CREATING THE CONDITIONS FOR HEALTH
IN MINNESOTA AND IN MINNESOTA’S CITIES
HEALTH IN ALL POLICIES APPROACH
Edward P. Ehlinger, MD, MSPH
Commissioner
Minnesota Department of Health
December 9, 2013
When the Assault Was Intended to the City
John Milton – born 12/9/1608
Captain or Colonel, or Knight in Arms,
Whose chance on these defenseless doors may seize,
If ever deed of honor did thee please,
Guard them, and him within protect from harms;
He can requite thee, for he knows the charms
That call Fame on such gentle acts as these,
And he can spread thy Name o’er Lands and Seas,
Whatever clime the Sun’s bright circle warms.
Lift not thy spear against the Muses’ Bow’r:
The great Emathian Conqueror bid spare
The house of Pindarus, when Temple and Tow’r
Went to the ground; and the repeated air
Of sad Electra’s Poet had the pow’r
To save th’ Athenian Wall from ruin bare.
Health In All Policies.
All policies affect health.
And health impacts all parts of society
• “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 Calcedon, Physician to Alexander the Great
John Snow and the Broad Street Pump
John Snow – Father of Epidemiology
Broad Street Memorial Pump
Control of Cholera
• Joseph Bazalgette
• Board of Guardians
• Responsible for public
health, welfare, and
sanitation
Memorial to Sir Joseph
Bazalgette
on Victoria
Embankment
Differing Perspectives on Cities
“Like a man who has been dying for
many days, a man in your city is numb
to the stench.”
Chief Seattle
“American cities are like badger holes,
ringed with trash--all of them-surrounded by piles of wrecked and
rusting automobiles, and almost
smothered in rubbish.”
John Steinbeck, Travels with Charley:
Search of America
In
Differing Perspectives on Cities
“All cities are mad: but the madness is gallant.
All cities are beautiful, but the beauty is grim.”
Christopher Morley
“It was a cruel city, but it was a lovely one; a
savage city, yet it had such tenderness; a
bitter, harsh, and violent catacomb of stone an
steel...and yet it was so sweetly and so
delicately pulsed, as full of warmth, of passion,
and of love, as it was full of hate.”
Thomas Wolfe, The Web and the Rock
Differing Perspectives on Cities
“I am not interested in living in a city
where there isn't a production by Samuel
Beckett running.”
Edward Albee
“If a family is an expression of continuity
through biology, a city is an expression of
continuity through will and imagination —
through mental choices making artifice, not
through physical reproduction.”
A. Bartlett Giamatti, Take Time for Paradise:
Americans and Their Games
Differing perspectives on health
• "Health is a state of complete
physical, mental and social well-
being and not merely the absence
of disease or infirmity.“
• WHO 1948
Differing perspectives on health
• “Health is a resource for everyday life,
not the objective of living. Health is a
positive concept emphasizing social
and personal resources, as well as
physical capacities."
• Ottawa Charter for Health 1986
What Creates Health?
What are the Determinants of Health?
Genes and Biology
10%
Physical
Environment
10%
Social and
Economic Factors
40%
Clinical Care
10%
Health Behaviors
30%
Tarlov AR. Public policy frameworks for improving population health.
Ann N Y Acad Sci 1999; 896: 281-93.
How do we invest in health?
95
5
Average social-service expenditures versus average health-services expenditures as percentages of gross domestic
product (GDP) from 1995 to 2005 by country. SOURCE: Bradley et al., 2011:3
The Cost of a Long Life
14
Average Health Care Spending per Capita, 1980-2009
Adjusted for differences in cost of living
Source: OECD Health Data 2011 (June 2011)
We need to restructure our investments
Healthy Communities
Healthy Living
SHIP
Public Health
Medical System
Chronic Disease Care
Hospitalization
Our goal is to
work upstream
to keep
Minnesotans
from falling in
the river of
medical care
and going over
the waterfall of
hospitalization.
Deaths Prevented And Change In Health Care Costs Plus Program Spending, Three
Intervention Scenarios, At Year 10 And Year 25.
Milstein B et al. Health Aff 2011;30:823-832
Life Expectancy (Years)
Public Health = Longer Lives
80
70
60
50
Life Expectancy at Birth,
United States, 1900 – 1996
40
Gained 23 years 1900 – 1960
Gained 7 years 1960 – 2000
30
1900
1910
1920
1930
1940
1950
1960
1970
1980
1990
Year of Birth
25 of the 30 years of life gained in the 20th Century
resulted from public health accomplishments
SHIP Three Year Results
Over 200
schools,
providing Safe
Routes to
School for
140,000
students.
Farm to School
efforts at 440
schools serving
more than
235,000
students.
Schools
Businesses
900 employers lead worksite wellness initiatives,
reaching over 200,000 employees
SHIP
Communities
Providers
About 60
clinics
engaging
patients
about
nutrition,
activity, and
smoking
59 postsecondary
schools are
working to have
tobacco-free
campuses.
Over 580 child
care sites
serving 10,000
work to improve
nutrition. Over
1,000 child care
sites serving
24,000 work to
increase
physical activity
160 new
farmers
markets
Almost 300
cities took
steps to make
physical
activity easier
20 cities have
or are working
on tobaccofree parks
policies
227 apartment
buildings have
adopted
smoke free
policies.
Another 142
are working
toward it.
About 73
promoting
breastfeeding
Source: Statewide Health Improvement Program Progress
Brief – Year 2, March 2012. First Two Years Ending June
2011
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 public health practitioners to
collaborate with other sectors to define and
achieve mutually beneficial goals.
Community Indicators for Health and Quality of Life
Health of the community depends on the
health of its members
Percent Of Color
1960-2010
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
U.S.
MN
Twin Cities
36%
24%
17%
1960
Source: mncompass.org
1970
1980
1990
2000
2010
+ Workforce diversity will increase rapidly
over the next 20 years
85+
80-84
75-79
70-74
65-69
60-64
55-59
50-54
45-49
40-44
35-39
30-34
25-29
20-24
15-19
10-14
5-9
0-4
White (non-Hispanic)
Of Color
Working-age
population
2010
Working-age
population
2020
Working-age
population
2030
0
100,000
U.S. Census Bureau
200,000
300,000
Poverty, 2012 ACS
Black
45.0
US Black
40.0
38.2
37.8
36.4
35.5
35.0
32.0
Percent Below Poverty
Black/White Disparity Ratio
35.6
34.2
32.9
30.0
29.5
28.1
25.0
20.7
20.0
16.3
15.0
10.0
5.0
4.3
3.0
2.6
3.1
IL
IN
IA
2.3
2.7
3.2
2.6
2.8
2.8
MD
MI
MN
NE
Big Ten States
NJ
OH
PA
3.6
0.0
WI
US
Per Capita Income, 2012 ACS
Black
30,000
US Black
White/Black Disparity Ratio
6.0
27,005
25,000
5.0
20,000
4.0
18,102
17,670
16,086
16,057
16,054
15,958
14,820
15,000
16,987
14,615
2.2
10,000
2.1
1.9
1.8
1.6
1.7
3.0
13,929
1.7
1.7
1.7
1.8
1.7
1.5
5,000
2.0
1.0
0
0.0
IL
IN
IA
MD
MI
MN
NE
Big Ten States
NJ
OH
PA
WI
US
White/Black Disparity Ratio
Per Capita Income in Dollars
22,406
Four Year High School Graduation, SY 2010-2011
Black
76
80
4.0
73
70
70
69
3.5
65
60
59
57
3.0
49
50
Graduation Rate
64
2.5
40
2.0
1.7
1.4
1.4
30
1.2
1.2
1.2
1.3
1.3
1.4
1.4
1.5
1.2
20
1.0
10
0.5
0
0.0
IL
IN
IA
MD
MI
MN
Big Ten States
NE
NJ
OH
PA
WI
White/Black Disparity Ratio
74
75
White/Black Disparity Ratio
Estimated Deaths Attributable to Social Factors in the
United States
• Less than High School graduation
• Racial segregation
• Low social support
• Individual level poverty
• Income inequality
• Community level poverty
245,000
176,000
162,000
133,000
119,000
39,000
Galea, et.al., American Journal of Public Health August 2011, Vol 101 no. 8
Place/Community Influences Health
Life Expectancy/Health Life Expectancy After age 65 - By Race
7.6/1.1
13.1/1.2
35.8/1.8
8.0/1.1
15.3/1.2
20.5/1.3
23.51/4
White/Black disparity – difference in % / ratio
14.9/1.2
16.9/1.3
9.2/1.1
7.2/1.1
Infant Mortality Rates per 1,000 births, 2007-2009
Black Infant Mortality Rate
16.0
14.5
14.0
14.9
U.S. Black Infant Mortality Rate
14.5
14.1
14.1
13.6
Black / White Disparity Ratio
13.3
13.4
Infant Mortality Rate per 1,000 live births
12.2
13.4
12.8
12.1
12.0
10.0
8.0
6.0
4.0
3.3
3.1
2.5
2.2
2.5
2.3
2.6
2.5
2.8
2.6
MD
NB
2.4
2.0
0.0
IL
IN
* U. S. Born Mothers
MI
MN*
OH
WI
IA
Big Ten States
NJ
PA
US
Place/Community influences health
Health Factors
Health Outcomes
Owner Occupied Housing, 2012 ACS
Black
60.0
US Black
White/Black Disparity Ratio
50.6
Percent of Owner Occupied Housing
50.0
42.8
40.0
39.4
43.3
42.5
40.2
38.2
36.3
32.6
29.8
30.0
27.8
21.3
20.0
10.0
1.9
1.9
2.5
IL
IN
IA
3.6
1.5
1.8
2.1
1.8
2.0
1.7
MD
MI
MN
NE
Big Ten States
NJ
OH
PA
2.6
1.6
0.0
WI
US
WHAT WOULD IT TAKE TO MAKE
MINNESOTA THE HEALTHIEST
STATE POSSIBLE?
“What stands out in
Minnesota is courtesy and
fairness, honesty, a capacity
for innovation, hard work,
intellectual adventure, and
responsibility.”
• August 13, 1973
Healthy Public Policy & Public Work
General
protection
Society's Health
Response
Targeted
protection
Primary
prevention
Medical and Public Health Policy
Secondary
prevention
Tertiary
prevention
Becoming no
longer vulnerable
Safer,
Healthier
Population
Becoming
Vulnerable
Vulnerable
Population
Becoming
Afflicted
Afflicted
without
Complications
Developing
Complications
Afflicted with
Complications
Dying from
Complications
Adverse Living
Conditions
DEMOCRATIC
SELF-GOVERNANCE
World of Transforming…
By Strengthening…
• Deprivation
• Dependency
• Violence
• Disconnection
• Environmental decay
• Stress
• Insecurity
• Etc…
• Leaders and institutions
• Foresight and precaution
• The meaning of work
• Mutual accountability
• Plurality
• Democracy
• Freedom
• Etc…
DISEASE AND RISK
MANAGEMENT
World of Providing…
• Education
• Screening
• Disease management
• Pharmaceuticals
• Clinical services
• Physical and financial access
• Etc…
Centers for Disease Control and Prevention Bobby Milstein
Differing Perspectives on Cities
“Cities have the capability of
providing something for
everybody, only because, and
only when, they are created by
everybody.”
Jane Jacobs, The Death and Life of Great
American Cities
“Public health is what we, as a society, do
collectively to assure the conditions in
which people can be healthy.”
-Institute of Medicine (1988), Future of Public Health
And Health In All Policies is a way to
move our collective actions.
Edward P. Ehlinger, MD, MSPH
Commissioner, MDH
P.O. Box 64975
St. Paul, MN 55164-0975
Ed.ehlinger@state.mn.us