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.
Ed