4/15/2015 CREATING THE CONDITIONS FOR HEALTH FOR ALL MINNESOTANS HEALTH IN ALL POLICIES APPROACH

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1 CREATING THE CONDITIONS FOR HEALTH FOR ALL MINNESOTANS HEALTH IN ALL POLICIES APPROACH Edward P. Ehlinger, MD, MSPH Commissioner, Minnesota Department of Health President-Elect, Association of State and Territorial Health Officials (ASTHO) April 10, 2015 National Public Health Week April 6-10 Healthiest Nation 2030 Monday: Tuesday: Wednesday: Thursday: Friday: Raising the Grade Starting from Zip Building momentum Building broader connections Building on 20 years of success State Health Rankings

2 Minnesota! Where the women are strong, The men are good looking, And all our health statistics are above average Unless you are a person of color or an American Indian. Disparities in Outcomes and Risk Factors White Black Hispanic Smoking (Percent of adult population) Binge Drinking (Percent of adult population) Drug Deaths (Deaths per 100,000 population) Obesity (Percent of adult population) Physical Inactivity (Percent of adult population) High School Graduation (Percent of incoming ninth graders) Chlamydia (Cases per 100,000 population) Diabetes (Percent of adult population) Infant Mortality (deaths/1000 live births) Cardiovascular Deaths (deaths/100,000 population) Cancer Deaths (deaths/100,000 population) Advancing Health Equity Health Report Equity February 1, 2014 in Minnesota the opportunity to be healthy is not equally available everywhere or for everyone in the state. 2

3 35.0 Infant Mortality Rate in Minnesota, White and U.S. Born African American * * * * Rates not calculated for less than 20 events White U.S. Born African American The role of public health The landmarks of political, economic and social history are the moments when some condition passed from the category of the given into the category of the intolerable. I believe that the history of public health might well be written as a record of successive re-definings of the unacceptable. Geoffrey Vickers Disparities in Birth Outcomes are the tip of the health disparities iceberg Disparities in Birth Outcomes Heart disease Hypertension Cancer Alcoholism Stroke Asthma Cirrhosis Unwanted pregnancies Diabetes Drug abuse Homicide Nephritis Obesity HIV Dementia STDs Substance Use Renal failure COPD Injuries Influenza Tuberculosis Suicide Depression Malnutrition Anxiety 3

4 Advancing health equity is not about averages It s about creating opportunities to be healthy April 6-10, 1968 Washington D.C. "Leffler Washington DC MLK riots" by Warren K. Leffler / Library of Congress. Licensed under Public Domain via Wikimedia Commons - Letter from a Birmingham Jail April 1963 Injustice anywhere is a threat to justice everywhere. We are caught in an inescapable network of mutuality, tied in a single garment of destiny. Whatever affects one directly, affects all indirectly. MLK, Jr 4

5 Why is addressing disparities important? 50 years of growing diversity 50% 40% 30% 20% 10% 0% Percent Of Color U.S. MN Twin Cities 36% 24% 17% Source: mncompass.org 0 Minnesota Is a Healthy State Minnesota s State Health Ranking Source: United Health Foundation WHAT WOULD IT TAKE TO CREATE THE GOOD LIFE FOR ALL MINNESOTANS? August 13, 1973 What stands out in Minnesota is courtesy and fairness, honesty, a capacity for innovation, hard work, intellectual adventure, and responsibility. 5

6 Frances Perkins Born April 10, 1880 U.S. Secretary of Labor 1933 to 1945 First woman appointed to the U.S. Cabinet Most of man s problems upon this planet, in the long history of the race, have been met and solved either partially or as a whole by experiment based on common sense and carried out with courage. "Frances Perkins TIME FC 1933" by Time Magazine. What would it take to create the Good Life for all Minnesotans? Common sense says that we need to change how we do our work. It will take courage to make that change. Advancing Health Equity and Achieving Optimal Health for All Requires changing how we do our work. 1. Expand the understanding about what creates health 2. Strengthen community capacity to create their own healthy future 3. Promote a Health in All Policies approach with health equity as the goal 6

7 1. Expand the understanding about what creates health Worldview shaped by individual, cultural, and community values, beliefs, and assumptions Public Narratives Frames Messages David Mann Themes of Dominant Worldview/Narrative Boot Straps Individualism Small Government Science is suspect Education is for job training Free Market Solutions Structural Discrimination is a thing of the Past Adapted from David Mann Breakthrough Initiative Survey 10/14 7

8 To change the narrative start with a broad definition of health "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. WHO 1948 Health is a resource for everyday life, not the objective of living." Ottawa Charter for Health 1986 Define Individual Health in Context of Community Health Community Indicators for Health and Quality of Life Consider What Creates Health Determinants of Health Genes & Biology Physical 10% Environment 10% Clinical Care 10% Health Behaviors 30% Social and Economic Factors 40% Determinants of Health Model based on frameworks developed by: Tarlov AR. Ann N Y Acad Sci 1999; 896: ; and Kindig D, Asada Y, Booske B. JAMA 2008; 299(17): World Health Organization. Ottawa charter for health promotion. International Conference on Health Promotion: The Move Towards a New Public Health, November 17-21, 1986 Ottawa, Ontario, Canada, Accessed July 12, 2002 at < Necessary conditions for health (WHO) Peace Shelter Education Food Income Stable eco-system Sustainable resources Mobility Social justice and equity 8

9 1. Expand the understanding about what creates health the real narrative Health is not determined solely by medical care and personal choices but mostly by living conditions. The Real Narrative About What Creates Health Inequities Disparities are not just because of lack of access to health care or to poor individual choices. Disparities are mostly the result of policy decisions that systematically disadvantage some populations over others. Especially, populations of color and American Indians, GLBT, and low income Structural Racism Asking the Right Questions About Worldview Helps Change the Narrative About What Creates Health The central questions to identify worldview are: What values underlie the decision-making process? What is assumed to be true about the world and the role of the institution in the world? What standards of success are being applied at different decision points, and by whom? 9

10 1. Expand the understanding about what creates health 2. Strengthen Community Capacity to Create Their Own Healthy Future Themes Indicators Outcomes Social Determinants Vision 2. Strengthen community capacity to create their own healthy future Health is not determined solely by medical care and personal choices but mostly by living conditions. 10

11 To Improve Living Conditions and Health: Organize the Capacity to Act Narrative: Align the narrative to build public understanding and public will. People: Directly impact decision makers, develop relationships, align interests. Resources: Identify/shift the resourcesinfrastructure-the way systems and processes are structured. Asking the Right Questions Can Help Empower Communities The central questions when looking at policies are: What are the outcomes? What outcomes do we want? Who is benefiting? Who is left out? Who should be targeted to benefit? Asking the Right Questions Can Help Empower Communities The central questions to examining processes are: Who is at the decision-making table, who is not? Who has the power at the table? How should the decision-making table be set, and who should set it? Who is being held accountable and to whom or what are they accountable? 11

12 Letter from a Birmingham Jail April 1963 Any law that uplifts human personality is just. Any law that degrades human personality is unjust... An unjust law is a code that a numerical or power majority group compels a minority group to obey but does not make binding on itself. This is difference made legal. By the same token, a just law is a code that a majority compels a minority to follow and that it is willing to follow itself. This is sameness made legal. A law is unjust if it is inflicted on a minority that, as a result of being denied (a) right had no part in enacting or devising the law. MLK, Jr 3. Promote a Health in All Policies approach with health equity as the goal Civilian Conservation Corps 4/10/1933 Public Works Administration National Industrial Recovery Act. Unemployment benefits, pensions, and welfare for Americans. WPA 4/8/1935 Workplace safety Child labor laws Fair Labor Standards Act First minimum wage and overtime laws Forty-hour work week. SSA "Frances Perkins TIME FC 1933" by Time Magazine. Born April 10, 1880 Frances Perkins Helped create the New Deal a Health in All Policies Approach. The New Deal began on March 25th, The day that the Triangle factory burned. 12

13 Health In All Policies Every aspect of government and the economy has the potential to affect health and health equity finance, education, housing, employment, transportation, and health, to name just six. While health may not be the main aim of policies in these sectors, they have strong bearing on health and health equity. Health In All Policies Health in All Policies (HIAP) is a collaborative approach that integrates and articulates health considerations into policy making and programming across sectors, and at all levels, to improve the health of all communities and people. HIAP requires practitioners in all sectors to collaborate to define and achieve mutually beneficial goals. 13

14 Obama links climate change to public health "I think we've always known that environment has an impact on public health Communities can start planning for prevention and mitigation efforts families and parents join with doctors and nurses to start putting some pressure on elected officials to try to make something happen to reduce the impacts of climate change." President Obama 4/8/2015 "Framing global warming as a public health issue rather than as an environmental or national security one produces the most emotionally compelling response among people. Time Magazine th Congress Accomplishments Health in All Policies approach Head Start Medicare and Medicaid The Voting Rights Act Job Corps VISTA Peace Corps School lunch program Food stamps 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 Community Health Centers 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, Etc. Poverty Trends

15 Average Health Care Spending per Capita, Adjusted for differences in cost of living Source: OECD Health Data 2011 (June 2011) African American Infant Mortality with Disparity Ratio compared to Whites United States African American IMR African American / White Disparity Ratio Infant Mortality Rate (IMR) Disparity Ratio Year 3. Promote a Health in All Policies approach with health equity as the goal Commission on Social Determinants of Health. (2010). A conceptual framework for action on the social determinants of health. Geneva: World Health Organization. 15

16 Policy and System Changes Related to Social Determinants of Health (selected) Marriage Equity Ban the Box Minimum Wage Target Corporation Contracting Policy Federal Transportation Policy REL(D) data Paid Leave Family &Sick Cabinet Embracing a HiAP Approach State Agency Policy Changes CIC (Big 10)/SHD Initiative Others depending on the opportunities Data Community energy Partnerships Life expectancy by median household income group of ZIP codes, Twin Cities Life expecanty in Years White Paper: Income and Health 74.1 Less than $35, $35,000 to $44, $45,000 to $59,999 $60,000 to $74,999 $75,000 or more Percent Adults reporting "fair" or "poor" health status by income, Minnesota Less $20, $20 to $34,999 $35 to $49,999 $50 to $79, $75,000 or more 11.7 DK refused Source: The unequal distribution of health in the Twin Cities, Wilder Research Analyses were conducted by Wilder Research using mortality data from the Minnesota Department of Health and data from the U.S. Census Bureau (population, median household income, and poverty rate by ZIP code Source: 2011 Behavioral Risk Factor Surveillance System Paid Parental and Sick Leave Linked to Improvements in: Infant mortality Health of infants and mothers Breastfeeding Vaccinations Well child check-ups Maternal depression Occupational injuries Routine cancer screenings Emergency room usage Days lost due to illness 16

17 % Eligible for Paid Sick Leave Disparities in Access to Paid Sick Leave Access to Paid Sick Leave by Income Rates for All Civilian Employees, U.S. (2014) 50 10% 0 0% <10% <25% 25%-50% 50%-75% 75%-100% 90%+ Income Percentile White Black Asian Hispanic Other Source: U.S. Bureau of Labor Statistics Source: Institute of Women s Policy Research Mothers' Access to Paid Leave by Education: U.S % 70% 60% 50% 40% 30% 20% Access to Paid Sick Leave by Race and Ethnicity: Minnesota, % 0% < High School High School Some college BA or higher Any Paid Leave Disability Leave Unpaid Leave Source: U.S. Census Asking the Right Questions Is a Path to Action for Change What would it look like if equity was the starting point for decisionmaking? Our work would be different. Public Health is not about swim lanes 17

18 What would it take to create the Good Life for all Minnesotans? Common sense says that we need to change how we do our work. It will take courage to make that change. Letter from a Birmingham Jail April 1963 My citing the creation of tension may sound rather shocking. But I am not afraid of the word "tension." I have earnestly opposed violent tension, but there is a type of constructive, nonviolent tension which is necessary for growth. Just as Socrates felt that it was necessary to create a tension in the mind so that individuals could rise from the bondage of myths and half truths to the unfettered realm of creative analysis and objective appraisal, so must we create the kind of tension in society that will help men rise from the dark depths of prejudice and racism to the majestic heights of understanding and brotherhood. MLK, Jr To Improve Living Conditions and Health: We need to do our work differently and create the Capacity to Act Narrative: Align the narrative to build public understanding and public will. People: Directly impact decision makers, develop relationships, align interests. Resources: Identify/shift the resourcesinfrastructure-the way systems and processes are structured. 18

19 Public Health: C.E.A. Winslow The science and art of : 1. Preventing disease. 2. Prolonging life, and 3. Promoting health and efficiency through organized community effort for: continued Winslow - continued a. the sanitation of the environment, b. the control of communicable infections, c. the education of the individual in personal hygiene, d. the organization of medical and nursing services for the early diagnosis and preventive treatment of disease, and e. the development of the social machinery to insure everyone a standard of living adequate for the maintenance of health, so organizing these benefits as to enable every citizen to realize his birthright of health and longevity. Health is essential to the success of the State of Minnesota When health is absent, wisdom cannot reveal itself, art cannot become manifest, strength cannot fight, wealth becomes useless, and intelligence cannot be applied. Herophilus of Chalcedon, BCE Physician to Alexander the Great 19

20 The success of the State is essential to the health of the Minnesota s residents When wisdom cannot reveal itself, when art cannot become manifest, when strength cannot fight, when wealth is not shared, and when intelligence cannot be applied, health is absent. Ed Ehlinger, 7/14/2014 CE Physician to the State of Minnesota Public health is what we, as a society, do collectively to assure the conditions in which (all) people can be healthy. -Institute of Medicine (1988), Future of Public Health Edward P. Ehlinger, MD, MSPH Commissioner, MDH P.O. Box St. Paul, MN Ed.ehlinger@state.mn.us 20