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

Well, thank you so much for that powerful talk. And we're going to now have two discussants, but before I introduce our discussants, I just want to take one moment to introduce that crack staffer who advised Mr. Sims that we don't use PowerPoint here at CDC. [Laughing] I'd like to introduce the Director of the Health Department in King County, Dr. David Fleming. David, would you stand up? [Applause] And for those of you who don't know Dr. Fleming, he is a much-beloved former Deputy Director of CDC, and we are thrilled to have you back again.

And now I'd like to introduce our two discussants this afternoon, both of whom have vast experience in dwelling on the health of our communities, on the health of our children, the health of our families, the health of our communities, whether they're in urban settings or rural settings. And I'm going to introduce both of them together. And our first discussant will be Dr. Robert Valdez. Dr. Valdez is with—a senior fellow at the Emory University Institute of Advanced Policy Solutions and an adjunct senior health scientist at Rand. He previously served as founding Dean and Professor of Health Policy and Management at the MCP Hahnemann University School of Public Health. He has vast experience in children's health and health care finance. He's been a board member and advisor to many, many community organizations, including Children Now, the Public Health Trust, the St. Francis Medical Center Foundation. And he currently serves as the Chairman of the Public Health Institute, the nation's largest nonprofit public health research and services organization.

And after he has taken a few minutes to comment on Mr. Sims' and the King County Equity and Social Justice Initiative, we're going to hear from Dr. Karen Minyard. Dr. Minyard is the Executive Director of the Georgia Health Policy Center at Georgia State University. It's an evidence-based research program development and policy guidance, which provides guidance locally, state-wide, and nationally. And recently, nationally—and Karen and her staff have been working very closely with CDC on our health system transformation initiative. The Center works throughout Georgia and 160 counties in 48 additional states, striving to help communities achieve health improvement. So I'm going to give each of them, starting with Dr. Valdez, a few minutes to discuss, and then we will open for questions. Thank you.

Well, thank you, first, thanks to the CDC for having me here today. It's been more than a decade since I've visited the campus. It's an amazing growth. And also thank you to Emory and to the Institute for inviting me to comment on King County's Equity and Social Justice Initiative. But really, thanks to Mr. Sims, because it's really his convictions and his focus on eliminating inequality and his leadership that will help us move forward. Those of us who work in health and health care recognize, it's leadership like his at the political level that make our work easier.

Unlike Mr. Sims, I'm going to use some slides. [Chuckling] If I can get them up. In the meantime, I actually learned a lot about Mr. Sims that we have in common. I learned that we're both rooters of the Seattle Mariners, him in Seattle and me in Albuquerque now, where they have a farm club called the Isotopes. [Laughter] I discovered that he grew up in a really small house that his parents—first house that they bought. So did I. I can't imagine how we all got in this little house, either. And I also discovered that, like he, my first love... I stalked her, too. [ Laughter] We ready to go? Here we go, all right. Uh... just push the button down? Great, I got it. Just these buttons? Yeah, mm-hmm.

Well, health is an asset and a resource critical to human development that benefits society as a whole. But realizing health for all members of society is a matter of social justice, which depends on reducing social and economic inequality and increasing democracy. In reading the King County Initiative, one of the things that struck me was—a framework was missing. Because we're really talking about creating a healthy republic. A healthy public, but a healthy republic. And certainly the focus on public health is here, but it's really trying to understand, what are those domains, those policy domains? You talked about them as departments. But many times, they're not departments. They're really about cross-departmental issues, and so if we stop and think about a new framework of looking at this, we find potential partners for those departments and how they should come together and where they should play together.

So this is adopted from Dave's book on really reinventing public health. Obviously, a focus on public health, but a focus on sustainable development, equally as important, that really looks at the environmental resources and risks: a look at human development—that's really looking at education and skills—that you pointed out so well. Economic development, which is really about occupation, employment, and income. These are the fundamental determinants that contribute to health—and to disparities, when they don't exist. Community development—it's really about social support and social cohesion. It's those issues that we almost never talked about, but you've begun that discussion. The sources of health inequities are rooted in injustices associated with racism, social class, and sex discrimination. There are important political implications of the various perspectives used to explain health inequities in the United States, as well as political implications for the alternative strategies for eliminating them. Now, King County's initiative shares one important perspective and offers at least a set of strategies that are focused on what local governments can and should be doing.

The United States has the greatest proportion of its citizens, among industrialized nations, in low-paying jobs, has the greatest number of poor people, has the greatest gap between rich and poor. And this condition is made worse by its especially low spending on social infrastructure and on services that support the citizenry. So I'm glad to hear that you're really already focusing on how to invest in infrastructure and where it should be. But we've got to get the state, we've got to get the feds, to help you. And I think that's what you were asking CDC to help you do, as well. This profile is a result of policy decisions made by governments and unfortunately endorsed by many Americans for whom these decisions are clearly not in their own interest. Policy solutions will require that there is recognition of the fundamental injustice of the profound economic inequality present in the United States.

And that recognition is only going to come about with the kinds of discourse and the kinds of discussions that you've begun in King County. Documenting the strong links between political, economic, and social aspects of a society and the health of its citizenry will be key to changing social norms that tolerate social inequities of the current magnitude. Americans and others need to be made aware that the primary determinants of whether they stay healthy or not is not whether they exercise, not whether they eat fruits and vegetables, but rather the economic and social conditions to which they are subjected, and that provide the context within which they make individual and family decisions about what to consume and how to behave.

"Go west, young man," advised Horace Greeley in 1851. A century later, he might have said, "Go to college.” The western frontier was the 19th-century land of opportunity. The frontier was a way out—not "away out," but a way out, out of poverty, out of dismal factories, out of the crowded eastern cities. The frontier was the great escape, but few escaped. The image of the frontier sustained the vision of economic opportunity and unfettered personal freedom in an emerging industrial system offering little of either. A new ideology of opportunity developed. The folklore of capitalism was revitalized. Education became the new frontier.

Rapidly expanding educational opportunities in the 20th century met many of the same functions served earlier by the western frontier. In school, an objective competition, as the story goes, provides an arena for discovering the limits of one's talents and the boundaries of one's life's pursuit. Educational reformers proposed that those who failed to measure up had only themselves to blame. The educational system provided an admirable safety valve for the economic pressure cooker. But by the 1950s, the educational frontier was pressing its limits. By the '70s, the expansion slowed to a crawl, with high school graduates going to college beginning to fall by the late '70s and an increasing hierarchy in higher educational institutions taking hold, with the Ivy League schools serving as the training ground of the elite and the powerful. There remains a hearty optimism in circles that social programs can be devised to alleviate social distress and restore a modicum of social harmony. At the core of this conventional wisdom has rested the conviction that within the free enterprise system of the United States, significant social progress can be achieved through a combination of enlightened persuasion and governmental initiative, particularly in the spheres of education and vocational training.

The educational system, perhaps more than any contemporary social institution, has become the laboratory in which competing solutions to the problems of personal liberation and social equality are tested, and the arena in which social struggles are fought out. The school system is a monument to the capacity of the advanced corporate economy to accommodate and deflect thrusts away from its foundations. Yet, at the same time, the educational system mirrors the growing contradictions of the larger society—most dramatically in the disappointing results of reform efforts. The politics of education are best understood in terms of the need for social control in an unequal and rapidly changing economic order. The founders of the United States school system understood that the capitalist economy produces great extremes of wealth and poverty, of social elevation and degradation. For a few, like me, like Mr. Sims, it has been an escape from poverty and has delivered personal freedoms.

But so many of our cousins, our brothers, our sisters remain in those same states. In fact, we can look at a similar situation about this gap if we look at life expectancy. Life expectancy, in fact, has been widening in our nation. Seeing a demographer at the Maternal and Child Health Bureau at HRSA shows between 1980 and 2000, those in higher socioeconomic groups experienced larger gains in life expectancy than those in more deprived groups, contributing to the widening gap that we see in our society. I want to thank Lydia Ogden for helping me put this graphic into this presentation. Without her, this presentation would have been more dry. [Chuckling] So what are the principles for change? Really, it's really quite simple. I think we really need to talk about expanding democracy—that is, increasing the number of voices and perspectives that are available—to come up with solutions, to think creatively, and to really be transparent in our decision-making. It's really about social norm change to support social cohesion and collective action and not simply individualism.

I can't tell you the shock I had after 10 or 12 years now of visiting an elementary school in my neighborhood—the same school that my child went to—and discovering that children didn't know how to play together. They weren't allowed to play together, they could only perform as individuals. They could only compete as individuals. They had no sense of the collective whole—of the benefit of the class. Social norm change—supporting social cohesion—has got to be part and parcel of our efforts to create individual liberty.

And lastly, we need to practice capitalism, really relying on our faith in reason. It's not reasonable to have such profound differences in our society. Fairness demands more equity. Now, King County's initiative really focuses on individuals and families within disadvantaged communities. But I really challenge them to pursue a statement they made in their own initiative, saying that they'll ensure opportunities for all communities. Because once you think universal, then everybody's part of the game. If you start segmenting, people are left out. The other thing, the other challenge I want to bring to King County is really my own bias and my own focus, and that is to focus on and invest in primary prevention, rather than trying to create programs of treatment, trying to put Band-Aids on hemorrhaging situations. I'm very encouraged by King County because of the leadership that they're showing. And I really am quite grateful to have been in Mr. Sims' presence and to be part of this presentation. [Applause]

I'm really happy to be here today, and thank you for inviting me. The future I stand for is one in which every person in every community has the opportunity for health. I know this future is possible, because of the many communities that I've had access to, especially over the last 10 years, and I've seen situations in which local government, public health, business, education, faith, philanthropy, hospitals, physicians, other health and human service workers, clinics have come together and said, "We want to make a difference.” In fact, most all of the difference that I've seen has been at the local community level. And that's why it's such a pleasure for me to hear about this particular situation and hear this story, because this is another example of local leadership and local collaboration that makes a difference.

There's one story that has really inspired me, and I wanted to tell you just a little bit about this, and many of you know it—and I'm going to go to the very end of these slides to just say a few words about the lessons of North Karelia in Finland. And this story has long been an inspiration to me. In the 1970s, this community was plagued with high deaths from cardiovascular disease. And they were just a general problem mainly because of the dairy farming community and the culture of eating that happened, and living, that happened in that community. And a lot of the people were dying at a very young age. And so they came together as a community, and they challenged each other as towns to compete with each other, they changed a lot of their policies, they created walking paths, they created cooking clubs, they changed the culture in their community. And they had remarkable results. They went from really worst to first in health. Their smoking rates dropped, their coronary heart disease mortality fell, their lung cancer mortality dropped by 71%. And they added 6 to 7 years of life expectancy.

When I read the materials about the King County Equity and Social Justice Initiative, it reminded me of North Karelia and of what had happened there, and I was excited, because I thought, "Oh, my goodness, it can happen in the United States.” And it has been something that I've been hoping for, and in many of the communities that I've worked for, I've talked to them about, "Let's think about the opportunity for creating a North Karelia in the United States.” And some communities have tried to really change, and it sounds like this is a place where that's really attempting to happen. I just wanted to show just a few facts that relate to what Ron had to say.

We talked some—I want to show just a little bit of information about Georgia. This is our home state. It's a state that I study a lot, because of being at the Health Policy Center. And the number of uninsured are growing. And when you look at the issues of how things are growing, related to family income, you see this disparity is happening more and more as it relates to people who are uninsured. We also have some of the challenges related to noncitizens. Our number of noncitizens has doubled in the last five years. The number of uninsured noncitizens has tripled. Half of the non-citizens lack coverage. And the noncitizens comprise 20% of Georgia's uninsured residents. This tells part of the story, and I know that access and insurance is only part of what we're looking at, and it's really a small part, but it's an important part. And so this is a challenge that we also have to deal with. I worked with a group of people in the southeastern United States who had been involved in trying to improve access for eight years as part of the Southern Rural Access consortium. And they got to the end of their eight years, and they asked the Health Policy Center to help them think about something that was puzzling them, because they said, "You know what, we've been trying to make sure we have doctors, we've been trying to make sure people go into health careers, we've been trying to make sure the doctors' offices are strong, we've been trying to create health networks.

And we really don't see any difference in health. And we think the problems are going deeper. And we would like for you to help us look at the bigger challenges, the other challenges. Why is it that some people just seem to be healthy and others don't? Why is it that the people who have more money seem to have access to information and knowledge and the ability to change their lives?” And so we worked with them over a year to really study some of what are the root causes of poor health. What's beyond all of this? And this figure of education, occupation, income, assets, all of those as precursors to health are the things that Ron was talking about when he said, "We've got to do something in our schools, we've got to do something in our job training, we've got to do something in our business, because this is where the difference in health is going to be.”

Anne mentioned a project that we've been doing with CDC, and a message that came out of that was in some ways a pretty complicated message, and it's really complicated for lay people to think about, but it's not complicated for Ron and his community, because all of these words, all of these challenges, all of these things of national, state, and local, upstream, intersectoral strategies that are focused on health promotion and prevention for the commons—for everybody—were part of the writings of his work and part of what he talked about. So these things that we're thinking about, everything that comes up in my research, my work in policy, my work in practice, Ron spoke to as he talked. And we talked about, in this project that we're working on, the importance of national, state, and local, public and private policy and money lining up.

And we talked a lot about this concept of playing a complicated triple-layer chess game. And what Ron said in his talk just now is, "The key is to create structures to deal with the circumstances that I grew up with.” And I think our job, when we're looking at national, state, and local policy and resources, our job is to create the structures, to create the opportunities that makes Ron's job easy. I was in a community recently where they were talking about how to have health and health reform. And one of the guys there said, "Well, you know, when people come home from work, their kids are hungry, they're tired, they need to eat, they go to Wendy's.” The default is an unhealthy choice.

We need for the default to be a healthy choice. We need for things to be different, and I would like to challenge us—this was a community in Ohio—to look at every single policy—the national, the state, and local policies, and to think about what would we have to change in every one of those policies that would make the default the healthy choice? And I think that's the kind of help that we're looking for in our national, state, and local decision-making, that creates the environment that King County can do what they're trying to do. I really think that the power for these changes comes from the community. And sometimes when I'm working at the national level or the state level, I get frustrated with the bureaucracy, the politics, the challenges, and there's a part of me that just wants to get in my car and drive to a community where things really happen. And so there's a part of me that wants to say, it's not always the CDC or the federal government or the state that's going to lead the way. I think that it's very often the community that's going to lead the way. And so my closing comment is, go, King County! Lead the way! [Applause]

Thank you very much, Karen and Robert, for those provocative comments and for attempting to bring this from one county that's doing so well to all the counties and all the communities that have a role in taking the responsibility for health back. And I'd like to open up the floor for just a few questions before we have our reception. But before I do that, I'd like to thank all of the members of local county commissions and county boards of health who came here today on our invitation to share in this experience and hear what's happening out in King County and learning from each other and perhaps sharing stories and sharing experiences and sharing best practices, so that we can replicate the work that's happening in King County in counties and communities all over the U.S. So thank you—there are a lot of folks sitting down here at the front—for coming.

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