The concept of health equity has gained urgency in public heath efforts in recent years.1 It has been incorporated into Healthy People 2020 goals, Centers for Disease Control and Prevention guidance, and is the subject of an extensive online course provided by the National Association of County & City Health Officials.2 The Association of State and Territorial Health Officials, the national nonprofit organization representing public health agencies in the United States, the US territories, and the District of Columbia integrated health equity into its organizational strategic plan and also has a separate health equity strategic plan, the central challenge of which is “to mobilize leadership to achieve health equity.”3,4 Association of State and Territorial Health Officials' definition of health equity is the “attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and healthcare disparities.”5 This definition aligns with the Centers for Disease Control and Prevention and federal Office of Minority Health's definitions.6,7
Each year, ASTHO's board of directors votes for a new president. Dr Ed Ehlinger, Commissioner of the Minnesota Department of Health (MDH), is the ASTHO Board President-Elect for 2014-2015 and will start his term as President at the ASTHO Annual Meeting in September 2015. Dr Ehlinger is one of many public health leaders who insist that health equity be a priority concern for public health agencies in the United States. He also intends to make health equity the focus of his ASTHO President's Challenge during his 2015-2016 term to mobilize his fellow state and territorial health officials to use their positions to promote effective, policy-focused approaches to health. The purpose of this case example on emerging practices will highlight how Dr Ehlinger promoted health equity in his state and will showcase several policy and administrative levers that MDH used to move toward this goal. The authors collected observations on the experience of MDH in operationalizing and prioritizing health equity over the course of the last 4 years to provide information for this article and to specifically highlight the practice of leadership in health equity. Other state health officials and their leadership staff, leaders of public health institutions, and staff at federal, state, and local health agencies will find this article and its lessons learned useful as they elevate health equity in their own work and organizations.
Health Equity and the Conditions for Health
In 1988, the Institute of Medicine wrote that the mission of public health is to “fulfill society's interest in assuring the conditions in which people can be healthy.”8 However, across the country, entire populations do not have access to the kind of conditions that are required for health, including safe living environments, a good education, and stable employment. Making a difference and achieving health equity in the United States requires a commitment to ensuring that all of the conditions that create health are available to all people. This requires going beyond familiar public health areas such as health education, disease prevention, water quality, and health care: health equity is reached only when every person has the opportunity to realize his or her health potential (the highest level of health possible for that person) without limits imposed by structural inequities. This working definition of health equity, adopted by MDH, is based on the definitions noted previously as well as the work of the World Health Organization and health equity experts.9,10
Health equity has gained importance as a public health issue largely because of significant and persistent disparities in health outcomes caused by structural inequities in social and economic factors, including employment opportunities, the law and the justice systems, education, housing, neighborhood environments, and transportation. These elements are otherwise known as the social determinants of heath. The opportunity or lack of opportunity to be healthy is too often associated with a person's socioeconomic status, race, ethnicity, gender, religion, sexual identity, or disability.11
Fairchild et al12 pointed out that public health efforts have been focused in different areas over the last century depending on how the mission of public health has been defined. The profession of public health, they note, moved away from early social reform efforts that required attention to living conditions to address infectious disease and toward a model, drawn from the emergence of medical science, which direct attention to the actions of individuals.12 These approaches (eg, focusing on health care systems and encouraging healthy behaviors) have not succeeded, by themselves, in making significant progress on the intractable issue of health disparities.
Research over the last several decades has shown that race- and ethnicity-based health disparities are the result of persistent social and economic inequities, which have a greater influence on health outcomes than either individual choices or health care system interventions.13 The social determinants of health are shaped through policy decisions and resource distribution, for example, through access to healthy environments and opportunities that create health. Most of the time, non–health agencies such as transportation, housing, built environment, labor, and others have the most control over the social determinants of health and are beyond the scope of public health. New public health approaches, sensitive to “the interplay of the varied social, political, and economic forces,”12 and collaborative approaches to policy change are required to address these complex and interdependent issues to improve population health.10
The Health in All Policies approach is being emphasized in both national and international public health arenas as a key framework for addressing the social determinants of health, focusing on the root causes of inequities and increasing the potential for improving health equity.14–1714–1714–1714–17 According to a national guide, a Health in All Policies approach should include efforts that (1) promote health, equity, and sustainability; (2) support intersectoral collaboration; (3) benefit multiple partners; (4) engage stakeholders; and (5) create structural or process change.13 Many issues that affect health, such as air quality or transportation, require coordinated action from multiple sectors. A Health in All Policies approach requires consideration of the health implications of these issues, while focusing on policies and strategies that can improve intersectoral collaboration. Through this approach, public health leaders focus on how policy decisions create and perpetuate the social and economic inequities that generate health disparities and then take steps to create a healthy policy environment to ensure the conditions in which people can be healthy.
Minnesota Leads in Health, Lags in Equity
Minnesota often ranks high in lists of the healthiest American states.18 But as many MDH reports note, the state also has some of the worst health disparities by race or ethnicity in the nation. Minnesotans of American Indian, African and African American, Hispanic/Latino, Middle Eastern, and Asian Pacific Islander descent are currently in the minority in the state. These individuals fare worse than Minnesotans of white European descent on nearly every social and economic indicator, from education to per capita income. These populations also face much higher rates of negative health outcomes in areas such as infant mortality, diabetes, injury, and cancer.
Minnesota's demographic profile is rapidly diversifying, a change that has vital implications for the state's health. When Dr Ehlinger accepted his appointment as the MDH commissioner, he recognized that this would provide an extraordinary opportunity to lead the state's primary public health organization in new directions to eliminate health disparities and advance health equity. Dr Ehlinger frequently quotes Sir Geoffrey Vickers (1984-1982), an English lawyer, administrator, writer, and pioneering systems scientist, who said:
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... the history of public health might well be written as a record of successive re-definings of the unacceptable.19
This quote reflects Dr Ehlinger's conviction that the persistent health disparities in Minnesota are unacceptable.
Like every newly appointed state health official, Dr Ehlinger did not walk into an empty space when he came to MDH. The department has nearly 1500 employees, 7 locations around the state, and a national reputation for excellence. Many department heads and senior staff are national leaders in their own fields and deeply committed public health professionals who shared Dr Ehlinger's concerns about health disparities. The challenge was not to convince them of the problem but to challenge prevailing public health paradigms and take the agency and its partners into new spaces. Dr Ehlinger's experience in Minnesota over the last few years showcases how a state health official can effectively use his or her position to advance health equity, in particular, as a convener, communicator, and leader. The elements of convener, communicator, and leader emerged from ASTHO's primer on “The Role of the State and Territorial Health Official in Promoting Health Equity” and are relevant to any public health issue the state health official chooses to address.20 This article will discuss these elements in the context of health equity, as state health officials' influence and leadership can create a health equity agenda across the health agencies' many programs, departments, divisions, and resources.20
Convening Stakeholders for Health Equity: The Role of the State Health Official
State health officials can use their expertise and influence to convene a broad array of organizations and agencies to work together toward a common goal. Convening for health equity must be understood as far more than calling meetings or forming partnerships. Convening in its most powerful sense is engaging the community in a common vision and action on issues that are larger than any single organization. Convening for health equity focuses on who is and is not “at the table,” ensuring that the populations experiencing the greatest disparities can participate fully and effectively in decision-making processes.
As Dr Ehlinger began his work, MDH was poised to begin the process of applying for national public health accreditation and had started preparing to fulfill the necessary prerequisites. National public health accreditation standards require that state health departments have completed a statewide health assessment (SHA), a statewide health improvement plan (SHIP), and a departmental strategic plan prior to applying for accreditation. Both SHAs and SHIPs require the involvement of a statewide leadership committee. Minnesota's previous state health official, Dr Sanne Magnan, had convened this committee, the Healthy Minnesota Partnership, shortly before leaving. The Partnership had only met once, but its members were energized and ready to answer the call of a new commissioner. Dr Ehlinger recognized this ready-made opportunity to engage with a spectrum of leaders from across the state and different sectors. He reconvened the Partnership and enlisted an assistant commissioner, Jeanne Ayers, to chair the Partnership and ensure that this group would support the movement toward health equity. Over the 4 years that the Partnership has now met, its membership has continued to evolve to better reflect a diverse range of stakeholders who inspire others to improve health equity in the state.
MDH received another opportunity to convene citizens and leaders on health equity via a legislative partnership. In 2014, the Minnesota State Legislature, through the efforts of Dr Ehlinger and his executive team, charged the agency to develop a report on health equity in the state. Jeanne Ayers and Melanie Peterson-Hickey directed and Dr Ehlinger supported an internal planning team that was determined to include the voices of individuals most affected by health disparities in the report. The team designed a convening process that engaged more than 100 MDH staff and more than 1000 stakeholders and public health partners across the state to provide the content for the report. The MDH professionals were trained to convene groups of their own constituencies: community partners, grantees, stakeholder groups, or colleagues. Each group discussed the same set of questions and uploaded the results of their conversations to an online survey. The planning team used feedback and comments from hundreds of pages of these contributions in its health equity report.
Dr Ehlinger also used his position as a state cabinet officer to encourage other state department heads to support the health equity effort. He has consistently brought the issue of health in all policies to cabinet meetings, one-on-one discussions, and presentations. As the MDH report, now titled “Advancing Health Equity,” was being finalized, Dr Ehlinger persuaded every state cabinet-level officer to add his or her name to the introductory letter acknowledging that “optimal health for everyone requires excellent schools, economic opportunities, environmental quality, secure housing, good transportation, safe neighborhoods, and much more.”21 Shortly after “Advancing Health Equity” was released, Dr Ehlinger convened a meeting of state agency heads to continue the conversation about the connections between their work and health and well-being. In large part due to this exposure and commitment to health in all policies, several state agencies are active participants on the Healthy Minnesota Partnership.
Another opportunity that Dr Ehlinger seized was the chance to partner with the University of Minnesota to encourage the Committee on Institutional Collaboration (CIC) to address health disparities in a coordinated way across Big Ten universities. The CIC universities will form academic-public health partnerships across the region and work in concert with state government offices in the 11-state region to address the issue of health disparities. They have commitment from the provosts of all Big Ten schools and all state health commissioners in those states. This collaboration will focus on states' needs, provide intercollegiate opportunities for research and data sharing, increase visibility of the issue of social determinants of health, and work on data analytics, policy analysis, and workforce development.
The CIC's next steps are to plan a summit, start a data collaborative, and study policy issues related to child health and development, including the minimum wage, the earned income tax credit, the state child tax credit, paid parental leave, paid sick or family leave, all-day kindergarten, child care subsidies, and housing policies. The effort will address social determinants of health to help advance health equity in a more systematic, coordinated way.22 To underscore the Health in All Policies approach, the CIC will focus more on the letters and sciences areas of the universities rather than health sciences.
Communicating for Health Equity: The Role of the State Health Official
An important aspect of a state health official's role is successfully communicating important public health messages to diverse audiences, including legislators and policy makers, other health professionals, the media, and the public. A skilled state health official can focus conversations and reframe issues to highlight the public health messages behind politics and create common ground between stakeholders. However, communicating for health equity presents state health officials with another challenge: because health equity requires changing policies and systems to create the opportunity for everyone to be healthy, it also requires confronting prevailing paradigms. State health officials must simultaneously prepare the ground for change and develop different ways of talking about health that do not fall prey to the standard “health care and individual behavior change” models that currently dominate public conversations about health.
In Minnesota, the collaboration of MDH with the Healthy Minnesota Partnership helped lay the groundwork for such change. One of the Partnership's first tasks was to develop the SHA according to the national guidelines for accreditation. Dr Ehlinger and Jeanne Ayers encouraged MDH staff to approach the Partnership with a proposal to use the social determinants of health in the SHA framework. This would ensure that both Minnesota's SHA and its SHIP would discuss the factors that create health.
Intent on social and economic factors being a central (not peripheral) part of the SHA, the Partnership went even further: at the encouragement of Dr Ehlinger and others, including the dean of the University of Minnesota School of Public Health, the Partnership recommended that the traditional public health indicators of disease and injury be moved to the back of the assessment, almost as an appendix, and that the bulk of the assessment focus on the social, economic, and environmental conditions that create the opportunity for people to be healthy. This shift in the SHA allowed MDH staff to detail a wide range of unconventional health indicators, focused on social and economic factors, and highlight the ways that Minnesotans are given or denied the opportunity to be healthy, which in turn allowed the Partnership to begin challenging the prevailing public health paradigms and take a different approach to the next required document: Minnesota's SHIP, “Healthy Minnesota 2020.”
In preparation for the SHIP process, the Partnership reviewed the findings from Minnesota's SHA to identify priority issues in the 5-year planning cycle. Here, the Partnership took an unusual turn. After multiple meetings and small group exercises, staff dedicated time to small group discussion, analyzing and sorting Partnership comments, and voting on issues. Instead of focusing on the usual goals, objectives, and indicators, the Partnership agreed on 3 significant themes that captured what Minnesota needed to realize its vision for health: (1) capitalize on the opportunity to influence health in early childhood, (2) ensure that the opportunity to be healthy is available everywhere and for everyone, and (3) strengthen communities to create their own healthy futures. Dr Ehlinger's direction, the efforts of MDH, and the willingness of leaders from multiple organizations and constituencies on the Partnership to participate actively and creatively in the process helped pave the way for a very different approach to statewide action for health.
Even as the SHA was underway and the themes of Healthy Minnesota 2020 were emerging, the Partnership recognized the need to change the paradigms governing public discussions about health. Dr Ehlinger, Jeanne Ayers, and many MDH staff and Partnership members agreed that talking about health care, health care reform, and individual responsibility for healthy behavior, has “taken up all the air in the room” for too long. These predominant paradigms of what people need to be healthy have left few opportunities in the public arena for talking about, for example, economic policy's impact on health, or education's relationship to health. Subsequently, the Partnership charged 2 subgroups with revealing and reducing dependence on these “dominant narratives” of health care and personal responsibility by
* developing tools that the Partnership could use to expand public conversations about health, including information on the factors that create health.
* identifying key policy issues, gaining attention at the state legislature around which these conversations could be organized (“strategic opportunities”).
This 2-part approach comprised the core strategy of the Partnership and was designed to build capacity and move Minnesota toward health in all policies.
Currently, the Healthy Minnesota Partnership's narratives team focuses on values and the language people use to talk about health, finding ways to emphasize social and economic conditions. The policy team seeks “hot topics” in play at the legislature to connect public policy discussions with the emerging narrative about what creates health. In the last 2 years, members of the Partnership have used the emerging Healthy Minnesota 2020 narrative to engage in public discussions about minimum wage (connecting income and health), multimodal transportation systems (connecting transportation and health), and paid family leave (connecting nurturing family environments and health). While white papers prepared by MDH (on income and health and on paid leave and health) showcase the research demonstrating the critical connections to health of these social determinants,23,24 the primary purpose of selecting these “hot topic” issues is not to advocate for particular policies (although some Partnership members are actively engaged in the legislative process) but to use these opportunities to expand the public conversation about health.
Leading for Health Equity: The Role of the State Health Official
State and territorial health officials play a significant executive role as public health directors in their states and are often encouraged to use their “bully pulpits” to draw attention to key issues. However, a state health official's skills go beyond merely speaking to audiences. Moving forward on a tough issue such as health equity (especially when challenging dominant paradigms) requires the ability to connect with different constituencies about values, authenticity and the willingness to speak hard truths, the ability to recognize people's skills and release them to do their best work, and the ability to learn as well as to teach.
Dr Ehlinger's position has given him many opportunities to bring health equity to the attention of Minnesota's leaders. Working with state legislatures is always challenging, as working across political lines requires a leader to connect on priority concerns at the level of values, not opinions. The many constituencies of MDH, from academia, to philanthropies, to communities of color, to health plans, are very diverse in their interests and often have competing priorities. The narrative work of the Healthy Minnesota Partnership narrative work supports Dr Ehlinger's efforts to keep health equity in the sights of all of Minnesota's elected officials, institutions, systems, and communities.
In Minnesota's Advancing Health Equity report, Dr Ehlinger used his position as the state's health commissioner in a unique and important way: to talk about structural racism. Recognizing and acknowledging the significant and persistent racial disparities in health outcomes in Minnesota, the report's planning team wanted to highlight the issue of structural racism in Minnesota. This hard truth had been raised in the course of work on health disparities over the past 10 years, but the community contributions to “Advancing Health Equity” revealed that the report's authenticity was on the line; structural racism needed to be addressed and prioritized in such a significant document if the report was to be believed and make progress. While the report also highlights other disparities and “isms,” the report's authors gave race and structural racism special prominence because they “are difficult to talk about, and it is not uncommon for these issues to get subsumed under broader conceptual terms, such as injustice, discrimination, or ...equity.”21
The issue of structural racism is not new to public health.25 But naming structural racism as an issue in an official state report and being open to having conversations about structural racism and other structural inequities—including with regard to its own programs—is unusual for a state agency. In fact, this feature generated more press coverage and national attention for the report than it might have had otherwise and underscored the document's credibility, especially among stakeholders from Minnesota's populations of color.26–2826–2826–28 Under Dr Ehlinger, the state health department showed itself willing to create space for difficult conversations to take place and has affirmed the need to speak hard truths. Dr Ehlinger pairs the truth about structural racism with a commitment to changing the way that the health department approaches health equity, ensuring a greater coherence between his words and the actions of MDH. For example, all MDH budget proposals had a health equity emphasis as the first line of review. (In other words, health equity would be the top criterion for consideration.) In the most recent round of 2-year budget proposals, Dr Ehlinger required all proposed MDH program and division budget requests to demonstrate how their funding would contribute to health equity. These proposals were reviewed and revised by the MDH's executive team before becoming part of the overall departmental budget request that was submitted to the governor.
Dr Ehlinger also has a commitment to developing teams of people who are able and ready to engage their passion in the work of advancing health equity. He relies on, listens to, and shares information with valued team members and executive leadership. He is points out the good work that his staff is doing and minimizes his own efforts, using his leadership position to pave the way for MDH staff's successes. While he speaks about health equity around the state and nationally, he also recognizes and supports the MDH professionals who use their own positions and talents to advance health equity at MDH and with their particular community partners.
Another reason Dr Ehlinger's tenure as state health commissioner is contributing to a changing public conversation about what creates health in Minnesota is that he is willing to learn and adapt as well as to lead and to instruct. He integrates new elements of the health equity work at MDH and in the Partnership into his thinking. He adapts, refines, and expands his own work on the basis of developing understanding and emerging messages of the Healthy Minnesota Partnership, the MDH Center for Health Equity, and other areas of health equity work. By learning as well as teaching, he increases the coherence and the potential of the department's efforts to advance health equity.
Leading by Design: Lessons Learned
It would be a mistake to assume that the efforts of Dr Ehlinger to advance health equity developed as part of a specific, preconceived, step-by-step plan. Although he came into office with a clear commitment to health equity and the intention to promote health in all policies, he could not have predicted the way this effort has unfolded. However, his approach was not without intent. The design of his approach is reflected in the following examples of the many lessons learned from Minnesota's experience to date, lessons that may benefit other state health officials as they attend to the issue of health equity:
* Be attentive to who is engaged in making decisions, who has the attention of state lawmakers, who is given leadership roles, whose voices are being heard, what kinds of partnerships are being formed, what messages are being shared, and how communities are being strengthened to create their own healthy futures.
* As a public health leader, be willing to learn and adapt as well as to lead and to instruct.
* Develop teams of people who are able and ready to engage their passion in the work of advancing health equity.
* Create an environment in which people feel safe enough to engage in difficult conversations and speak the hard truths about health inequities in your state or organization.
* Organize other heads of state departments in support of the health equity effort; for example, bring the issue of health equity and health in all policies to cabinet meetings, to one-on-one discussions, and to presentations.
* Challenge the ideas that dominate public conversations about health (eg, that health is solely an individual responsibility or that health disparities are only an issue of adequate health care) and take the practice of the department and its partners in new directions.
None of the parts of the design are sufficient on their own: it is not enough to create a new narrative, or to call new people to new levels of engagement, or to speak hard truths, or to develop new modes of action. “Developing health equity practice...is best seen as a movement-building strategy. It is a long-term process that requires a transformation of organizational culture and practice, and the larger public understanding of what most influences health.”29 All the parts of the design work together in synergy, repeating and creating persistent echoes of the vision and themes of health equity, to reinforce and reinvent and regroup and reenergize the efforts of state and territorial health officials across the country to create the conditions in which all people can be healthy.