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This podcast is presented by the Centers for Disease Control and Prevention. CDC – safer, healthier people.

I want to thank you very much. I want to thank the CDC Foundation for all the changes that have occurred here and their investment in this lecture series, as well. I don't think people realize how lucky you are to have a CDC Foundation and all that it has done for the Centers for Disease Control. It is an honor to be here. I'm really, really nervous. So you'll have to excuse me, because the more I talk, the more relaxed I'll become. I'm extremely excited, though, about King County's own Equity and Social Justice Initiative. And we have been very heartened by our response. But it's also very difficult, because what happened in our county is, we just assumed that all was well. We were the magical county. All things were working.

And let me tell you the genesis of it—the genesis was that I was back in Washington, D.C., and my family was with me, and I asked my sons to go to a press conference that I couldn't attend. And it was put on by the Joint Center. And the Joint Center is an African-American think tank there, and they produced a report called the Dellums Report. And I told my kids, as always, when you go to any place, take as much paper as you can, and bring it back, because it makes good reading, good education, and if you dwell on it, you can have new ideas. And the report basically said, here's what's happened to African-American males in particular, across the country. Very dire and disturbing report. And my sons said, "That couldn't be happening in Seattle.” So I simply said, "Okay.”

So I tasked my staff—at King County, we have over 13,000 employees, and our budget is $4.9 billion annually. And so I took our core staff and said, "I want you to tell me, statistically, what is happening to people of color and people who are immigrants and people who are poor in our county.” And after 18 months, they came back with that report. That was very sobering for everyone, for we realized that there are two counties in King County. There are those who have and will continue to enjoy. Then there are those individuals in our county who, we believe at this moment, when they say they have no hope, they can rightfully say they have no hope. The barriers are so terrific, so extensive, and so put in motion that it will require a deliberate action by the public, by the business community, the nonprofit community, and government, to provide just the doorways of opportunity. And our report deals with every facet of our government, and those facets we can't control. We're the regional government, responsible for the planning of the county, the transportation system, the waste water systems, the park systems, public health systems, jails, courts, just, you know, entire range of social services. Well, we can control those and we can influence those, but we can influence schools, but you cannot talk about disparities and health disparities without talking about schools. You cannot talk about that, when you talk about job training. You can't talk about that and talk about business promotion.

What we simply said is, our report will affect those things we can control, but that we're going to use the bully pulpit of our government being the largest government to say we have to head in another direction. It was a sobering report. Somebody said, "Wow, you just opened the doors, you know, your dirty linen.” And we said, "No, this isn't dirty linen, this is human beings.” These are the people that I grew up with in my community, and we're simply saying that it is time in our county, in the 21st century, to make a change, to move boldly in another direction, because in this most competitive century in the history of humankind, there will be winners and losers, and the extent to which people embrace social equity in all of its forms and we end the fact that race is a factor, and we remove the barriers that have so affected people of color for so very long, those communities will win. Those communities that do not move forward will lose in a century that's going to be without mercy. Global economic activity alone will simply say that a person in Shanghai will not care what happens in King County. They'll tell those companies, "Move to Shanghai.” That's what we're faced with. The new global world. As a politician, though, I am sure you can imagine I usually start my talks by turning down the lights and showing a PowerPoint of slides full of data. But my crack staff has informed me that that particular style of presentation would be highly unusual at the CDC. [Laughter] So instead, I will do something not common for me, and I'll just give a speech, so please bear with me. I'm an admirer of public health and its significant accomplishments—in particular, in the 20th century. Two of my favorite, which you talk about in your famous MMWR top ten accomplishments, are immunizations and the decline of tobacco use. Through multi-pronged strategies, immunization rates have improved across wide sectors of our society. Technological innovation, public health practice, and political will have combined to achieve extraordinary results, including drastic reductions in deaths due to infectious diseases, nationality, and the eradication of smallpox globally. Tobacco use is a similar success story, where taxation, smoke-free policies, labeling in packaging, treatment education campaigns, and even public interest litigation have resulted in dramatic drops in the rates and huge gains in health.

Today, in the 21st century, however, we have a shift in our preventable disease burden. Our old public health approaches are not sufficient—and have proven not to be sufficient—to address our most pressing challenge, and I am talking about inequities. In King County, we have tremendous wealth and opportunities. We have industry powerhouses, including Microsoft, the Boeing manufacturing divisions, Costco, Starbucks, amazon.com, and many others. Nevertheless, our inequities in health mirror national and global trends. Today in King County, our leading actual causes of death are tobacco use and obesity. And they've also become the leading causes of what we call inequity-related deaths. For tobacco, an adult in our county without a high school education is almost four times more likely to smoke than a person with at least a college education. With obesity, we recently collab-- I have braces, and I'm trying to talk around my braces—collaborated with the University of Washington on a zip code study, and we found that the single best predictor of BMI was neighborhood assessed property values. The lower the assessed property value, the higher the rate of obesity. Obesity rates reached 30% in most of the deprived areas but were only 5 percent in the most affluent zip codes in our county.

These disparities are repeated for infant mortality, mortality from violence, HIV/AIDS, and chronic diseases. In fact, we see them for almost every single risk factor. So even in my county, which is relatively well off, the eighth wealthiest in the country—and we had to back out all the billionaires, so as not to throw off our data because there were so many of them—but there were 67,000 households whose cash value was $1 million or more. It is a wealthy county, a county of "haves,” for the most part. But even in that county, which is well off, the color of your skin or your home address are good predictors of whether you will have a low-birth-weight baby, suffer from asthma, or die from diabetes—essentially, how healthy you are and how long you live is still determined by wealth and by color. Your skin color, income, educational level, and home address are also very good predictors of many other important non-health outcomes, such as whether your children live in a single-parent household, are homeless, or end up in jail. Though we have made enormous strides as a society and we have success stories in public health and general well-being in my county, like the rest of the United States, we have two groups of people—those with opportunities, who are briskly climbing up the ladder, and those who are not.

We are paying a price, both in human terms and financially, for those trends. We are spending a significant amount of money in King County, 71 percent of what we call our current expense budget, which is about $600 million, is spent on criminal justice services: jails, courts, prosecutors, and police. In other areas of our budget, we are in large part filling holes, whether it's in the areas of mental health, homelessness, or other crisis services. In my county, 17 percent of our local tax dollars goes to health and human services, which mainly consist of service delivery and treatment of our poorest communities. Sure, we are instituting some creative ways to control our costs in our region, such as with the Puget Sound Health Alliance and the Children's Health Initiative, both of which I launched to improve access and quality of health care for the region. But we can only do so much to control costs when so much money goes to stopping the bleeding and finances the services of those in dire straits. We all absorb the cost when a significant portion of our population is faced with high rates of disease and lack access to health insurance. We all experience the economic results when our workforce is not as productive as it might be. And it's particularly in an increasingly competitive world. We all share in the lost productivity and economic expense associated with criminal justice and other crisis services. And these factors are linked—income, education, race, and neighborhood on the one hand, and health and many other quality-of-life outcomes on the other. Why are income, education, and neighborhood determinants of not only your health, but also numerous other outcomes? What drives them?

We must recognize that a person's health and well-being are not just a product of individual characteristics—genetics, age, and gender—but also of underlying root causes that are determinants of health. Determinants like income and other forms of wealth, employment, affordable and quality housing, transportation, quality education, safe neighborhoods, and social networks—all of those determine health outcomes, every single one of them.

So I'll give you a consequence. African Americans in my community with a college degree will make 2/3 of the income of a white person with the same degree. But what do you do when you have escalating housing prices? One group is priced into their house, and the other one is priced out of their house. Yet we know affordability and housing is very, very important in terms of health outcomes. My parents were renters, I remember, for so long. Their first house—1218 E. 5th Avenue, Spokane, Washington 99202. Area code 509-536-- 535-3601. That was a small, teeny house, but it was my first house my parents every bought. They lived there for the rest of their life. And the amazing thing about that house—it was teeny! I mean, I don't know how five people lived into that house. It'll be the mansion of my life. It was the first time I had permanence, belonged to a community and had stability. We gave out—my parents moved to that house July 12th of—my birthday was July 5th—we passed out birthday cards for the upcoming year, because we could, for the first time. So, when people tell me, "Is housing important?” the answer is, housing is absolutely important. It is a stability factor.

There are so many things that impact health care. We need to focus on people and people's needs. We need to know what people want and we've got to focus on individuals and tackle those things that are barriers, I believe, to health and stability and in communities. Our initiative in King County touches every single facet, and I tell people I am not an African American—I am not a County Executive who happens to be African American. I am a Black County Executive. I grew up in an African-American neighborhood, in an African-American family, going to African-American churches, but I'm the best County Executive they will ever have. Because the key is to create structures that address what I grew up and saw. I can remember—and I always tell people, Mrs. Maxim, Mrs. Curtley in County Baptist Church, singing a song that was pretty extraordinary. The lyrics were so powerful. When things got really tough, really tough, they'd get up in those a cappella voices, and the lyrics, I can still remember them. Still remember them, so powerful. "I am no ways tired. I've come too far from where I started from.” "Nobody told me that the road would be easy. But I don't believe He brought me this far to leave me.”

And I tell my staff, you don't come into public service for any other purpose than to serve and to provide a quality of life that is better than the one you inherited, and to make sure that everyone achieves that extraordinary benefit. And it requires us to wrestle with things that are uncomfortable, like race—because nobody wants to talk about race. Nobody wants to talk about poverty, no one likes talking about immigration. Those are the no-nos that you set aside. But this country is the grand experiment in the world. Never before has a democracy or a nation been so conceived and become so powerful in world history like ours, and we have no common gene pool. All other countries had common gene pools. Ours did not. We all got here by boat, voluntarily or involuntary, or land bridge. We are a country that doesn't even have common customs. My wife used to say to me, "If you're --" I'm a people watcher. She'd say, "Sit at a shopping mall and see how many people wear the same kind of shoes or clothes.” And you can sit there all day long, and you realize that there's got to be a whole lot of shoes, clothes, styles, a lot. We are the world's grand experiment. When I was in the Republic of Georgia, looking as elections monitor there, I remember, you know, God, the people that they were—you know, the Abkhazians and the Ossetians and the seventeen people of the Caucasus Mountains, the Kurds, the Georgians, Armenians and Russians, who were shooting at each other all day long.

So finally, in the meeting, I said to them, "You know, you all look the same to me.” [Laughter] "You're beautiful people. Your wine drinks well, doesn't travel well. Your food is great. You know, why?” And they hearkened back to some place where they'd been fighting for 2,000 years as nomads. Differences remained. This country has been able to resolve its differences peacefully. And this country can export far more than its peace. And far more than its people living together. This country has to do something that it has been unable to do in its entire history—resolve its issues of race and inequity.

My son volunteered me to climb Mount Rainier. Mount Rainier is 14,300 feet high. When you're on top of that mountain, you're taking in 1/3 less oxygen than you're normally used to, so you're reduced to one step. I remember getting a letter from school—"Dear Mr. Sims, thank you for volunteering to be the parent chaperone on the Mount Rainier climb.” [Laughter] I said to my wife, "Look what the sadist did to me this time.” But I managed, through some apt psychological processes, to make sure that I wasn't going to climb that mountain. I was going to be the base camp cook. [Laughter] They took me—I remember, at the first parent meeting, they said, "Mr. Sims, you're on rope team number 4.” My life passed before me. I went to my doctor of 21 years, waited—unscheduled—waited until he saw me, said, "Doc, you're going to make the most important medical decision you've ever made. I want to know, are we doctor-patient, or are we Ron and Mike?” And he said, "Well, I'd hope, after 21 years, we're Ron and Mike.” I said, "Mike, I need a medical reason not to climb Mount Rainier.” He said, "Friends don't tell friends to lie.” So we had these practice sessions. Young women did not want to climb with young men. Young women said that young men were careless, not conscie-- you know, had no—they weren't conscientious, and therefore would lead us into every crevasse on the side of the mountain. Young men said that young women were too weak, and where would they go to the bathroom? And young people—they looked at me and said, "Too old.” Mount Rainier is one of those things in life that will never be captured. There are things that are presented that are designed to overwhelm us. Overwhelm us. How do you describe clouds playing hide-and-seek? Or running right at you, and right before they get to you, turning? How do you describe it? You ever see forever? From the top of a mountain, you see forever. Or on a cold night, touch the stars.

What I learned on that mountain, though, is not its immense beauty, but that everybody counts on a rope team. You're as strong as your weakest member, and you're as fast as your slowest member. I was on a rope team with three young women. They said, "Mr. Sims, are you ready?” I said, "Yes.” And they pulled me right up the mountain. And young men can handle heavier loads, and people my age know that mountains literally and figuratively in life are conquered one step at a time. Everybody counts. Our equity report in King County says everybody counts. We cannot achieve as a community if we don't remove the barriers that inhibit people of different colors to move to their fullest potential. We can't do that if we don't appreciate the value of gender. We can't do that if we don't appreciate sexual orientation. We can't do that if we don't appreciate the diversity of languages and cultures. So our report simply says that we're going to grapple with those, we're going to measure ourselves every single year in every facet of our activity, and produce a report. And that report will talk about what we have gained and what we have lost. In our own endeavors in King County, we will measure all of our operational activities and determine what we're doing wrong that reduces the ability of poor people and people of color to achieve, and those things that we're doing that we believe will elevate what people of color will be able to achieve and what poor people will be able to achieve. We're going to measure ourselves publicly and hold ourselves accountable for that performance.

We have been... I don't know if you'd call it motivated, but inspired, by the PBS series that's going to be coming out called Unnatural Causes: Are Inequalities Making Us All Sick? It has been a powerful tool—whenever we get really tired and we need to motivate ourselves, we remember what that PBS series is saying—things that we can control are making people sick. Our land-use decisions make people sick. In our county, we believe not in sprawl—we believe, in fact, in controlling growth, because it's affordable to do that, cheaper to do that. We also know through our land-use decisions that the further you have to go out to sprawl, the unhealthier you're likely to be, and who goes out there now? People who bought subprime mortgages—that's where the defaults are. Our inner cities and our exterior areas have the same phenomenon—immigrants, people of color, lack of supportive facilities, lack of parks, lack of playgrounds, lack of schools, lack of stores, lack of doctors, lack of jobs. Two different ghettoes in every single sense of the word. We believe in our county that it is important then to have density, where we can have transit services as a choice for people to take. Because we realize in our data—that our data, called HealthScape, that people who took transit were more likely to be healthy than people who didn't. We know that bike trail proximity is very, very important. Parks are very important. Services are very important—land use, education, job development—all of these are intertwined in having people be healthy.

It is not just the access to health insurance, although that is key. I am a proponent of universal health care. I want to see that happen. But it doesn't do it alone, because we would still have inequities and inequality, we would still find people dying earlier of diabetes, because it's not your health insurance that determines that, it's whether you have local stores selling fresh fruits. It's whether you have walkable communities. In an age of global warming, it doesn't always affect everybody equally. Arizona State University did a beautiful study which pointed out that what neighborhoods get hit harder in an age of global warming—we call microclimates—poorer neighborhoods. And the Phoenix community showed that. And now Mayor Daley has adopted that for Chicago, and we are adopting that same kind of model for King County. So when we talk about carbon emissions and reducing global warming—which we marry with our health issues, which we marry with our sustainability issues—we integrate all of them for the single purpose of saying that we are not going to have any community that's going to lose in the 21st century.

We're not going to have health outcomes because we ignored global warming, we're not going to have poor health outcomes because we ignored education, we're not going to have it because we ignored where we put trails and transit services. We're not going to simply have disparities; we're not going to be the problem. We expanded, through our Citizens' Initiative, taxes to provide transit services, and we targeted those neighborhoods who didn't have them. We have a place called White Center—the poorest urban area in the entire state of Washington. And I told people it was poor by design. It was, you know, I said, "We all knew White Center existed.” 173 different languages, income had not changed—income, set income had not changed since 1982. I said, "We all knew that was by design.” I said, "I grew up in a neighborhood like White Center.”

I grew up in Spokane, where if my neighborhood had fallen off the planet, they would probably have had a celebration. I didn't know I wasn't supposed to achieve, though. Great parents and some few great teachers, some high expectations. . . We went into White Center, and we made investments in transit-oriented developments, because they didn't have any transit-oriented development or adequate transit services. We put in new parks, teamed up with a major company, Starbucks, who gave us a grant to build new parks and playgrounds. The YMCA decided to move in. King County Library System decided to build a library there. We transformed the neighborhood by listening to them—just by listening. Because they talked about what they didn't have, and we talked about, "We will deliver what you always dreamed of.” And every single indicator that we wanted is beginning to change. Attendance rates, crime reductions, income, every indicator has moved in a positive direction. So what does that say about this country and about what you can do at the CDC?

I've got to say this about the CDC—CDC has name. I mean, I'm telling you, you—CDC—you got name. That's called potency. Potency! I mean, oh, my—I wish my name had the same potency as the CDC. But here's what I want the CDC to do—I want them to lead. You can't talk about health outcomes and silo the CDC and not talk to the Federal Transit Agency and the U.S. Department of Highways. They've got to be in play. You cannot talk about outcomes and not talk to HUD about how it makes its investments. I mean, the federal government is so siloed. And I want to say, you can't make silo decisions in the 21st century. They've got to come crashing down—who better than the CDC? You raise the issue of health care and talk about all the other risk factors—and there are a number of them—all those things that we end up being, causing poor determinants of health, all of them, you could change how we function in this country in terms of its investments and the strategies. The CDC needs to lead. To lead—with the cachet CDC has, lead! My goodness, lead!

And I'll tell you why. When I was in high school, I was in love every day. I tell my son, "I loved her, I loved her—turn the page—I loved her, I loved her.” I tried to—I know every Motown lyrics, and I can tell you who I tried to sing it to. [Laughter] But when I was in college, it was the first time I ever fell in love. I was walking across the football field, I saw this young lady, I said, "Ooh! This is the big one!” Right after practice, I run off the field, didn't even shower, changed clothes, ran to the dormitory to find out her name. I sat next to her for two consecutive weeks. I got her class schedule. I sat next to her for two consecutive weeks, no pencil, no paper, no books. The most incredible peripheral vision, though, known to humankind. [Laughter] So she asked me, "Are you in my class?” I turned to her and said, "No.” She took a scientific interest in me—what is this? I can remember, we moved from scientific interest to acquaintanceship to friendship, and then that first love. I smile at the first love. I know what it's like—I know what love is now—but that first one, it is sweet, innocent. It is succulent. It is... stupid, very, very stupid. Our first candlelight dinner... first candlelight dinner, I have Smokey Robinson playing on a hi-fi set. I broiled a steak. It was charcoal through and through. Had two things trying to be candles, and at the end of the dinner, she said—I was eating pound cake, my favorite cake—and she smiled at me, and I smiled at her, and she said, "I forgot the sugar in the cake.” And I said, "Hey, hey, hey, you're all the sugar I will ever, ever need.” [Laughter]

I followed her to Seattle—she to be a teacher to open up young minds, and me to be a politician that would close them right back. Timing was there—timing never was there. Passion was there, love was there, but the timing never, ever was there. I saw her after 18 years, and I said, "Whoo! You're as beautiful as the first day I saw you!” She said, "And you, Ron, you're...healthier.” [Laughter] We talked a lot about what it was like to make a difference every single day. She a teacher and then a superintendent, what it was like to make a difference every single day.

And I talked about how envious I was of making a difference when I did her eulogy one week later. For I knew the last time I saw her was going to be the last time. So you just hold hands and you talk. And she fell asleep, and I knew that I had to say goodbye, and so I said, "Ron, say it now, while she's asleep.” So I went over, and I kissed her on the cheek and told her goodbye, and I started to walk out of the room. I turned around and I stood there for an eternity. I stood there for an eternity. And then she woke out of this sleep, and she said, "You silly man, you silly man, come here, you silly, silly man.” And so I took my first step—but I coach kids, and I tell the kids I coach, "Never show emotion. Be focused to go.” And so I remember the tear coming—I said, "Ron, be strong.” And I got to her bedside, I cried like a little boy, and I will always cry like a little boy. She just held me. And then she said something I will never forget. She said, "My job is done, and my life has come to its end, but you have so much to do.”

And I would tell all of you in this room that your job is not done. A higher authority than any of you in this room has determined your job is not done. And all I'm asking the CDC to do is remember that there are disparities in this country and there are solutions to them. You can do it by changing your community guide and beginning to incorporate within that guide the broader issues of health determinants. The CDC needs to emerge as a leader, so these issues don't fester anymore. There's somebody out there who is sick, and they're waiting for you. Because your journey's not done. . . There are diabetics; there are people with undiagnosed diseases and illnesses. In our county, 28 percent of all kids on subsidized lunch have eight active, decaying teeth. They are learning in pain in second grade. So I'm just asking you to change the direction of health in this country. That's all I'm asking you to do. What—who else, other than you, who else other than you? That is your mission. That is your mandate. Shirk off all those things we've done in the past that held us back, and say, "We're going to redefine what health care is and how we measure it and who can benefit. And you're going to grab all those other people, and you're going to put them on your rope team. And we will ascend the summit of our dreams and our hopes. We will touch the stars, and we will see forever. And children will have health care, and adults will have health care. And we won't see people sentenced by our indifference to early death. We won't see people's hopes and beliefs vanquished. No, we will be the grand experiment in this world that worked mightily. King County's Equity and Social Justice Initiative is simply that—our local effort to change the world. Our local—but you... you can do so much more. So we just stand at the door... [Knocking] And we knock, hoping you will answer and invite us in to your table, and we will see a great America and a great health care system. Thank you. [Applause]

For the most accurate health information, visit www.cdc.gov or call 1-800-CDC-INFO, 24/7.