Irritating Grains of Sand

I attended the 2014 ADVANCING CANCER HEALTH EQUITY Conference in Bloomington, MN last week. It was a half-day program. You will noticed in the agenda that there were two Plenary Sessions and two break-out opportunities. The plenary speeches gave me much food for thought. I need to better understand what attitude is being irritated by these grains of sand.
Here is the briefest synopsis of my afternoon:

“Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” World Health Organization, 1948. Speakers at the 2014 Advancing Cancer Health Equity were united in expressing the reality of, the nature of and serious degree of health inequity in Minnesota. According to Keynote Speaker State Health Commissioner Edward Ehlinger, MD, MSPH, the solution lies in making effort to provide “all people with the opportunity to attain their highest level of health.” We need to “engage and empower communities to create conditions for health.” Easier said than done. It was an information packed afternoon. Many more challenges than solutions, but the process is clear: engaging and empowering underserved communities; focusing on social justice; leading to changes in public policy; and bringing about improved public health.

One of the break-out sessions I attended at the conference, “Minnesota Center for Cancer Collaborations (MC3) Community Engagement Lessons Learned and Opportunities” made it very clear that although efforts are being made to engage communities, after 5 years there has not been substantial gain in increasing their opportunity to maintain maximum health.

As Chair of the Community Advisory Board of the Masonic Cancer Center, University of Minnesota, I am familiar with the work, passion and commitment of Kola Okuyemi, M.D., M.P.H..
In this article in the University of Minnesota Foundation Medical Bulletin the reality of inequity in health care in Minnesota is well documented and not overstated. “Minnesota consistently rates as one of the country’s healthiest states — and is recognized as having one of the top health care systems — with a glaring exception: Minnesota has the largest health disparities in the country, even larger than states where there is a deeper level of poverty. Yes, we have one of the best health care systems, but it doesn’t reach out to everyone.” Read More

So what am I to do?

Edward Ehlinger MD, MAPH; Commissioner of the Minnesota Health Department, described the challenges well, using meaningful information, insightful quotes (by Will Durant and others) and statistics:

“As documented in the annual “Cancer Facts and Figures 2011” released by the American Cancer Society, poverty remains one of the most potent carcinogens….Dr. Samuel Broder, who was director of the National Cancer Institute in 1991, had suggested that “poverty is a carcinogen, a cancer-causing agent.”

Commissioner Ehlinger, referring to the 2008 World Health Organization (WHO) Commission on Social Determinants of Health, stated: “The poor health of the poor, the social gradient in health within countries, and the marked health inequities between countries are caused by the unequal distribution of power, income, goods, and services, globally and nationally, the consequent unfairness in the immediate, visible circumstances of peoples lives – their access to health care, schools, and education, their conditions of work and leisure, their homes, communities, towns, or cities – and their chances of leading a flourishing life. This unequal distribution of health-damaging experiences is not in any sense a ‘natural’ phenomenon….Together, the structural determinants and conditions of daily life constitute the social determinants of health.”

He concluded his remarks with the admonition that there needs to be social change – public policy change. Public Health = Public Policy + Social Justice. We need to engage the population and empower the communities to create conditions for health. Public health is whatever a society can do collectively in which all people can be healthy. Using the analogy of a swimming pool, he said, “We need to get out of our individual swimming lanes. Take down the lane lines and be in the pool. The pool is public health.

Everyone has a desire and a need for community. Community Organization is powerful and essential.  I have long admired Parker J. Palmer,  founder and Senior Partner of the Center for Courage & Renewal, and a well-known writer, speaker and activist. Here is a July 2014 article featuring Palmer’s “Thirteen Ways of Looking at Community”.  In it he emphasizes new thinking about community:
New Thinking
• Community is a gift, not just a goal..
• We receive community by cultivating a capacity for connectedness.
• Community does not depend on intimacy and must expand to embrace strangers, even enemies, as well as friends.
• Community that can withstand hard times and conflict can help us become not just happy but “at home.”
• Leadership and the authority to lead toward community can emerge from anyone in an organization.
• Suffering lets our “hearts break open” enough to hold both a vision of hope and the reality of resistance without tightening like a fist.

Closing speaker, Dean John Finnegan, Jr, PhD, MA, University of Minnesota School of Public Health, spoke on how it is that we communicate about health. The statement that struck me most powerfully was “Storytelling is the framework for understanding and meaning.”  I am a storyteller.  I use storytelling in all of my workshops and encourage every audience to “Name their narrow spots. Tell their stories. And gather the resources to navigate life’s journey.”  Narrative is an essential part of our human nature.  We live it, hear it and create it each day. Stories connect us to others and help us process, heal, problem solve, express feelings, remember and celebrate.

There is a relationship between teller and listener. To enter a story is to make room for its teller.  With someone to hear their stories, tellers know they are not alone and feel gratitude for being heard.  As listeners to someone else’s stories, we realize that we can help just by listening, and being a witness.  The listener confirms the worth of the teller by attending seriously to what he or she tells. Storytelling is prevalent in every culture on the globe. “The fact is that we human beings speak the same language. And the language that we speak is the language of storytelling,” Harold Scheub. Can storytelling be a pathway to health equity? Is this a potential tool to enlist and engage communities – underserved or not – to swim, play and work together in “the pool”?

I was introduced to a new term: Medical Narratology.  Certainly a concept that is supportive of my objective and premise. Dr. Rita Charon of the Columbia University School of Medicine, is the architect of narrative medicine, “Narrative medicine,” says Dr. Charon, “is designed to recognize and interpret the stories of patient illness in a comprehensive way, using an integration of humanities, primary care medicine, narratology and the study of doctor-patient relationships.” Read More  It is a brief article concluding with these thought-provoking questions:

• Should physicians be encouraged to study narrative medicine in medical school?
• What do you think are the practical benefits of narrative medicine to physicians, patients and the health care system more generally?

Dean Finnegan also described “Health Literacy” as a key component in creating the opportunity for all people to attain their highest possible level of health. The U.S. population is more diverse than ever before in terms of race, ethnicity, language, socioeconomic status, and education level. According to the The Institute of Medicine (IOM), an American non-profit, non-governmental organization founded in 1970, Health Literacy is “the degree to which individuals have the capacity to obtain, communicate, process, and understand basic health information and services needed to make appropriate health decisions.” Read More

A Health Literate Organization:
• Promotes leadership
• Plans, evaluates, improves
• Prepares workforce
• Includes consumers
• Communicates effectively
• Ensures easy access
• Designs easy-to-use material
• Explains coverage, costs
• Focuses on groups-at-risk
Brach, C. et al (2012 Jun). Ten Attributes of Health Literate
Health Care Organizations, IOM Discussion Paper

While this would require a huge investment of time , talent and resources on the part of current health care systems, it would also accomplish the goal of enlisting, engaging and empowering communities, leading to social justice, policy change and a vast improvement in public health.

There…I now have a few more pearls on my string.  While I may not add this issue to the mantle of my mission and message, I have a clearer understanding of the big picture and will continue to strive to respectfully listen when people share their stories.

Thank you for listening.