Prologue

This is a story of how the Minnesota Department of Health (MDH) and community partners continue to reframe the narrative of what creates health for Minnesotans. Since 2011, the MDH has focused on health equity — understood as when every person has the opportunity to realize their health potential without limits imposed by structural inequities. Along this journey, MDH came to see the necessity of leading with race as a way to understand and address all health inequities.

View the Advancing Health Equity Report here

Part I. “Not our swim lane…”

MDH has focused on health disparities for some time, but participation in a community meeting on housing access as a root cause of these disparities raised concerns about the involvement of agency leadership, since housing was not a traditional public health “swim lane.” The challenge is similar for public health practitioners who have sought to address upstream issues affecting health. It was clear that space needed to be made in MDH to address issues like housing, education, transportation, and incarceration. Department leadership responded to this challenge by asking “How do we make addressing upstream factors an expected aspect of public health work?”

It’s the responsibility of public health to tell the truth about what affects health.

There is a long but forgotten history—from Rudolf Virchow’s 1848 report on social class and health outcomes to the current WHO framework on social determinants of health—of public health’s role in addressing social inequities. These conditions are socially determined, meaning they are created by decisions and policies that affect society at large.

“Health is something we create as a society and as communities, not something an individual can purchase or produce alone.”

Advancing Health Equity in Minnesota, Report to the Legislature, page 11

Virchow, 1821–1902 — “The physicians are the natural attorneys of the poor, and social problems fall to a large extent within their jurisdiction.”

DuBois, 1868–1963 — “The matter of sickness is an indication of social and economic position…Negro death rate and sickness are largely matters of condition and not due to racial traits and tendencies.”

Marmot, 1945-Present — “At all levels of income, health and illness follow a social gradient: the lower the socioeconomic position, the worse the health…Social injustice is killing people on a grand scale, and the reduction of health inequities…is an ethical imperative.”

The World Health Organization defines social determinants of health as the conditions in which people are born, grow, live, work and age. These circumstances are shaped by the distribution of money, power and resources at global, national, and local levels.

Understanding the social determinants helps public health make the case that health and living conditions are connected.

But how do we get to change?

Part II. Developing the Capacity to Act

To do this work, MDH knew that they need a broader base at the table — both for knowledge and support. The Healthy MN Partnership was formed, asking for a high level of buy-in, commitment and ownership. Another key aspect of the Partnership was its identity: those at the table represented different stakeholder constituencies in order to increase the reach and accountability of the health department.

The partnership was influential in shifting the narrative of health. By challenging MDH to shift the view from measuring sickness to assuring living conditions, the broader lens of social determinants of health was adopted. The 2012 Minnesota Statewide Health Assessment was the first tool of the new narrative, reorienting the health department story, and thus their responsibility to act.

“Why do we keep talking about how sick we are?”

“Let’s talk about what we need to be healthy.”

The work to develop the Healthy MN Partnership and, in turn, to expand the narrative of health in Minnesota didn't happen in a vacuum. The theory of change guiding this work at MDH is grounded in a community organizing perspective, which moves beyond the connection between health and living conditions, and recognizes the capacity to act is critical to impact health.

Capacity to act = POWER

Building the capacity to act is necessary at the State and local health departments, as well as with community-based partners: churches, neighborhood associations, community-based organizations, schools…

According to MDH, power is built through organized people, narrative and resources:

People: develop accountable relationships and partnerships that align interests and directly impact decision-makers.

Narrative: build public understanding and public will to support action that reflects health equity.

Resources: shift the way resources, processes and systems are structured to advance health equity.

Part III. The “New” Public Health Swim Lane

This new narrative of focusing on “what we need to be healthy” shifted the scope and responsibility of MDH to address health equity. In 2012, MDH created the Healthy Minnesota 2020 framework, laying the groundwork for shifting resources to take the next step for health equity. Three health themes/priorities lead to nine indicators as shown below.

Starting with traditional public health indicators like prenatal care & breastfeeding, and moving through the social determinants of health toward incarceration, MDH broadened the understanding of what creates health.

…there’s something we’re not addressing directly…

Structural

RACISM

In developing the narrative and framework of “what we need to be healthy,” it became clear to the Partnership that addressing structural racism — the normalization of historical, cultural, institutional and interpersonal dynamics that advantage white people while disadvantaging people of color and American Indians — was necessary to advancing health equity in Minnesota.

“Race is not the only factor in structural inequities, but is a significant one. Even when outcomes related to other factors such as income, gender, sexual orientation, and geography are analyzed by race/ethnicity, greater inequities are evident for American Indians, African Americans, and persons of Hispanic/Latino and Asian descent. A concerted effort to specifically address the issues of structural racism and to develop the language and tools to uncover and change the structures shaped by racism will be invaluable for addressing other structure-based inequities.”

Advancing Health Equity, Report to the Legislature, page 24

PART IV. The Advancing Health Equity Report

Informed by this narrative of health, in 2013 the State Legislature directed MDH to prepare a report on health equity in Minnesota. To fulfill this call, MDH drew on community organizing practices by asking over 100 staff to reach out to their networks, organizations, churches, and communities to build the report. Over two months, these existing relationships yielded conversations with 1,000 people, 180 organizations, and 100 survey responses and 200 pages of written comments. These are the basis of the Advancing Health Equity report and recommendations.

Built through the ongoing inclusion of many people, the Advancing Health Equity narrative leads with the devastating impact of structural racism on individuals, communities and the State. Its recommendations organize resources for health equity by transforming MDH practices — for example, targeting grant-making to smaller, less represented organizations — and by making government more accountable to the impacts of all policies on health.

Report definitions

Report recommendations

1. Advance health equity through a health in all policies approach across all sectors.
2. Continue investments in efforts that currently are working to advance health equity.
3. Provide statewide leadership for advancing health equity.
4. Strengthen community relationships and partnerships to advance health equity.
5. Redesign MDH grant-making to address health equity.
6. Make health equity an emphasis throughout the Minnesota Department of Health.
7. Strengthen the collection, analysis and use of data to advance health equity.

Part V. Health Equity in Action

Building on Recommendations #1 and #7, Centro de Trabajadores Unidos en Lucha hoisted signs and banners with data from the Health Equity Report and the White Paper on Income and Health, while demonstrating for worker rights. They ultimately won policy on unionizing rights, and advanced efforts on minimum wages initiatives. Similarly, workers at the Minneapolis-St. Paul Airport won rights to paid sick days in December 2014.

“For too long, retail janitorial companies have been stealing years off of our lives and off of the lives of our children by paying poverty wages, and in some cases not paying workers their full wages.” — Maricela Flores, June 2014

Epilogue

The Advancing Health Equity report has generated significant energy and attention:

Minnesota Public Radio: ‘Structural racism’ blamed for some of state’s severe health disparities

Star Tribune: Wide health gaps tied to race

TC Daily Planet: Minnesota’s good life for Whites only?

Community Response: 85 pages of feedback to MDH about the report

However, as MDH Commissioner Ed Ehlinger notes,

“This is not a one-year program…This is changing how we do business from this point on, and everybody has a role in it.”

Acknowledgments

This website was created by Catherine Harrison, Susie Levy and Evan Bissell for Professor Jason Corburn’s Healthy Cities graduate course at the University of California, Berkeley School of Public Health and Department of City and Regional Planning.

We would like to thank Professor Corburn for his guidance and instruction on the theoretical and analytic basis of this project. We would also like to thank David Rabenal, graduate student instructor for Healthy Cities.

Finally, we wish to thank MDH Assistant Commissioner Jeanne Ayers for leading this work at the state health department. Her insight and feedback was crucial to understanding MDH efforts to advance health equity for all Minnesotans.