Collaboration to Create Healthier Communities in Minnesota

Health-wise, many other countries look better than the United States. The French, the Germans, the Swedes, the Israelis, for example – they all live longer than we do in the U.S. Our nation currently fixates on Obamacare, with narrow-minded public officials and pundits of all persuasions asserting their positions on how to finance health care, arguing over whom to blame for system problems, and debating alternatives.

“Narrow-minded” – I use that term not pejoratively, but rather to raise awareness about the limited scope of the health care debate and to focus attention on the fact that the formal system of health care influences our health to a much lesser extent than other things influence our health – for example, our environment and our lifestyles. The formal health system, despite its 21st century technology which can save the lives of people with injuries and conditions fatal in years past, nonetheless does not influence the length of our lives as significantly as do our income, education, and nutrition.

Cynthia Boyd, a reporter with MinnPost, wrote recently that good and affordable housing might be considered a “lifesaving vaccine.” She used medical terminology to drive home the importance of social, economic, and environmental factors in determining our health.

That’s why Wilder Research teamed up with the Federal Reserve Bank of Minneapolis to promote collaboration in Minnesota between public health practitioners and community development finance professionals. Despite similar missions, these two groups have worked to promote our quality of life using different lenses and independent approaches. Public health has focused primarily on increasing awareness of healthy behaviors (eating nutritious food, exercising, not smoking, etc.), on policies which protect the public from harm (food handling laws, fluoridated water, smoking bans, etc.), and on increasing access to health services. Community development finance professionals have focused on designing living environments best suited to good health and on financing major projects which can offer access to health care, child care, housing, and better food, for example.

So, in 2012, we convened people from throughout Minnesota who share the mission to promote community health. We sought to raise awareness about the social determinants of health, develop a common understanding of how to make progress, and spark additional action.

In 2013, we invited people back – this time emphasizing action. Nineteen projects from around the state shared their experiences with cross-sector collaboration, involving nonprofit organizations, government, private businesses, and academia. These projects showed how they have educated the public, promoted exercise and nutrition, connected people with health care, and improved access to healthy food. National speakers offered insight into how we can do our work better; they also noted that Minnesota has made more progress than many other states. You can see posters from the projects, as well a pick up other information from the conference here.

Elaine Arkin, manager of the Robert Wood Johnson Foundation Commission to Build a Healthier America, delivered a keynote speech at the conference. She described the process of building recommendations for the promotion of healthy communities. Those recommendations will come forward during a webinar on Monday, the 13th of January, 2014. She also drew attention to the use of a national report prepared by Wilder Research and the Minneapolis Fed. The report documents the extent of collaboration around the country and identifies challenges and opportunities for further progress to improve health through collaboration between public health and community development finance organizations.

We took great satisfaction in doing the national research and preparing that report for the Commission to Build a Healthier America. We feel part of a movement, inspired by the Robert Wood Johnson Foundation and grounded in sound research, which can enable all people in our nation, poor or rich, to live healthier, happier, and more fulfilling lives.

How can our state be so good, yet so bad?

It’s the Minnesota Paradox. We need to solve that paradox, to ensure the prosperity of our state and a high quality of life for all of our residents. Minnesota has steadily grown in population since the mid-20th century; projections show continued steady growth for at least the next few decades. How those residents will fare, however, depends on critical choices we must make now.

The good part

Minnesota ranks high overall on many important measures of quality of life.

The American College of Sports Medicine, puts us in first place for overall health. CNN Money identifies several of our Twin Cities area’s municipalities among the best 20 places to live in the United States. Prevention Magazine rated the Twin Cities the 3rd “happiest, healthiest” place in the United States. America’s Health Rankings place Minnesota fifth among the 50 states for overall health.

Among the 25 largest metropolitan areas, the MSP metro region ranks “numero uno” on the proportion of adults who work, fourth on the proportion of adults with a bachelor’s degree, and fifth on median household income. So, we beat out places like Seattle, New York City, Miami, Phoenix, Philadelphia, with our better employment, education, and income.

Based on these numbers, the Land of 10,000 Lakes looks very, very good.

So, what’s the bad?

As I told a full auditorium at the Minnesota Policy conference last Wednesday, these overall numbers mask severe problems.

Before considering those problems, note as context two important features of the state’s current growth. First, the population is dramatically aging – yes, the good old baby boomers pig-in-a-python are progressing into their 60s and beyond. That has positive implications – more people living longer, healthier lives and contributing in various ways to their communities. It also has negative implications – more people with chronic health conditions requiring care for longer periods of time, for example.

Second, our state’s residents have greatly diversified over the past 50 years and will continue diversifying into the future. For instance, in 1960, our entire state had only about 42,000 persons of color; by 2010, that number had increased to about 900,000. In the Twin Cities region, during the first 10 years of this century, residents of color increased by more than 200,000, while white residents actually decreased by several thousand.

Keeping that context in mind, problems become apparent when we look below the top line “Minnesota high ranking” numbers. So, consider the proportion of adults working: Minnesota overall ranks 4th. Yet for persons of color, we rank 22nd, resulting in one of the largest employment gaps between whites and persons of color in the nation, putting us 46th out of 50 states.

Or consider the poverty rate. We rank number 11 among the 50 states. However, for persons of color, we rank 30th; and for the gap between white people and persons of color, we fall near the bottom, at 44th place.

Minnesota sits among the worst five states in the nation for on-time high school graduation for Black, American Indian, and Hispanic young people.

Differences between white residents and residents of color begin early, and they persist over time. You can see them in 3rd grade reading, for example. (See Minnesota Compass.) Some of it relates to income and, as a study suggested this year, results from a “language gap” starting as early as 18 months of age.

Do these disparities matter? Yes, for individuals, and yes, for our communities in Minnesota.

The disparities noted above affect individuals’ health. Some racial and ethnic groups have a greater chance of developing chronic diseases; members of some groups die much earlier than other groups. For example, an African-American in the Twin Cities will likely die 7 years earlier than a white person and 9 years earlier than an Asian person. I don’t know about you, but losing seven to nine years of my life sounds like a big deal; it means something.

For our communities, we risk the debilitation of our rising stars. The younger generation consists increasingly of persons of color. We rely on them to assume positions of community leadership and business leadership, to shape community institutions, and to successfully rear children. How will they sustain Minnesota’s communities without adequate education, health, and other resources? How will our communities support our aging residents if the supply of people in their working ages diminishes not only in quantity, but also in quality? The demographics portend declines in both. However, we can do a lot, if we put our minds to it, to change the trends.

How should we take action?

How to boost Minnesota to the top constitutes a topic more extensive than just this one essay can cover. For sure, the existence of such notable racial disparities suggests a need to eliminate racism. However, it’s overly simplistic to consider the elimination of racism a cure-all. It’s necessary, but not sufficient.

In addition, we will need to identify strategic points of intervention – some short term, to meet immediate needs – others long term, to prevent future problems from occurring. For example, long-term strategies to sustain affordable housing must receive our attention alongside short-term strategies to provide shelter to currently homeless and marginally-housed people. We must create long-term strategies to upgrade the math and science skills of our young people at the same time that we take steps to attract and retain professionals already trained in these skills.

We will need to work “upstream”, focusing on negative social and economic features of our communities which take a while to change. We will need to break out of our common ways of thinking – to recognize, for example, that tax policies can affect health and that early childhood education can influence economic development. Partnerships including business, nonprofits, and government will need to form and act in new ways.

Current demography need not inexorably shape our destiny. I look forward to taking up the challenge to think in new ways and partner in new ways, to make our communities truly number one in all their dimensions, not in just whatever first meets the eye!

50 Years - How much change has occurred?

I vividly remember the 1960s. I remember watching Dr. King speak live. I remember listening to the debates about civil rights, and eventually participating in them. I remember the news reports and the reactions to the murder of Medgar Evers, just shortly before the March on Washington.

The fearful identified with the words that Yeats had used to characterize Europe ravaged by World War I: “anarchy is loosed upon the world…the ceremony of innocence is drowned; the best lack all conviction, while the worst are full of passionate intensity.” The hopeful, however, espoused the vision of Dylan that “times they are a changing”. They heard his call to “gather ’round people wherever you roam,” admonishing the “writers and critics,” “senators, congressmen,” and “mothers and fathers” to lend a hand in deconstructing old systems to create a new world that would serve everyone’s needs.

In matters of race at that time, overt discrimination had the acceptance, if not the approval, of many in the majority community. Even in the north, landlords and real estate agents could admit they would not show rental or sales properties to Blacks. Some chose to leverage that stance as a selling point. Although the government had tried to remedy employment discrimination in its civilian and military work forces at least as early as the 1940s, legislation to guide private employers did not arrive until the 1964 Civil Rights Act. I remember one of my relatives who was ostracized by coworkers because he had hired a Black military veteran to work as a janitor in an otherwise all-white business.

These are some of my memories, but what about some facts? Do the data tell us that any of the basic elements of quality of life have changed for the races over these past 50 years?

Nationally, the Economic Policy Institute suggests that the dreams of Dr. King and the other speakers on August 28, 1963 have not yet reached fruition. Unemployment was twice as high for Blacks than for Whites in 1960—it had the same two-to-one ratio in 2012. Integration of our schools has not occurred: three quarters of Blacks attend schools where more than half of students are persons of color. Although the gap in poverty rates between Whites and Blacks has narrowed since 1960, the Black poverty rate remains twice as high as the White rate.

What about Minnesota?

If the dream of those who marched in August of 1963 included equality of opportunity, it looks like Minnesota falls short. The latest data for our state, published just yesterday, shows a 33 percentage point gap between the proportions of White and Black students meeting state reading standards.

If the dream envisioned equality of outcomes, we fall even shorter. For example, in 1960, in Minnesota, White household income was 50% higher than the household income of persons of color (Whites: $4,695; Persons of color: $3,116). In 2011, the difference had increased to 60% (Whites: $57,150; Persons of color: $35,500). For Black Minnesotans, the figure drops to $25,410. So, despite achievements in legislation to promote equality, the numbers, at least for income, suggest greater, not less, disparity between Whites and Blacks.

In 1960, in Minnesota, Whites and persons of color had very similar rates of labor force participation: Just over half of both groups (who were age 14 and older) participated in the labor force. Fifty years later, the situation shifted: About 78% of Whites (ages 16 to 64) participated in the labor force, compared to 65% of persons of color in that age group.

In fact, Minnesota is currently home to some of the very largest White – Of Color gaps in the nation including disparities in poverty rates (7th largest racial gap among states); proportion of adults working (5th largest); and home ownership rate (the largest gap in all of the 50 states). Unfortunately our “above average” quality of life, regularly touted in national media, while true for the state as a whole, is not shared in all quarters of our state.

Should the numbers discourage us? I don’t think so. Our efforts over the past 50 years have changed attitudes, and we have influenced culture. We have improved life for many, even if we have not succeeded in improving life for all. I remain inspired by Dr. King’s assertion that “I can never be what I ought to be until you are what you ought to be, and you can never be what you ought to be until I am what I ought to be. This is the inter-related structure of reality.”

On that note, we need to persevere. As we make life better for any of us, we make life better for all of us.

Should Homeless People Smoke?

I pondered that question at about 11:30 p.m. on a Friday night in June, while attempting to fall asleep on my cot in the basement of a church I had never set foot in previously, where I served as an overnight volunteer for Project Home.

Project Home provides emergency shelter for children and their families in Ramsey County, by arranging sleeping accommodations and breakfasts in the basements of churches and synagogues. The overnight chaperone socializes with the families before bedtime, tries to get a little sleep overnight, and awakens early to offer the parents and children food before a bus arrives early to take them to a day program.

While chatting on the church steps until the mandatory 10:00 p.m. bedtime, several of the parents smoked, and the secondhand smoke caused me to cough a few times – yes, even in the fresh air. Later on, pondering the effects of the smoke on the kids kept me awake.

An article in the July 18 issue of The New England Journal of Medicine notes that, “Although the prevalence of smoking in the United States has declined, vulnerable and marginalized groups continue to use tobacco at high rates.” The article points out that smoking-related deaths among homeless people occur at a rate twice as high as the rate among people in stable living situations.

Unique challenges do exist with respect to reducing smoking among homeless people – such as above average nicotine dependence, psychiatric conditions, and histories of abuse and trauma, in addition to lack of health insurance which limits access to smoking cessation services.

Yet, my experience that Friday night convinced me we must make reducing smoking among the homeless population a priority.

A 9-week-old baby staying at the shelter, who appeared healthy for the most part, had a raspy wheeze. And despite the fact he had seemingly very loving, caring parents, they were heavy smokers. His mother said that a nurse informed her that tobacco smoke could cause wheezing. I tried to remain supportive, nonjudgmental, so I mildly affirmed the nurse’s comment, even while I choked back my emotions.

A 30-something father talked with pride about his 12-year-old daughter, who accompanied him to the shelter. She had earned all A’s and B’s at school during the past year, despite the lack of housing stability and despite some stressful events involving racist taunting, which she had to endure. The girl demonstrated athletic ability out on the sidewalk. Her father, who smoked several cigarettes that evening, said that she wanted to play two different sports, but her asthma prevented her from engaging in prolonged and intense physical activity. Might the severity of her asthma have some connection to his smoking? I tried to understand why the girl’s father was unable to make the connection between his daughter’s asthma and the smoke he blew around her.

The children in these shelters are precious resources. We know that their environments – family and community – will significantly shape their health; environmental influences of many types will literally add/diminish years from their lives. (See, for example, our report on “the unequal distribution of health”.) So, at a minimum, we should perhaps seek to transform the adage that “your right to swing your fist ends where my nose begins” to “your right to blow smoke ends where a child begins to inhale.”

In 2004, Minnesota State Representative Marty Seifert proposed that welfare clients who smoke cigarettes should have a reduction in their benefits. As the StarTribune reported, his proposal “drew laughs and criticism from Teresa Nelson, legal counsel for the Minnesota Civil Liberties Union. ‘That's pretty wild,’ she said. ‘Certainly, giving up the right to put legal substances in your body should not be a condition of qualifying for government benefits.’”

Well, giving attorney Nelson the benefit of the doubt, I attempted, to no avail, to identify some justification for her assertion. Smoking typically appears as a condition affecting the cost of life insurance, for example. So, what socially responsible value or principle should inhibit  government from taking a life-saving approach for adults and their children, saying: “If you do not smoke, you will receive X amount of dollars, but if you do smoke, you will receive less”? That approach would put pressure on people to engage in behavior which protects their health and the health of others, and we could evaluate its effectiveness.

Financial rewards and penalties constitute just one approach. We probably need multiple approaches, given the complexity of the issue – addiction, psychiatric illnesses, etc. In the case of homeless shelter volunteers such as me, even some coaching about key messages, what to say when a shelter resident lights up a cigarette, might help. Perhaps you have thoughts to share?

In the final analysis, though, we must not deal with this problem by ignoring it. I concur with the authors of The New England Journal of Medicine article, who conclude strongly that we must “change the culture of complacency that has enabled our acceptance of smoking as an inextricable aspect of homelessness. Though the challenges of addressing tobacco use in this population are many, we believe that ignoring this issue is no longer justifiable — and that the conversation should shift away from the question of whether to address smoking among homeless people and toward the question of how.”

"Independence" Day?

The day after the Fourth of July, I encountered a man wearing a shirt which proclaimed: “I built my business. The government didn't build my business.” His declaration of independence very much tempted me to ask:

• Did you build the roads that your customers use to drive to your business, that your suppliers use to bring the materials you need to conduct your business, and for that matter, that you traverse every day, expecting that the traffic lights will work, that the pavements will contain no hazards, and in the event of severe weather, that maintenance crews will plow snow, clear fallen trees, and do whatever else your safe passage might require?
• Did you create the monetary system that your customers use to make purchases from your business?
• Did you hire the teachers who educated your employees?
• Did you create your own police and fire services, to ensure the safety of your business?

It might have proved interesting to engage in conversation that man with the t-shirt, to determine the extent to which he truly believed that he had “done it alone”, although something about his demeanor suggested that he probably would not have opened up to rational dialogue on the matter. In any case, the notion that the “I” succeeds in this world absolutely independently, with no reliance on government and others, is ludicrous.

The American Founding Fathers declared political independence – the establishment of a separate nation. That very act, however, along with the entire American Revolution, relied entirely on interdependence – mutual collaboration among people, organizations, and colonies, to wage war and to establish a new social and economic order.

The next couple of centuries of European settlement in North America involved extensive interdependence (not to mention the years of interdependence among native people prior to the Europeans’ arrival, but that’s a different discussion). Individuals worked in common to create communities, produce goods and services, and form political, social, and religious institutions. Not to say that people always agreed with one another. Sometimes disagreement even turned violent, the Civil War being probably the most extreme division. However, joint efforts, humans engaging with other humans, produced all notable achievements within these United States throughout the course of the nation’s history.

As we confront the challenges of the 21^st century, our interdependence motivates us to recognize our common fate, develop joint goals, and collaboratively forge inventive solutions to social, economic, and environmental issues. Those issues range all over the map: international development; national security; local business development; community crime prevention; affordable, energy-efficient housing; long-term care of the aging; climate change; education relevant to a changing world. You can add to the list of local, national, and international issues that we need to address.

John Donne said it poetically:

"No man is an island,

Entire of itself,

Every man is a piece of the continent,

A part of the main. …

Any man's death diminishes me,

Because I am involved in mankind."

At Wilder Research, we work on issues which call for joint effort, sometimes motivated by an inventive, entrepreneurial desire to improve communities’ quality of life and build a better world, sometimes motivated by compassion to remedy a problem, right an injustice, or eliminate an obstacle that prevents communities from thriving. Our understanding of our interdependence leads to our acknowledgement of the responsibility to do nothing less. Not only does the death of another human being diminish us, so also does their inability to acquire adequate education, shelter, food, or nurturing. Because we are all interdependent.

As we move forward from this Fourth of July holiday – Happy Interdependence Day!