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: In Search of America

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 SHIP Healthy Living 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

Public Health = Longer Lives

80 70 60 50 40 Life Expectancy at Birth, United States, 1900 – 1996 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 20 th Century resulted from public health accomplishments

SHIP Three Year Results

SHIP Schools Farm to School efforts at 440 schools serving more than 235,000 students. Businesses Over 200 schools, providing Safe Routes to School for 140,000 students.

59 post secondary schools are working to have tobacco-free campuses. 900 employers lead worksite wellness initiatives, reaching over 200,000 employees 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 Communities 160 new farmers markets Almost 300 cities took steps to make physical activity easier 20 cities have or are working on tobacco free parks policies 227 apartment buildings have adopted smoke free policies. Another 142 are working toward it. Providers About 60 clinics engaging patients about nutrition, activity, and smoking 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 1970 1980 1990 2000 2010 Source: mncompass.org

+

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 population population 2030 0 100 000 200 000 300 000 U.S. Census Bureau

45,0 40,0 35,0 32,0 30,0 25,0 20,0 15,0 10,0 5,0 3,0 0,0 IL 32,9 2,6 IN 35,5 3,1 IA Black 16,3 2,3 MD

Poverty, 2012 ACS

US Black Black/White Disparity Ratio 36,4 2,7 MI 37,8 4,3 34,2 3,2 MN NE

Big Ten States

20,7 2,6 NJ 35,6 2,8 OH 29,5 2,8 PA 38,2 3,6 WI US 28,1

30 000

Per Capita Income, 2012 ACS

Black 27 005 US Black White/Black Disparity Ratio 6,0 25 000 5,0 22 406 20 000 17 670 16 086 15 958 15 000 10 000 1,8 1,6 1,7 1,5 16 054 14 820 14 615 2,2 1,9 1,7 1,7 16 057 16 987 1,7 1,8 13 929 2,1 18 102 4,0 1,7 3,0 2,0 5 000 1,0 0 IL IN IA MD MI MN NE

Big Ten States

NJ OH PA WI US 0,0

80 70 74 60 50 40 30 1,2 20 10 0 IL 75 IN

Four Year High School Graduation, SY 2010-2011

73 1,2 1,2 IA 76 Black 1,2 MD 57 1,4 49 1,7 70 1,3 1,3 MI MN

Big Ten States

NE White/Black Disparity Ratio 69 NJ 59 65 1,4 1,4 OH PA 64 4,0 3,5 3,0 2,5 2,0 1,4 1,5 1,0 0,5 WI 0,0

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

16,0 14,0 13,6

Infant Mortality Rates per 1,000 births, 2007-2009

Black / White Disparity Ratio 14,5 Black Infant Mortality Rate 14,9 14,1 14,5 U.S. Black Infant Mortality Rate 14,1 13,3 12,2 13,4 12,1 13,4 12,8 12,0 10,0 8,0 6,0 4,0 2,5 2,2 2,5 2,0 0,0 IL IN * U. S. Born Mothers MI 3,1 2,3 2,6 2,5 2,8 MN* OH WI IA

Big Ten States

MD 2,6 NB 3,3 NJ 2,4 PA US

Place/Community influences health

Health Factors Health Outcomes

60,0 50,0 40,0 39,4 38,2 30,0

Owner Occupied Housing, 2012 ACS

Black US Black White/Black Disparity Ratio 50,6 42,8 40,2 36,3 43,3 32,6 29,8 27,8 21,3 20,0 42,5 10,0 0,0 1,9 IL 1,9 IN 2,5 IA 1,5 MD 1,8 MI 3,6 2,1 MN NE

Big Ten States

1,8 NJ 2,0 OH 1,7 PA 2,6 WI 1,6 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 Society's Health Response

General protection Targeted protection Primary prevention

Medical and Public Health Policy

Secondary prevention Tertiary prevention

Safer, Healthier Population

Becoming no longer vulnerable Becoming Vulnerable

Vulnerable Population

Becoming Afflicted

Afflicted without Complications

Developing Complications

Afflicted with Complications

Dying from Complications

Adverse Living Conditions DEMOCRATIC SELF-GOVERNANCE DISEASE AND RISK MANAGEMENT World of Transforming …

• • • • • • • •

Deprivation Dependency Violence Disconnection Environmental decay Stress Insecurity Etc… By Strengthening …

• • • • • • • •

Leaders and institutions Foresight and precaution The meaning of work Mutual accountability Plurality Democracy Freedom Etc… 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 [email protected]