Expanding the Narrative About What Creates Health

One News Story At A Time

Edward P. Ehlinger, MD, MSPH

Commissioner, Minnesota Department of Health

Past President
Association of State and Territorial Health Officials (ASTHO)

July 14, 2017

 The media are my friends and neighbors
Relationships sometimes smooth, sometimes rocky
We challenge each other.
We learn from each other
We need each other at different times for different
reasons
Weare integral to our community and together we
make a better community
What Ive learned about what the media likes:
Loves an infectious disease or foodborne illness crisis and the flu
Really likes ticks, mosquitoes
Always willing to cover tanning booths and skin cancer. Why?
Women in bikinis
Loves data and will report it, if it is big and simple e.g. More
than half of Minnesota third graders have had a cavity
Is open to doing public health stories but needs a hook Pitch the
Commissioner
Thinks prevention is boring important, but boring.
 How I view and use the media.
Media is a public health tool to be used
proactively and reactively
The media can help change the narrative
about health
The media can help educate and
advocate
Themedia help with quality assurance
they educate me
I try to educate the media
 Mary Baker Eddy
Born on July 16, 1821

Founder of the Church of Christ, Scientist

Founded The Christian Science Monitor in
1908
Truth is immortal; error is mortal.
Diseaseis an experience of a so-called
mortal mind. It is fear made manifest on
the body.
 Expanding the Narrative Of What Creates Health

Looking over the newspapers of the day,

one naturally reflects that it is dangerous to
live, so loaded with disease seems the very
air. These descriptions carry fears to many
minds, to be depicted in some future time
upon the body. A periodical of our own will
counteract to some extent this public
Mary Baker Eddy
nuisance;
 Expand the narrative about what creates health
Importance of Narrative
Public sentiment is everything. With
public sentiment, nothing can fail; without
it nothing can succeed. Consequently he
who molds public sentiment, goes deeper
than he who enacts statutes or pronounces
decisions. He makes statutes and decisions
possible or impossible to be executed.
-Abraham Lincoln
 Policies have the greatest impact on health
19th Amendment greatest public health achievement of the 20th century
(EE perspective)
Policies are the most important determinant of health and health equity

Usual focus of
media stories
Commission on Social Determinants of Health. (2010). A conceptual framework for
action on the social determinants of health. Geneva: World Health Organization.
 The Media Reflect the Dominant U.S. Narrative

People would be healthy if Health is the responsibility

they worked hard; made of individuals until they
good choices about diet, get sick, then it becomes
physical activity, and the responsibility of the
substance use; and had
healthcare system.
good medical care.
 Predominant U. S. Worldview
Boot Straps Individualism
Virtue of Work

Small Free Market

Government Solutions

Mistrust of Education is for

Science job training

Reliance on Structural Discrimination

technology/specialization is a thing of the Past
 Dominant Health Narrative
Health is an individual
responsibility

Health is a Competition and

private matter consumer choice

I know whats best for Healthcare should run

me and my family like a business

Medical care will Anyone can choose

cure me if I get sick to be healthy
Dominant narrative leads to an investment in medical care
And an under investment in public health and social services
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 Public Health

0 20 40 60 80 100
Constant redefinition
of the unacceptable.
Two perspectives on progress on life expectancy

We had different public

narratives in 1900 and 2009.
U.S. life expectancy inversely related to investments in healthcare
Life expectancy vs health expenditures - U.S. and OECD Countries 1970 - 2014
 Unacceptable rate of improvement in life expectancy
Life Expectancy at Birth US and OECD Countries by Gender 1960-2010

US life expectancy declined in 2015

 Unacceptable rate of improvement in infant mortality
Infant Mortality Rates U.S. and OECD Countries 1960-2010
35

30
U.S. OECD median
25

20

US Rank 12 (1960)
15

10 US Rank 38 (2015)

0
1960 1970 1980 1990 2000 2010

Source: http://stats.oecd.org, accessed 6-10-16

Unacceptable rise in maternal mortality
U.S. Ranked 49th in Maternal Mortality in 2008

Data from UNICEF, WHO, UN Population Fund,

and World Bank with standardized methodology.
Improvements slowed when our disparities increased
Life Expectancy, by race: United States, 1970 - 2010

SOURCE: CDC/NCHS, National

Vital Statistics System, Mortality.
Improvements slowed when our disparities increased
Black/White Disparity in Infant Mortality Rates, US, 1935-2007

National Center for Health Statistics, Health United States, 2009 (updated)
 "What Sets the Goals of Public Health?"
Sir Geoffrey Vickers - 1958

The landmarks of political, economic and social

history are the moments when some condition
passed from the category of the given into the
category of the intolerable. I believe that the history
of public health might well be written as a record of
successive re-definings of the unacceptable.

The media chronical the political, economic, and social history

and my job is to provide the media a broader perspective.
To Advance Population Health and Health Equity,
We Need a Different Approach

Public health is what we, as a society, do

collectively to assure the conditions in which
(all) people can be healthy.
The Future of Public Health
Institute of Medicine, 1988
 Living Conditions Impact Health

Social/economic exclusion
Social/economic inclusion Good Few small businesses
Thrivingsmall businesses and Health
Fast food restaurants
entrepreneurs Status
Unsafe/limited parks
Grocery stores
Rental housing/foreclosure
Parks & trails
Sufficient healthy housing Poor Poor and limited housing stock
Good transportation options and
Health Few transportation options
infrastructure Status Payday lenders
Financial institutions Poor performing schools
Contributes
Home ownership to health Increased pollution and contaminated
disparities:
Better performing schools drinking water
Obesity
Diabetes Limited IT connections
IT connectivity
Asthma Weak local governance
Strong local governance Cancer
Injury
The Public Health Approach to Advancing Health Equity
and Optimal Health for All

Social
Cohesion
Expand the Understanding of What Creates Health
Necessary conditions for health (WHO)
Determinants of Health Peace
Shelter
Genes and Biology Social and Economic Education
Physical 10% Factors
Food
Environment
10% 40% Income
Clinical Stable eco-system
Care 10% Sustainable resources
Social justice and equity
30% IT connectivity
Health Mobility
Behaviors
Health Care
Determinants of Health Model based on frameworks developed by: Tarlov AR. Ann N Y Acad Sci 1999;
896: 281-93; and Kindig D, Asada Y, Booske B. JAMA 2008; 299(17): 2081-2083.
Social responsibility
World Health Organization. Ottawa charter for health promotion. International Conference on Health Promotion: The
Move Towards a New Public Health, November 17-21, 1986 Ottawa, Ontario, Canada, 1986. Accessed July 12, 2002 at
http://www.who.int/hpr/archive/docs/ottawa.html.
 Attributable Causes of Death

Firearms
Tobacco 42%

Diet/Physical Activity 35%

Alcohol 9%
Tobacco
Microbial Agents 7%

Toxic Agents 5%
Diet/Physical Activity
Firearms 2%

Each year
McGinnis inWH.the
JM, Foege United
Actual causes of death in States:
the United States. JAMA. 1993;270:2207-2212.

$15.3 Billion is spent marketing tobacco

$6 Billion is spent marketing alcohol
$2.9 Billion is spent marketing soda (by just 1
company)
 Expand the Understanding of
What Creates Health
Ehlingers beliefs about the contributions to health determinants
Genes and Biology Social and Economic
Physical Factors
Environment
10%
Determinants are created & enhanced
10% mostly by policies and systems that impact
Clinical
Care the physical and social environment
10% 60% Disparities are mostly the result of policy
decisions that systematically disadvantage
10% some populations over others.
Health Populations of color and American
Behaviors Indians, GLBT, immigrants, refugees
Structural Racism
 Expand the understanding about what creates health.
Contrasting/Alternative Worldviews

Interdependence Boot Straps

Social Cohesion Individualism
Virtue of Work Virtue of Work

Small Free Market

Necessary Social responsibility
Government Solutions
government Social Justice
Individual-centric
Worldview
Community-centric Dominant View Today
Worldview Mistrust of Education is for
Cooperation Education is for
science job training
Collective Action enlightenment

Reliance on Structural discrimination

Need for generalists Equity is the challenge
technology/specialization is a thing of the past
of the present
 Implement a Health in All Policies Approach
with Health Equity as the Goal

Minimum Wage Air/Water quality

Paid Leave Ag Buffer strips

Criminal justice Food Charter

Energy Marriage Equity

Transportation Payday Lending

Broadband connectivity Freedom to Breathe

E-Health Health Care Reform

Housing/Homelessness Climate Change

 Strengthen the Capacity of Communities to Create Their Own Healthy Future
Healthy Public Policy & Public Work Medical and Public Health Policy
Traditional Public Health Primary Care Specialty Care
Primary Prevention Secondary Prevention Tertiary Prevention

DEMOCRATIC
SELF-GOVERNANCE MANAGEMENT OF
RISKS & DISEASES
Improving Living Conditions

World of Transforming By Strengthening

World of Providing
Deprivation Democracy
Dependency Mutual accountability Health education
Violence Leaders and institutions Screening tests
Disconnection Plurality Disease management
Environmental decay Freedom Pharmaceuticals
Stress Foresight and precaution Clinical services
Insecurity The meaning of work Physical and financial access
Etc Etc Etc

the community in the fullest sense is the smallest unit of healthto

speak of the health of an isolated individual is a contradiction in terms.
Milstein B. Hygeia's constellation: navigating health futures in a dynamic and democratic world. Atlanta, GA: Syndemics Prevention Network, Centers for Disease Control and Prevention; April 15, 2008. Available
Wendell Berry in Health is Membership
at: http://www.cdc.gov/syndemics/monograph/index.htm
 How dominant narrative shapes reporting by media
Conflates healthcare and health
Implicitly supports idea that health is determined by
individual actions with its strong news you can use frame
diet tips, exercises, studies about diseases, etc.
Prefers the economic frame over the health frame recent
MN tobacco tax debate was about money not health.
Doesnt fully understand how is spent on health care and
who pays for it. Seldom provides context Recent study
shows $50 million in wasted tests. $50 million out of $27
billion in MN
Has no perspective on what kills us little time spent on
chronic disease
 How dominant narrative shapes reporting by media
Assume cancer clusters always exist based on erroneous
belief chemicals in the environment cause the majority of
cancer.
Has no problem with false equivalency vaccine debate
Sees regulations as generally inefficient, burdensome red
tape in the abstract but always expects and prefers
health regulators to be punitive and strict in specific
cases of wrongdoing.
Prefers to share suicide details and promote contagion,
unless educated to do otherwise St. Paul High Bridge
 Data Release Media Trainings

Hospital Treated Sexual

Suicide Assaults Data
Released data after Safe Media primer on
Reporting on Suicide covering sexual assault
training and the language of
September 2016 sexual violence
November 2016

7/16/2017

35
Suicide reporting dos and donts

http://reportingonsuicide.org/
 Social Media
On our own timeline
We monitor news and respond
Media monitoring services
We amplify good messages
YouTube - APHJ
Commissioners Blog
Twitter personal and professional
Facebook
 Beatrix Potter (July 1866 December 1943)
Author of Peter Rabbit
Once upon a time there were four little rabbits, and
their names were Flopsy, Mopsy, Cottontail, and Peter.
They lived with their mother in a sandbank,
underneath the root of a very big fir tree. One morning
old Mrs. Rabbit said, "I'm going to the bakery to get
some brown bread. You may go into the fields or down
the lane, but don't go into Mr. McGregor's garden. Your
father had an accident there; he was put in a pie by
Mrs. McGregor." Flopsy, Mopsy, and Cottontail, were
good little bunnies... but Peter, who was very naughty,
ran straight to Mr. McGregor's garden and squeezed
under the gate!
Living Conditions of the McGregor and Rabbit Families

Social/economic exclusion
Social/economic inclusion Good Few small businesses
Thrivingsmall businesses and Health
Fast food restaurants
entrepreneurs Status
Unsafe/limited parks
Grocery stores
Rental housing/foreclosure
Parks & trails
Sufficient healthy housing Poor Poor and limited housing stock
Good transportation options and
Health Few transportation options
infrastructure Status Payday lenders
Financial institutions Poor performing schools
Contributes
Home ownership to health Increased pollution and contaminated
disparities:
Better performing schools drinking water
Obesity
Diabetes Limited IT connections
IT connectivity
Asthma Weak local governance
Strong local governance Cancer
Injury
Public health is what we do collectively to assure the
conditions in which all people can be healthy.

Social
Cohesion