State of Public Health 2017:
Telling the Story of Public Health
Edward P. Ehlinger, MD, MSPH
Commissioner, Minnesota Department of Health
State of Public Health Forum
April 3, 2017
State Health Rank: 42
State Health: 32
State Health Rank: 50
State Health Rank: 7
Story: Tale of Two Cities by Charles Dickens
Published in weekly installments starting in April 1859
“It was the best of times, it was the worst of times,
it was the age of wisdom, it was the age of
foolishness, it was the epoch of belief, it was the
epoch of incredulity, it was the season of Light, it
was the season of Darkness, it was the spring of
hope, it was the winter of despair, we had
everything before us, we had nothing before us, we
were all going direct to Heaven, we were all going
direct the other way—in short, the period was so
far like the present period.”
I've Been to the Mountaintop - Best of Times
Speech by Dr. Martin Luther King, Jr. delivered 3 April 1968, Memphis, Tennessee
“Something is happening in our world. … if I
were standing at the beginning of time… and
the Almighty said to me, “…which age would
you like to live in?" I would take my mental
flight (through Egypt, Greece, Roman Empire, Renaissance,
Wittenberg with ML, Emancipation Proclamation, etc.)… But
I wouldn't stop there. Strangely enough, I would
turn to the Almighty, and say, "If you allow me
to live just a few years in the second half of the
20th century, I will be happy."
“…the reason I'm happy to live in this
period is that we have been forced to a
point where we are going to have to
grapple with the problems that men
have been trying to grapple with
through history, but the demands didn't
force them to do it.
…let us keep the issues where they are.
The issue is injustice.”
The Root of Public health is social justice
• “The philosophy behind science is to discover truth.
• The philosophy behind medicine is to use that truth
for the benefit of your patient.
• The philosophy behind public health is social
justice.”
• William Foege – CDC director, 1977-1983
Health equity is the public manifestation
of social justice.
“Injustice anywhere is a threat to
justice everywhere.”
• Letter from Birmingham Jail, April 16, 1963
Best of times
25 of the 30 years of life gained in the 20th Century
resulted from public health accomplishments
We used to be above average
Life Expectancy at Birth US and OECD Countries by Gender 1960-2010
Life Expectancy, by race: United States, 1970 - 2010
SOURCE: CDC/NCHS, National
Vital Statistics System, Mortality.
It’s not for lack of money -
Life expectancy vs health expenditures - U.S. and OECD Countries 1970 - 2014
Best of times for health care;
worst of times for health.
Total Investment in Health and Human Services
In OECD, for every $1
spent on health care,
about $2 is spent on
social services.
In the U.S., for every $1
spent on health care,
about 55 cents is spent
on social services.
Distribution of Resources
Medical Care
0
20
40
Public Health
60
80
100
Infant Mortality Rates U.S. and OECD Countries
1960-2010
35
U.S.
30
OECD median
25
20
15
10
5
2015 – 38th
0
1960
1970
1980
1990
2000
Source: http://stats.oecd.org, accessed 6-10-16
2010
Ratio of non-Hispanic black and non-Hispanic white infant
mortality rates,* by state — United States, 2006–2008
AMERICA’S HEALTH RANKINGS® 2016 ANNUAL REPORT
Source: National Vital Statistics System, NCHS, CDC
AMERICA’S HEALTH RANKINGS® 2016 ANNUAL REPORT
U.S. Ranked 49th
in Maternal Mortality in 2008
Data from UNICEF, WHO, UN Population Fund, and World Bank with standardized methodology.
Disparities in Maternal Mortality Rates
Best of times/Worst of times
AMERICA’S HEALTH RANKINGS® 2016 ANNUAL REPORT
The Story of Public Health is Determined by the Dominant
Worldview
Contrasting/Alternative Worldviews
Interdependence
Social Cohesion
Virtue of Work
Boot Straps
Individualism
Virtue of Work
Small
Government
Free Market
Solutions
Dominant
U. S. Worldview
Mistrust of
science
Reliance on
technology/specialization
Necessary
government
Social responsibility
Social Justice
Alternative Worldview
Education is for
job training
Structural discrimination
is a thing of the past
Cooperation
Collective Action
Need for generalists
Education is for
enlightenment
Equity is the challenge
of the present
Principles/Characteristics of Public Health & Medical Care
•
•
•
•
•
•
•
•
•
•
•
Public Health
Science-based
Population-based
Health an individual & societal responsibility
Broad definition of health
Interdisciplinary/multidisciplinary
Prevention/Promotion/Protection
Long-term responsibility
Collaboration/ Cooperation
Social responsibility
Social justice
Medical Care
* Science-based
* Focus on individual
* Health an individual responsibility
* Focus on specific illnesses or diseases
* Specialization
* Treatment
* Short term responsibility
* Competition
* Reimbursement driven
* Market justice
Dan Beauchamp
• “Market justice is the primary roadblock to dramatic
reductions in preventable injury and death. More
than this, market justice is a pervasive ideology
protecting the most powerful or the most numerous
from the burdens of collective action. If this be true,
the central goal of public health should be ethical in
nature: The challenging of market justice as fatally
deficient in protecting the health of the public.”
Public health as social justice.
Inquiry. 1976 Mar;13(1):3-14.
The Public Health Approach to Advancing Health Equity and
Optimal Health for All
Social
Cohesion
Back to the story of
our public health roots.
Back to the 1854 - 1865 Cholera Epidemic In London
Dr. John Snow
Broad Street Memorial Pump
Sir Joseph Bazalgette
Abbey Mills Pumping Station
(the Cathedral of Sewage)
Board of Guardians
Rev. Henry Whitehead
Water Map of London 1854
Back to our investment in public agencies to address social issues
to advance the public good.
The mission of Land Grant Universities: focus on practical academic disciplines
to address issues created by changing economic conditions and social class.
Back to the Children’s Bureau in Department of Labor
• "Work for infant welfare is coming to be
regarded as more than a philanthropy or an
expression of good will. It is a profoundly
important public concern which tests the public
spirit and the democracy of a community.”
Julia Lathrop, director of Children’s Bureau, 1912-1921
• “Justice for all children is the high ideal in a
democracy.”
Grace Abbott, director of Children’s Bureau, 1921-1934
Back to our professional values and mission
“…the physician’s function is fast becoming social
and preventive, rather than individual and
curative…(do) not to forget that directly or
indirectly, disease has been found to depend
largely on unpropitious environment…a bad
water supply, defective drainage, impure food,
unfavorable occupational surroundings…(these)
are matters for ‘social regulation,’ and doctors
have the duty to promote social conditions that
conduce to physical well-being.”
Abraham Flexner
1910 Flexner Report
Back to Women’s Suffrage which embodied the
principles of the Triple Aim of Health Equity
• Demonstrated the need to engage all members and all sectors
of society in creating health
• Demonstrated the power of engaged communities to create
the conditions for health
• Changed the conversation about what creates health
Expand our Understanding of What Creates Health
Back to early definitions of public health
C. E. A. Winslow - 1920
Public health is the science and
art of :
1. Preventing disease.
2. Prolonging life, and
3. Promoting health and
efficiency through organized
community effort for…
C.E.A. Winslow, Dean
Yale School of Public Health
continued
Expand our Understanding of What Creates Health
Winslow – definition of public health continued
the sanitation of the environment
the control of communicable infections
the education of the individual in personal hygiene
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.
a.
b.
c.
d.
Back to a Health in All Policies approach to community health
1965-1967 - 89th Congress War on Poverty
• Expanded Title V – C and Y, MIC, and FP
Projects
• Head Start
• Medicare and Medicaid
• Neighborhood health centers
• Food stamps
• The Voting Rights Act
• Job Corps
• VISTA
• Peace Corps
• School lunch program
• 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
• 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.
Back to the story “Best of Times/Worst of Times”
I've Been to the Mountaintop
Speech by Dr. Martin Luther King, Jr. delivered 3 April 1968, Memphis, Tennessee
“… The issue is injustice.
I just want to do God's will. And He's
allowed me to go up to the mountain. And
I've looked over. And I've seen the Promised
Land. I may not get there with you. But I
want you to know tonight, that we, as a
people, will get to the promised land!”
Jefferson/Lincoln/Public Health and Liberty
The gloomy night before us flies
The reign of terror now is o’er
Purveyors of deceit and lies
Opponents of hope are no more.
From foreign wants and woes remote
A friendly space of waves between
Here plenty cheers and hope promote
With smiles from every village green.
Rejoice, Columbia’s sons, rejoice!
To tyrants never bend a knee,
But join with heart and soul and voice,
For Jefferson and liberty
Here strangers from a thousand abodes
Compelled by slavery to roam,
Shall find by traveling dangerous roads
A nobler and a happier home.
Let foes to freedom retreat in dread
From the blessed humane decree
Thrice fifty thousand souls were led
For freedom and equality
Rejoice, Columbia’s sons, rejoice!
To tyrants never bend a knee,
But join with heart and soul and voice,
For Abe Lincoln and liberty
From Texas to Grand Marais
To both seas from Mississippi’s shore
Ye workers of public health loud proclaim
The reign of inequity is no more.
Here health shall lift her laurelled head
Prosperity and peace divine
And where dark hopeless conditions spread
Urban and rural communities shine.
Rejoice, all Minnesotans, rejoice
Health for all is what we see
And join with heart and soul and voice
For social justice and democracy.
In communities throughout the land
Creative minds with vision dwell
Together they work heart and hand
So hopes for all people begin to swell
So with the vision of public health
Take on the challenges that we face
For everyone in our commonwealth
Help make this world a better place.
Rejoice, all Minnesotans, rejoice
Health for all is what we see
And join with heart and soul and voice
For social justice and democracy.
“Something is happening in our world.”
I've Been to the Mountaintop Speech by Dr. Martin Luther King, Jr.
“There never was a higher call to greater
service than in this protracted fight for
social justice.”
Senator Robert M. (Fighting Bob) La Follette, Sr.