balance, individual choices make a tremendous difference in one’s health score.  

Finally, the horseshoe pitch itself is a metaphor for the social determinants of health (income, wealth, economic opportunity, education, housing, transportation, etc.) which are the most influential factors in creating a healthy community. Before being able to play any game and be competitive one needs access to the game and the rules have to be fair. These are policy issues that are often outside the control of an individual. For horseshoes the issues are: Who owns the horseshoe pitch? Who controls it? How is it financially supported? Who gets to use it? Who are the decision makers about its use?  Where is it located? Can people get to it? What are its hours of operation? Who sets the rules for play? And do those rules provide the opportunity for everyone to be competitive?

The same questions have to be asked about the policy decisions made related to the social determinants of health. Who is at the decision-making table and who has the power to make the decisions that affect health? In horseshoes, if you can’t get into the pitch, where and how you throw the shoe doesn't matter. In health, without access to economic opportunities, safe and stable housing, and a good education, health care and individual choices are still important but less impactful than they could be in achieving good health.

In addition, once in the game, the rules have to provide equal opportunities for everyone to be successful. Knowing that throwing a 2-pound 10-ounce horseshoe 40 feet may exceed the physical capacity of some individuals, the rules in horseshoes allow men over 70 and women to pitch from 30 feet. That helps equalize the opportunity to be competitive. To create a healthy community, we also need to have some flexibility in the rules to assure the conditions that allow everyone the opportunity to be healthy.

At the risk of pushing this metaphor too far, I’ll make one last comparison. You don’t have to be good at horseshoes to enjoy the sport. I’m a great example of that. Just being on the pitch with people who are moving, conversing, and laughing engenders great satisfaction and joy. However, the more you participate, the better you become. Practice makes better.

Similarly, with our individual health and the health of our communities. One doesn't need to be an expert to get involved in building a healthy community. In fact, different levels of expertise and experience lead to richer conversations and innovative ideas. Just being involved makes a difference. And, like horseshoes, the more involved you are the better you become at helping to improve the conditions that create health.

This week I will be in St. Louis County where I will be pitching horseshoes and public health in the place that generated the idea for my “Pitch the Commissioner” tour. I may not get many actual ringers with my horseshoes while I’m on the pitch, but I’m confident that there will be many ideas and concerns that the community will pitch me that will be ringers for the health of our state.