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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.
• “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
Health In All Policies.
All policies affect health.
And health impacts all parts of society
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
Social and
Economic Factors
40%
Health Behaviors
30%
Clinical Care
10%
Physical
Environment
10%
Genes and Biology
10%
What Creates Health?
What are the Determinants of Health?
Tarlov AR. Public policy frameworks for improving population health.
Ann N Y Acad Sci 1999; 896: 281-93.
95 5
How do we invest in health?
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
Hospitalization
Chronic Disease Care
Public Health SHIP Our goal is to
work upstream
to keep
Minnesotans
from falling in
the river of
medical care
and going over
the waterfall of
hospitalization.
Healthy Communities Healthy Living
Medical System
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
30
40
50
60
70
80
1900 1910 1920 1930 1940 1950 1960 1970 1980 1990
Year of Birth
Lif
e E
xp
ecta
ncy (
Yea
rs)
Life Expectancy at Birth,
United States, 1900 – 1996
Gained 23 years 1900 – 1960
Gained 7 years 1960 – 2000
25 of the 30 years of life gained in the 20th Century
resulted from public health accomplishments
SHIP Three Year Results
SHIP
Schools
Businesses
Communities
Providers
900 employers lead worksite wellness initiatives, reaching over 200,000 employees
Farm to School efforts at 440
schools serving more than 235,000 students.
Over 200 schools,
providing Safe Routes to School for
140,000 students.
59 post-secondary 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 tobacco-free parks policies
227 apartment buildings have
adopted smoke free
policies. Another 142 are working toward it.
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
Source: mncompass.org
Health of the community depends on the
health of its members
36%
17%
24%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
1960 1970 1980 1990 2000 2010
Percent Of Color 1960-2010
U.S. MN Twin Cities
+
0 100,000 200,000 300,000
0-4
5-9
10-14
15-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
85+White (non-Hispanic)
Of Color
Workforce diversity will increase rapidly
over the next 20 years
Working-age
population
2010 Working-age
population
2020 Working-age
population
2030
U.S. Census Bureau
32.0 32.9
35.5
16.3
36.4 37.8
34.2
20.7
35.6
29.5
38.2
28.1
3.0 2.6 3.1 2.3 2.7
4.3 3.2 2.6 2.8 2.8
3.6
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
45.0
IL IN IA MD MI MN NE NJ OH PA WI US
Perc
en
t B
elo
w P
ov
ert
y
Big Ten States
Poverty, 2012 ACS
Black US Black Black/White Disparity Ratio
17,670
16,086 15,958
27,005
16,054
14,820 14,615
22,406
16,057 16,987
13,929
18,102
1.8
1.6 1.7
1.5 1.7
2.2
1.9 1.7 1.7 1.8
2.1
1.7
0.0
1.0
2.0
3.0
4.0
5.0
6.0
0
5,000
10,000
15,000
20,000
25,000
30,000
IL IN IA MD MI MN NE NJ OH PA WI US
White/B
lack D
isparity
Ratio
Per
Capita I
ncom
e in D
olla
rs
Big Ten States
Per Capita Income, 2012 ACS
Black US Black White/Black Disparity Ratio
74 75 73
76
57
49
70 69
59
65 64
1.2 1.2 1.2
1.2
1.4
1.7
1.3 1.3
1.4 1.4
1.4
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
0
10
20
30
40
50
60
70
80
IL IN IA MD MI MN NE NJ OH PA WI
White/B
lack D
isparity
Ratio
Gra
duation R
ate
Big Ten States
Four Year High School Graduation, SY 2010-2011
Black White/Black Disparity Ratio
Estimated Deaths Attributable to Social Factors in the
United States
• Less than High School graduation 245,000
• Racial segregation 176,000
• Low social support 162,000
• Individual level poverty 133,000
• Income inequality 119,000
• Community level poverty 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 14.9/1.2 16.9/1.3 9.2/1.1 7.2/1.1
White/Black disparity – difference in % / ratio
13.6
14.5 14.9
14.1 14.5
14.1
12.2
13.3 13.4
12.1
13.4
12.8
2.5 2.2
2.5
3.1
2.3 2.6 2.5
2.8 2.6
3.3
2.4
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
IL IN MI MN* OH WI IA MD NB NJ PA US
Infa
nt
Mo
rtality
Rate
per
1,0
00 l
ive b
irth
s
Big Ten States
Infant Mortality Rates per 1,000 births, 2007-2009
Black Infant Mortality Rate U.S. Black Infant Mortality Rate Black / White Disparity Ratio
* U. S. Born Mothers
Place/Community influences health
Health Outcomes Health Factors
39.4 38.2
29.8
50.6
42.8
21.3
32.6
40.2
36.3
43.3
27.8
42.5
1.9 1.9 2.5 1.5 1.8
3.6 2.1 1.8 2.0 1.7
2.6 1.6
0.0
10.0
20.0
30.0
40.0
50.0
60.0
IL IN IA MD MI MN NE NJ OH PA WI US
Perc
en
t o
f O
wn
er
Occu
pie
d H
ou
sin
g
Big Ten States
Owner Occupied Housing, 2012 ACS
Black US Black White/Black Disparity Ratio
WHAT WOULD IT TAKE TO MAKE
MINNESOTA THE HEALTHIEST
STATE POSSIBLE?
• August 13, 1973
“What stands out in
Minnesota is courtesy and
fairness, honesty, a capacity
for innovation, hard work,
intellectual adventure, and
responsibility.”
Safer,
Healthier
Population Becoming
Vulnerable
Becoming no
longer vulnerable
Vulnerable
Population Becoming
Afflicted
Afflicted
without
Complications Developing
Complications
Afflicted with
Complications
Targeted
protection Primary
prevention
Secondary
prevention
Dying from
Complications
Tertiary
prevention
Society's Health
Response
General protection
Adverse Living
Conditions
World of Providing…
• Education
• Screening
• Disease management
• Pharmaceuticals
• Clinical services
• Physical and financial access
• Etc…
Medical and Public Health Policy
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…
Healthy Public Policy & Public Work
DEMOCRATIC
SELF-GOVERNANCE
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
