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February 2009 | Back to Table of Contents

Cover Story

The $64 Million Dollar Question

Given millions to improve health, how would you spend it?

Although the United States spends 50 percent more per capita on health care than any other country, our health statistics are hardly first rate. The World Health Organization ranked us 37th overall for our national health system (between Costa Rica and Slovenia) and 24th for life expectancy (between Israel and Cyprus) when it last did its comparisons in 2000.

By these measures, it would seem our large investment in medicine—our expenditures on pharmaceuticals, medical devices, research, and health care delivery—hasn’t paid off. Why might this be the case? A growing body of research suggests that health is largely the product of factors such as socioeconomic status, the environment, education, housing, and personal behavior. Spending on health care just doesn’t improve these things.

Given this line of thinking, Minnesota Medicine asked a few folks to dream a little. If they had vast sums—$64 million—to spend on improving the social and other determinants of health in Minnesota, what would they do? What would have the biggest impact on the most people? What would give the state the biggest health-related bang for all those bucks? A handful of people took us up on the challenge. Here’s what they had to say.



Invest in Good Teaching

By James F. Hart, M.D.

The greatest basketball coach of all time was John Wooden, whose UCLA teams won 10 national championships and between 1971 and 1974 won 88 straight games. It is said that on the first day of practice each season, Wooden would spend half an hour teaching his players how to put on a sock. “Wrinkles can lead to blisters,” he would warn. The huge players would sneak looks at each other and roll their eyes. Eventually, they would do it right. “Good,” he would say, “And now for the other foot.”1

This simple and perhaps humorous example may overstate the relationship, but Wooden was making the point that good performance is related to good preparation. (He also had some things to say about long hair, by the way.)
A major component of the preparation needed for good living and good health is a good education. Hence, I would argue that we ought to spend the $64 million on education (likely focusing on birth to grade 3; but I will leave it to others to debate how these resources should be distributed).

Many studies have found a strong correlation between education level and health status.2 This correlation may reflect other determinants of health that are less easily measured than education and may have a very long latency period. In other words, the correlation may well be because of the health of one’s mother during pregnancy, where one ends up living, housing quality, or income attainment. The “causative” relationships between these things and health are the subject of ongoing research. In spite of this caveat, I’d still argue that education is the most fruitful place to add resources in order to improve health.

The size of such a public health challenge should not be underestimated, given the current state of literacy in the United States. In a recent article for the World Daily News, Chris Hedges wrote: “There are over 42 million American adults, 20 percent of whom hold high school diplomas, who cannot read, as well as 50 million who read at a fourth- or fifth-grade level. Nearly a third of the nation’s population is illiterate or barely literate. And their ranks are growing by an estimated 2 million a year. But even those who are supposedly literate retreat in huge numbers into an image-based existence. A third of high school graduates, along with 42 percent of college graduates, never read a book after they finish school. Eighty percent of the families in the United States last year did not buy a book.”3

We can assume that this lack of literacy and intellectual curiosity will likely have profound effects on the health status of our society. The Harvard Center on the Developing Child puts it this way, “Early experiences determine whether a child’s brain architecture will provide a strong or weak foundation for all future learning, behavior, and health.”4 So, it seems prudent to put the hypothetical resources into the development of our young peoples’ brains.

We need to enhance the ability of parents, child care providers, early childhood educators, and other community members to interact positively with young children in stable and stimulating environments so that they can build a sturdy foundation for later school achievement, economic productivity, and responsible citizenship. To do that, we need to spend more money on such things as improving teacher salaries and reducing class sizes.

Wouldn’t it be nice if all of our teachers could feel as if they were not only preventing blisters on feet but putting new wrinkles on brains and helping create health? And that their work was leading to “national championships” of one kind or another? That is not too much to ask, and I bet Coach Wooden would agree.

James Hart is director of the executive program in public health practice and an assistant professor in the University of Minnesota School of Public Health.
1. Wooden J. Wooden: A Lifetime of Observations and Reflections On and Off the Court. Chicago: Contemporary Books, 1997.
2. Evans R. Why Are Some People Healthy and Others Not? New York: Aldine De Gruyter, 1994, p.84.
3. Hedges C. “America the Illiterate,” World News Daily, November 19, 2008.
4. Harvard University Center on the Developing Child. Available at: Accessed January 5, 2009.



Build Social Capital

By Sanne Magnan, M.D.

I am a strong believer in the social determinants of health. Our state’s recent decline in America’s Health Rankings points directly to the importance of “upstream” factors. Although we were still ranked the fourth healthiest state in the nation, it was not as high as we have come to expect—and that indicates that we face some challenges. To make substantive, lasting improvements to the health of our population, we must improve education, create well-paying jobs, increase the supply of affordable housing, ensure access to preventive health care, and address other determinants.

But is it all about the money? As I consider this $64 million question, I am also looking at Minnesota’s state budget deficit of nearly $5 billion for the coming biennium. As tantalizing as the idea of having $64 million to spend on health care may be, I have to wonder if monetary capital is the only solution. Whether our funds are finite or seemingly limitless, we still need to prioritize our efforts to make the biggest difference in health. And I believe that an important factor that is often overlooked and underappreciated is social capital.

Not long ago, a public health nurse in northwestern Minnesota who had just finished emergency preparedness training said something I found interesting. “Commissioner,” she said, “I now know the fire chief, and he knows me. I now know the school board chair, and she knows me. These are new relationships. And with these relationships, we can solve lots of problems.”

What that nurse was talking about is social capital, the crucial interconnectedness between individuals and groups of people. Her comments strike a chord with me and reflect the message of a book that has influenced my thinking, Robert Putnam’s Bowling Alone: The Collapse and Revival of American Community. A Harvard public policy professor, Putnam argues that our social connections with each other create far-reaching benefits that include a sense of belonging, trust, reciprocity, and commitment to our communities. Two kinds of social capital are important: social bonding within similar groups and social bridging between diverse groups. Putnam argues that the current decline in our social networks adversely affects our safety, productivity, prosperity, happiness, democracy—and even our health. He cites a number of studies that have linked lower death rates with joining volunteer organizations, taking part in cultural events, attending church, calling and visiting friends and relatives, and taking part in other social activities. In fact, he notes that a person who belongs to no groups but decides to join one actually cuts in half his or her risk of dying in the next year.

Whether we’re dealing with a $64 million windfall or the constraints of our current state budget, improvements in the determinants of health can be magnified through our connections with others. How can we build much-needed social capital?

One way is by increasing informal social ties. Involving diverse groups of citizens in developing a plan to prevent obesity in the community can help stem the tide of preventable chronic disease and, at the same time, build new relationships. Walking groups are an effective way of both increasing physical activity and building social relationships. For millions of people, social networking websites such as Facebook have redefined community. Can we use social networks to reduce tobacco use or increase high school graduation rates?

Another way to build social capital is by encouraging political and civic involvement. We must engage our citizens in the process of building and uniting our neighborhoods. Consider Minnesota’s participation in National Night Out each year. It brings together neighbors so they can get to know each other, which fights crime and promotes safety. Can we develop a similar method of engagement for community health?

As part of Minnesota’s 2008 health care reform legislation, we are developing health care homes. We should think creatively about how these homes can reach beyond clinic walls to build community and improve public health. Recently, a family physician said the concept of health care homes may be too limiting. He wondered if we could instead create “health homes” in the community that would engage patients differently. For example, can we build intergenerational communities where citizens care for one another? Can we highlight the social connections that are good for people’s health—and that transcend the latest medicine, test, or procedure?

A third way to increase social capital is by building understanding and trust. We must look for ways to include varied perspectives as we address the social determinants of health. Our work must span multiple generations, ethnic and racial groups, geographic areas, and socioeconomic groups. For example, as we strive to eliminate health disparities among racial and ethnic groups, we must work across populations to increase understanding among diverse groups of people. By building understanding, we can cultivate trust, and trust is essential to solving some of our most vexing problems.

Regardless of our budget situation, we can build informal social ties, engage people in social and civic activities, and cultivate understanding and trust in order to create a sense of belonging and a feeling of community. As the nurse in northwestern Minnesota discovered, having relationships to draw from bolsters our ability to tackle problems of all sorts. Building social capital, I argue, will make Minnesota—and Minnesotans—healthier.

Sanne Magnan is commissioner of health for the state of Minnesota.



Protect First Environments

By David Wallinga, M.D., and Lindsay Dahl

For at least 15 years, we have known that many adult chronic diseases originate in a child’s early environments. Ever-stronger science now supports this notion, known as the Barker hypothesis, across a range of diseases, from cancer to cardiovascular disease to infertility to obesity. Developing cancer in adulthood following fetal exposure to the synthetic estrogen diethylstilbesterol is just one example.

It is clear that children’s early chemical environments, whether they include the presence of health-promoting nutrients or health-detracting pollutants, are critical determinants of long-term health. The elegantly sequenced ballet we call child development is going full tilt in the womb across a number of different organ systems including the endocrine, immune, cardiovascular, and neurological systems. Often, hormones produced by the body are the choreographers of this dance. Anything that disturbs their action and blocks or diverts early development can potentially alter organ function during adulthood.

Because organ development doesn’t stop at birth, the early postnatal environment is also important in determining whether a child will reach her full potential later in life. We know that breast milk—a child’s first food—offers a multitude of benefits for babies, including the potential for a healthier immune system and an enhanced IQ. More than 80,000 largely untested and unregulated industrial chemicals are used by industry; many are made into consumer products. These chemicals make their way to places they shouldn’t, such as breast milk. We know that dozens of pesticides, industrial pollutants, and other chemicals that are believed to disrupt hormone signaling are added to children’s products. Bisphenol A (BPA), for example, is a chemical estrogen commonly used in plastic baby bottles, sippy cups, and infant formula cans. An impressive body of science now links early exposure to BPA with adverse effects on development.

Bisphenol A is a “poster chemical” for a much larger problem, however. Unfortunately, our society has done little to ensure that mothers’ wombs and milk are protected from such contaminants so that children can be launched on a path to life-long health. Protecting these “first environments” through public policy as well as through personal choices should be a top priority for us as clinicians. By doing so, we help prevent expensive chronic diseases even before they are programmed into our children.

If we had $64 million to spend on initiatives that would preserve these first environments, we would do three things. First, we would implement a system within the state’s Pollution Control Agency to ensure that chemicals used in children’s products would be safe and tested before they end up on the market. This is beginning to happen already in Maine, California, and several other states. Second, we would spend $20 million on a new green chemistry institute at the University of Minnesota. Green chemistry is the science behind developing safer, less-toxic chemicals and finding ways to use them in everyday products. Since green chemistry principles include reducing pollution, waste, and energy consumption, such an institute would help make Minnesota’s industries more efficient, while better positioning them to compete in an increasingly polluted, climate-challenged global economy. Finally, we would make it a priority for this new institute to assess the feasibility of creating safe biomaterials from renewable feedstocks such as soybeans or sugar beets. Sustainable biomaterials have the potential to be a win-win-win for farmers, rural communities, and concerned consumers.

As physicians, we know prevention works. We are still tallying the hundreds of billions of dollars in economic benefits “earned” by taking lead out of gasoline and, thus, making subsequent generations of children smarter and more productive. What we need now is an approach to stop putting many other untested, unproven industrial chemicals into products before they, too, can affect entire generations.

Left unchecked, the ongoing rise in chronic disease threatens to bankrupt our nation’s health care system. The evidence tells us that preventing our earliest exposures to industrial chemicals is one step toward preventing disease long before it manifests. What smarter, more cost-effective public investment could there be?

David Wallinga is director of the food and health program at the Institute for Agriculture and Trade Policy. Lindsay Dahl is coordinator of Healthy Legacy, a Minnesota coalition that promotes healthy living by supporting the production and use of everyday products made without toxic chemicals.



Improve Education

By Michel Boudreaux, Annie Mach, Nathan Hunkins, Juliet Massie, and Donna McAlpine, Ph.D.

As public health students, our goal is to understand and improve the health of the population. Our job is to look beyond the health of the individual and consider the broader community. And our challenge is to balance ideal programs with the reality of limited budgets. Given the opportunity to dream without the usual worries about funding, we decided it was worthwhile to look closely at a basic determinant of health and well-being—education.

Education and health are intertwined.1-3 Americans with the least amount of schooling are more likely than those who have more education to have heart disease, heart attacks, and diabetes and experience feelings of anxiety or depression.4 Recent gains in life expectancy are concentrated among the well-educated, and, on average, people without a high school education die seven years earlier than their more educated peers.5

Similar patterns can be seen in Minnesota. Residents with less than a high school education are nearly five times more likely to report fair or poor health than those who have a bachelor’s degree.6 Not only does education affect the health of individuals, it also affects their children. Minnesota infants born to mothers with less than 12 years of schooling die at twice the rate as babies born to mothers with at least 16 years of education.7

The reasons why education is important to health are complex and cannot be fully explained by the fact that people who are ill are less likely to complete their education. Instead, it is important to look at the opportunities and resources that come with education.1-3 Education brings the chance for a better job, more money, access to health care, a less stressful life, and a greater sense of control over one’s destiny—all of which are important determinants of health.

Given the strong connection between education and health, we believe the $64 million would best be spent on education. We could start by helping all Minnesotans graduate from high school. Although Minnesota has one of the best graduation rates in the country, that number doesn’t tell the whole story. The dropout rate for black students is three times higher than that for non-Hispanic white students. Among American Indian students, the rate is four times higher, and for Hispanic students, it is almost five times higher than it is for white students.8 These disparities in high school graduation rates mirror disparities in health: Infant mortality for black and Hispanic Minnesotans is significantly higher than it is for whites; nonwhites have higher rates of cancer and diabetes; and nonwhites are more likely to report poor health.9

Increasing graduation rates is not easy. In order to make it happen, we need to start by emphasizing the importance of education early. Children who attend high-quality early childhood education programs perform better academically, have higher high school graduation rates, and are more likely to attend college than children who do not.10-11 Long-term follow-up of kids who were enrolled in early education programs shows that attending preschool may reduce the high school drop out rate by as much as 50 percent.11

Minnesota can do more to improve access to early childhood education and, thus, increase the likelihood of high school graduation. The state ranks 37th in access to early childhood education for 4-year- olds and 19th in access for 3-year-olds. State spending on early childhood education per student has decreased in recent years.12 At the same time, the state’s public education system is spending nearly $113 million annually because children enter school unprepared.13 We propose hiring and training high-quality teachers and working with school districts to guarantee that every child benefits from classrooms that have small teacher-student ratios. We could look at model early childhood education programs from states such as Georgia, then tailor our efforts to meet local needs, emphasizing comprehensive services, small classrooms, well-trained teachers, and support for families.

Would Minnesotans live longer, healthier lives if everyone graduated from high school or participated in post-secondary education? In short, yes. Investing in education, starting in early childhood, makes achieving these goals more likely. When asked to dream, we see a more educated Minnesota in which educational attainment is not determined by the lottery of life but is expected of every resident. Good health is sure to follow.

Michel Boudreaux, Annie Mach, Nathan Hunkins, and Juliet Massie are students in the University of Minnesota’s School of Public Health. They wrote this piece with the support of Donna McAlpine, Ph.D., associate professor of health policy management at the University of Minnesota.
1. Cutler DM, Lleras-Muney A. Education and health: evaluating theories and evidence. Working Paper 12352. National Bureau of Economic Research. Available at: Accessed January 15, 2009.
2. Ross CE, Mirowsky J. Refining the association between education and health: the effects of quantity, credential, and selectivity. Demography. 1999; 36(4):445-60.
3. Low DM, Low BJ, Baumler ER, Huynh PT. Can education policy be health policy? Implications of research on the social determinants of health. J Health Polit Policy Law. 2005:30(6):1131-62.
4. National Center for Health Statistics. National Health Interview Survey, 2007 National Center for Health Statistics, Centers for Disease Control and Prevention, Hyattsville, Maryland. 2008. Available at: Accessed January 15, 2009.
5. Meara ER, Richards S, Cutler DM. The gap gets bigger: changes in mortality and life expectancy, by education, 1981-2000. Health Aff. 2008:27(2):350-60.
6. U.S. Census Bureau Current Population Survey, Annual Social and Economic Supplement. Available at: Accessed January 15, 2009.
7. Robert Wood Johnson Foundation: Commission to Build a Healthier America. Unrealized health potential: a snapshot of Minnesota. Accessed at Available at: Accessed January 15, 2009.
8. Minnesota Department of Education.Dropout Prevention, Retention, and Graduation Initiative. Available at: Accessed January 15, 2009..
9. Henry J. Kaiser Family Foundation. Health Status—Minnesota. Available at: Accessed January 15, 2009.
10. Gorey,K M. Early childhood education: A meta-analytic affirmation of the short- and long-term benefits of educational opportunity. School Psychol Quarterly. 2001:16(1);9-30.
11. Karoly LA,Kilburn RM, Cannon JS. Early Childhood Interventions: Proven Results, Future Promise. RAND Corporation. 2005. Available at Accessed January 15, 2009.
12. National Institute for Early Education Research. The State of Preschool 2007. Available at: Accessed January 15, 2009.
13. Wilder Research Institute. The cost burden to Minnesota K-12 when children are unprepared for kindergarden. Available Accessed January 15, 2009.



Emphasize the Early Years

By Arthur Rolnick and Rob Grunewald

Our past research has made the case that tax dollars spent on early childhood development for at-risk children yield extraordinary economic returns.1 Indeed, those returns accrue at an annual rate of between 7 percent and 18 percent, adjusted for inflation. Some of the benefits are private gains for individuals in the form of higher wages later in life; but most are benefits to society. At-risk children who participate in high-quality early childhood development programs are more likely to grow into adults with greater skills than they otherwise would have. These children are less disruptive in the classroom, less likely to spend time in jail or need social services later in life, and better able to contribute to their local economies. With the benefit of prenatal mentoring for their mothers, many of these children are more likely to be born at a healthy birth weight and are consequently healthier and in need of less medical attention.

Clearly, early childhood education has holistic benefits for society. However, the challenge to receiving high rates of return is to identify those families in greatest need and to provide high-quality programs for their children. So what would we do with $64 million? We would establish programs that connect nurse-mentors with at-risk mothers during pregnancy and continue those relationships through infancy. Then, when those children turn 3, we would grant them scholarships to attend high-quality early childhood education programs.

The premise for such a plan is based on fundamental facts about early human development. A child’s quality of life and the contributions that child makes to society as an adult can be traced to the first years of life. From birth until about age 5, a child undergoes tremendous development. If this period of life includes support for development of language, motor skills, adaptive abilities, and social-emotional functioning, the child is more likely to succeed in school and later contribute to society. Conversely, without support during the early years, a child is more likely to drop out of school, rely on social services, and commit crime—thereby imposing significant burdens on society. Long-term costs to society also include health outcomes. Research shows a direct relationship between adults who reported adverse experiences during childhood and their odds of suffering from alcoholism, depression, and heart disease later in life.

Investment in early childhood development has the potential to promote healthy development from the earliest years. Long-term studies have shown that children from disadvantaged environments who participated in a nurse home-visiting program or a high-quality early childhood development program are more likely to perform well in school and earn more in the workforce, and are less likely to commit crime, compared with children living in similar situations who didn’t participate in such programs.

These findings, promising though they are, pose a challenge: Small-scale early childhood development programs have been shown to work; but can their success be replicated on a much larger scale? Large-scale efforts would need the flexibility, innovation, and incentives that are inherent in the marketplace; they would also require the long-term assurance and stability that government backing provides.

To establish a successful, large-scale early childhood development program, we propose establishing a permanent scholarship fund for all families with at-risk children. The scholarships would cover tuition for children to attend qualified programs plus the cost of mentoring parents. Scholarships would be outcome-based, meaning that they would include incentives for achieving significant progress toward developing the skills needed to succeed in school. Parent mentoring would start before the birth of the child and include counseling on health and parenting; information about financial, health, and human services resources available to them; and guidance on selecting an early childhood development program.

An innovative model that combines home visits that start before a child’s birth and scholarships for 3- and 4-year-olds is currently underway in two poor St. Paul neighborhoods. A four-year pilot began in January 2008 with funding from the Minnesota Early Learning Foundation. The scholarships provide up to $13,000 a year to pay for two years in a full- or part-time early childhood development program. A parent mentor conducts home visits providing families with information about available early childhood development programs and helping connect them with other community resources.

Although the success of this pilot is just starting to be evaluated, early signs show that it is a relatively efficient way to provide early childhood resources to families who need them the most. Furthermore, the model combines the best health and education resources in the area—well-trained parent mentors and high-quality early childhood development programs. In our opinion, a $64 million investment in an early childhood scholarship and parent mentoring program would achieve a high rate of return for the public and make Minnesota a safer, healthier, and more productive place to live.

Arthur Rolnick is a senior vice president and the director of research at the Federal Reserve Bank of Minneapolis, where Rob Grunewald is an associate economist. The views expressed are the authors and not those of the Federal Reserve.
1. Rolnick AJ, Grunewald R. A proposal for achieving high returns on early childhood development. Working paper, Federal Reserve Bank of Minneapolis, March, 2006. Available at: Accessed January 19, 2009.



Build Places to Call Home

By John Song, M.D.

We thought we would help people like Thomas when we opened the Phillips Neighborhood Clinic, a student-run, volunteer clinic in Minneapolis whose mission is to provide accessible and culturally appropriate health care to persons who are homeless, underinsured, or disenfranchised from the health care system. Thomas was suffering from severe lower extremity cellulitis, could barely walk, and was in need of antibiotics, pain medications, and a stool softener. Those we could easily provide. But, as we sent Thomas into the night, knowing he would spend it under a bridge, we all thought the same thing: What Thomas really needed to get healthy was a roof over his head.

So if I had $64 million to better the health of Minnesotans, I wouldn’t spend the money on health insurance or hospital beds. I’d spend it on homes.

Why, as a physician, would I spend the money on homes? Because the patient I just discharged with orders for bedrest will have one to recover in. Where does the homeless individual go to rehabilitate after surgery or gain strength after an asthma exacerbation?

Why homes instead of free medications? Because my patient with cirrhosis will have a bathroom to facilitate his lactulose use. Not having refrigeration, power, a bed on which to elevate one’s legs, a place to store medications and the equipment needed to administer them, or access to water and food (when a drug needs to be taken on a full stomach) make it difficult for homeless patients to adhere to treatment recommendations.

Why homes instead of free medical clinics? Because my patients with chronic medical conditions can spend their time and energy working with health care providers rather than looking for a place to spend the night. One study found that homeless persons with subsistence needs such as food and shelter were much more likely than others to forego needed medical care.1 If a homeless patient is late for his appointment, have sympathy. Perhaps he was waiting for a meal, meeting with his case manager, or scrounging money for the bus ride to the clinic.

Why homes instead of more insurance coverage? Because emergency shelters are often cold, confined, and poorly ventilated. They put residents at risk for violence and infectious diseases such as tuberculosis. And because homelessness itself is a risk factor for poor health. In one large study, homeless persons were far more likely to report poor health than individuals living in poverty who had homes. And, of course, both groups had far poorer health indices than the U.S. population in general.2

Why spend the money on homes? Because I have been fortunate to know the emotional and physical comfort of having one. I have known my home as my refuge, my place of safety, my kingdom. Everyone deserves to know the same.

But these are desperate times, and it feels wrong to dream without acknowledging our fiscal crisis. Which is why I feel even stronger about spending money to house individuals for their health. Homelessness is expensive. It adds to the cost of health care. In a study published in the New England Journal of Medicine, Salit and colleagues found that homeless patients stayed 4.1 days, or 36 percent, longer per hospital admission on average than other patients, even after adjustments were made for clinical and demographic characteristics.3 The average cost of transitional housing services for a family in Hennepin County is around $4,000; these services are about 93% effective in keeping families off the street. In Dakota County, officials estimate it costs about $1,600 to prevent an episode of homelessness. Not only will spending money on efforts to house people make our community healthier, it also makes fiscal sense.

John Song is an assistant professor of medicine and in the Center for Bioethics at the University of Minnesota. He founded the student-run Phillips Neighborhood Clinic.
1. Gelberg L, Gallagher TC, Andersen RM, Koegel P. Competing priorities as a barrier to medical care among homeless adults in Los Angeles. Am J Publ Health. 1997;87(2):217-20.
2. Gallagher TC, Andersen RM, Koegel P, Gelberg L. Determinants of regular source of care among homeless adults in Los Angeles. Med Care. 1997;35(8):
3. Salit SA, Kuhn EM, Hartz AJ, Vu JM, Mosso AL. Hospitalization costs associated with homelessness in New York City. N Engl J Med. 1998;338(24):1734-40.



Design Healthier Neighborhoods

By Carissa Schively Slotterback, Kevin Krizek, and Ann Forsyth

There is growing public interest in the link between the way towns and cities are built and human health. Citizens, elected officials, and health professionals are starting to ask questions: What role can parks and trails play in promoting physical activity? How much pollution is being emitted from cars? How are specific land uses affecting our air quality? How can community design contribute to mental health and social capital?

Local governments have the greatest say in how we use land, how we get around, and how and where we live. From creating options for physical activity, increasing public safety, providing safe routes to schools, dealing with poor air quality, and ensuring access to grocery stores that offer healthful foods, there are many ways they can keep an eye on health when planning developments and allocating public resources.

Educating local governments about the influence of community design on health is one way we would spend some of the $64 million. Local governments are often challenged by political and economic incentives that encourage them to plan shorter-term and piecemeal initiatives rather than think about the design of their community in more comprehensive, long-term ways. Educating government leaders about health policies and at the same time teaching health professionals about community planning could go a long way toward promoting healthier environments and people.

We need to help governments make the ideological and practical changes necessary to consider health in local planning. For example, we should give local governments proven, evidence-based tools such as model ordinances and plan language, mapping resources, and systems for collecting and analyzing health information that can be tailored to their communities.

Until recently, the state of Minnesota provided significant technical assistance to local governments with urban planning issues. Renewing this technical assistance program would be another important investment. The program could provide training to planners and elected officials about the connection between health and urban planning, help them collect and distribute data related to the health of local populations, provide them with language and graphics that could be integrated into local plans and ordinances, and even offer grants to help communities address these issues. A technical assistance provider might also help communities document how their local plans and policies improve health. Effective approaches could serve as examples for other communities in Minnesota and the United States. Finally, technical assistance might also foster collaboration among city planners, parks and recreation staff, public safety personnel, public health experts, local business owners, elected officials, and transportation advocates. Having these parties meet, learn about each others’ fields, and collaborate across jurisdictional and professional boundaries would move us toward designing communities that promote the health of their residents.

The health outcomes of this approach may be more difficult to measure than efforts such as mass vaccinations, providing universal access to health insurance, and anti-smoking campaigns; but this approach can, over many decades, foster health for everyone—from children to seniors.

Carissa Schively Slotterback is an assistant professor of urban and regional planning at the Humphrey Institute of Public Affairs at the University of Minnesota, Kevin Krizek is an associate professor of planning, design, and civil engineering at the University of Colorado, and Ann Forsyth is a professor of city and regional planning at Cornell University. The authors are collaborators on the Design for Health project, which bridges the gap between the emerging research base on community design and healthy living and the everyday realities of local government planning.



Wire the World

By Ashok M. Patel, M.D.

Physicians have a professional and moral responsibility to care for the sick, to prevent suffering, and to promote well-being. We also have a social responsibility to take action against poverty because it can lead to ill health. Poverty and social inequalities may be the most important determinants of poor health worldwide.1 Studies have clearly demonstrated that reducing poverty can improve health for people across the socioeconomic spectrum.2

Although it cannot eliminate or reduce poverty, health information technology (HIT) has the potential to mitigate its effect on health. It can help identify patients who are at risk for disease and illness and help them get the preventive care they need, it can bring specialty health care to underserved communities, and it can connect physicians with expertise to which they might not otherwise have access.

Thus, as my answer to the $64 million question, I’m advocating for sufficient investments in HIT infrastructure and networking tools to deliver health care to the poor that is preventive, efficient, and based on best practices and to educate them about issues related to their health. I’d like to see systems that optimize, automate, and simplify clinical approaches and extend the reach of experts so that it is feasible for Minnesotans in all socioeconomic classes to receive high-quality health care.

My first priority would be to support clinics and hospitals that serve poor patients and emphasize preventive services in their efforts to acquire networked electronic health records. One example of an organization already doing this is the Northern Minnesota Network. The network consists of primary care clinics that serve migrant and seasonal farm workers as well as uninsured and underinsured residents of rural Minnesota and eastern North Dakota. Using federal grant money, the network is establishing an electronic health record system that will allow providers at community and migrant health clinics timely access to patient information. The initiative will also allow them to track and manage the health information of patients who move around the state and aren’t consistently seen in one clinic.

Another important area for investment is telehealth technology, which connects doctors in one location with patients in another. Telehealth technology is especially useful for bringing specialty and mental health care to people in underserved and remote parts of the state. The Minnesota Telehealth Network, for example, has used telemedicine technology to bring psychiatry, cardiology, dermatology, endocrinology, gastroenterology, neurology, urology, and other specialty services and consultations to residents of 27 counties in northern Minnesota.

We also need to invest in the infrastructure for and promote technologies that facilitate the sharing of information among physicians.3 Internet-based social networking sites are a low-cost way for physicians who are treating patients in underserved areas to interact with experts elsewhere in the state and nation in order to get help diagnosing and treating unusual cases and keep up with the latest research and evidence-based practices.

Finally, we need to invest in technologies that lead to better overall connectedness so that we can improve our communication during emergencies by using cell phones to deliver alerts and public health advisories, and provide centralized data and outcomes surveillance for critical conditions and threats.

At the individual level, HIT could enable more comprehensive management of all relevant medical information, making it easier for physicians and health care safety-net organizations to keep track of patients’ health records and keep them up to date on important preventive care, which is often missing in the lives of poor people who may not see their doctor for annual check ups or who may move often. At a societal level, interoperable HIT will improve individual patient outcomes by connecting providers and researchers who may live and work in different parts of the country—or the world—in order to learn from each other. The challenge is getting us to think creatively and collaboratively about how we can use HIT to get the best information or support to the right person at the right time and in just the right amount in order to have the best outcomes.

I believe that by using HIT to help us create an ever-more connected, motivated, and knowledgeable global village, we can have a profound influence on the health of the people who live in it.

Ashok Patel is a consultant in the Division of Pulmonary and Critical Care Medicine at Mayo Clinic.
Dr. Nina Schwenk, Shyamala Bhat, Dr. Lou Yaniw, Mahesh Lad, and Anjana Sharma assisted with this article.
1. McCally M, Haines A, Fein O, et al. Poverty and ill-health: Physicians can, and should make a difference. Ann Intern Med. 1998; 129: 726-33.
2. Metzler M. Social determinants of health: what, how, why, and now. Prev Chronic Dis. 2007; 4(4). Available at: Accessed January 20, 2009.
3. Minnesota e-Health Initiative. Minnesota Department of Health. Available at Accessed January 20, 2009.

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