Health and Social Justice  [Printer-friendly version]
June 1, 2003


A starting point for Advancing Health Equity Through Social and
Economic Change

[Rachel's introduction: The Minnesota Department of Health has
adopted modern public health goals, embodied in Goal 18: to "foster
the understanding and promotion of social conditions that support
health" and health equity. This is the story of Goal 18 and the "Call
to Action" report that it provoked.]

By Gavin Kearney

[This is chapter 26 from the book Health and Social Justice,
subtitled "Politics, Ideology and Inequity in the Distribution of
Disease -- a Public Health Reader" (San Francisco: Jossey Bass, 2003),
edited by Richard Hofrichter, with new and updated links. -- Rachel's
News editors]

In 2001, organizations and individuals committed to understanding and
addressing the effect of social and economic conditions on health in
Minnesota published a report titled A Call to Action: Advancing
Health for All Through Social and Economic Change. The group, the
Social Conditions and Health Action Team, was born out of a larger
effort in Minnesota's public health community to address public health
needs and the large racial and ethnic health disparities that exist in
Minnesota. Completed under the stewardship of the Minnesota Department
of Health, this report strongly urges that Minnesota's public health
community adapt to the growing understanding of the relationship
between the health of individuals and communities and the social and
economic environment in which they live. To an extent, this shift has
already begun. The Call to Action and the efforts from which it arose
have led to a number of positive developments in Minnesota. However,
the ultimate goal of remedying health disparities and promoting health
for all is necessarily a continuous effort.

This largely descriptive chapter tells the story of the Call to
Action. It begins by discussing the developments that led to the
formation of the action team and the production of the report. It then
provides a summary review of the report, discussing key findings and
highlighting recommendations and strategies. Next, it overviews the
primary ways in which the report's approach and recommendations have
been implemented in Minnesota. It concludes by critiquing our
accomplishments thus far, analyzing in broad terms the challenges that
lie ahead.[1]


The Call to Action report and the shift in thinking that it embodies
were driven by several developments affecting the public health
community in Minnesota. For a time in the 1990s, universal health care
appeared to be a real possibility for the United States. It was one of
the most prominent (and contentious) political issues and for a time
had the support of President Clinton. Its realization would have had
significant implications for Minnesota's public health community.
Public health in Minnesota focused primarily on service delivery and
filling the gaps of the health care system, roles that would be
obviated significantly under a universal system. As a result, members
of the community began to contemplate what public health in a society
with universal health care would look like. From this contemplation
arose the idea of creating a more effective and integrated public
health system by ensuring that the various sectors within it --
public, private, and nonprofit -- functioned in concert. The
Minnesota Health Improvement Partnership (MHIP) was created in 1997
to further this aim.

MHIP is composed of a variety of state, regional, and local health
agencies in Minnesota, along with other public and private entities
such as hospitals, community-based organizations, university-based
researchers, and representatives of the business community. In
addition, governmental actors from critical areas outside of the
traditional health sector, such as planning, education, and human
service agencies, are also members.[2] The purpose of MHIP is to
"develop coordinated public, private, and nonprofit efforts to improve
the health of Minnesota residents."[3] As one of its first actions,
MHIP reviewed and updated a set of health improvement goals that the
state had developed in 1995. Completed in 1998, a report titled
Healthy Minnesotans 2004 presented updated goals, along with a
preliminary set of strategies for pursuing them.

A growing awareness that while Minnesota's population was generally
among the healthiest in the country, the state possessed some of the
country's largest racial and ethnic disparities in critical health
areas affected the goal-setting process. In addition, research
indicated that these disparities were in large part a function of the
disparate socioeconomic conditions of different racial and ethnic
groups in the state. In 1997, the Minnesota Department of Health (MDH)
collaborated with the Urban Coalition, a nonprofit research and
advocacy organization, to publish the Populations of Color Health
Status Report. This report found that populations of color in
Minnesota have significantly higher levels of risk than whites for a
number of leading causes of death. The report also found that the
overall mortality rates for African Americans, American Indians, and
Hispanics was up to 3.5 times higher than that of whites in
Minnesota.[4] Moreover, a growing body of research suggested that
these disparities were not solely a product of behavioral differences
and disparate access to health care. Clearly, phenomena beyond the de
facto sphere of public health, such as education, housing, employment,
and the environment, played large roles in generating these


In setting health goals for the state, MHIP sought to define goals and
develop strategies that could be pursued and implemented at all levels
of geography and by various public, private, and nonprofit actors.

"None of the public health goals or objectives contained in this
publication," states Healthy Minnesotans 2004, "are intended to prompt
new legislative mandates. Instead, each is intended to inspire
voluntary action on issues that affect the health and well-being of
people across the state, from reducing the number of tobacco users, to
ensuring babies are born healthy, to helping the aged maintain their
independence, to preventing or controlling the spread of infectious
diseases such as tuberculosis, hepatitis and sexually transmitted

Healthy Minnesotans identifies eighteen health improvement goals to
be accomplished by 2004. Of these, seventeen are updated versions of
goals originally articulated in 1995, and many of these target
specific health risks or risk behaviors. The new goal, Goal 18,
reflects the broadened understanding of health emerging at the time
and is the goal that led to the Call to Action report. Generally
stated, the goal is to "foster the understanding and promotion of
social conditions that support health."[6] The report suggests that
critical steps toward achieving this goal are raising awareness of the
connections between health and social conditions and raising awareness
of the need for critical actors within the state to establish
"voluntary partnerships" across disciplines and sectors.

MHIP articulated the following objectives for the public health
community and other key actors to achieve by 2004 in furtherance of
Goal 18:

* Review and summarize existing studies and data sources that identify
concrete linkages between social conditions and health.

* Stimulate and support efforts to develop the knowledge base to
better characterize the multidimensional relationships between social
conditions and health.

* Promote societal attitudes that include a philosophy of shared
responsibility for addressing the social conditions that affect

* Discuss the impact of social conditions that contribute to poor
health in terms of their organization's sphere of influence.

* Collaborate with community efforts to improve social conditions that
affect health.

Subsequent to the adoption of these updated health goals, MHIP chose
to make the pursuit of Goal 18 one of its priority areas and formed
the Social Conditions and Health Action Team (SCHAT). The SCHAT's
charge included developing strategies for the public, private, and
nonprofit sectors to use to increase understanding of the ways in
which social conditions affect health and to address the conditions
underlying Minnesota's health outcomes. Funded through the Robert Wood
Johnson Foundation's Turning Point program, the SCHAT was an
interdisciplinary, intersectoral group that met from 1999 to 2001. Its
work culminated in April 2001 with the submission of A Call to Action
to the Commissioner of Health, Jan Malcolm.[7]


The Call to Action reviews the state of health in Minnesota and
summarizes research findings about the relationship between social
conditions and health. After discussing some of the implications and
conclusions of these research findings, it culminates with
recommendations and strategies for implementing a public health agenda
responsive to the role that social conditions play in generating
health outcomes and responsive to health needs in Minnesota. This
section overviews the report, placing particular emphasis on the
recommendations and strategies.

The report highlights several key aspects of the health status of
Minnesota. First is the significant racial and ethnic disparities
across key health indicators, despite Minnesota's relatively high
overall level of health. The report also notes that Minnesota's
rapidly growing foreign-born populations tend to have lower health
status than most Minnesotans, in part due to barriers in accessing the
health system as a result of such factors as language, culture, and
religion. The report draws a direct link between social and economic
factors and these disparities. It references the roles that
discrimination, segregation, and unequal access to resources and
opportunity in critical life areas such as education and housing play
in generating health inequalities and notes the lesser role of
behavior in explaining these outcomes.

The report then summarizes existing research on the relationship
between health and social and economic conditions. It indicates that
as with measures of health, Minnesota fares well in the aggregate on
socioeconomic measures such as employment, income, and poverty, but
these overall measures mask areas of concern. Minnesota has high child
poverty rates, a growing portion of the job market that pays poverty-
level wages, significant levels of racial and economic segregation, a
significant lack of affordable housing, and growing income

Moreover, the report finds that these socioeconomic concerns have
important implications for health. Reviews of outside research
established the following, among other things:

** Community and social support promote health; social exclusion
generates negative health consequences.

** Housing plays a significant role in determining a family's well-
being, depending on whether it is affordable, safe, and connected to
resources such as transportation, education, and employment, and
amenities such as quality grocery stores, cultural centers, and
recreational facilities.

** Health is affected by various aspects of employment conditions,
including wages, safety of the working environment, scheduling, and
health and family policies.

** Macroeconomic trends, such as income distribution, employment
rates, and other labor market trends, have important health

In sum, the SCHAT found that "more supportive social and economic
conditions are needed to eliminate disparities and achieve Minnesota's
overall health improvement goals." While the SCHAT suggested a need
for more research "to understand precisely how these factors affect
health and health disparities, and how to translate these findings
into the most promising policies and programs," it found existing
evidence compelling enough to recommend significant changes in the
public health community. The Call to Action concluded that "the
challenge is clear: public, private, and non-profit organizations in
Minnesota need to act collectively on this deeper understanding of the
social determinants of health, at the same time that we increase
access to culturally competent health care, promote healthy behaviors,
and strengthen the existing public health infrastructure." As a way of
spurring future action, the SCHAT developed a series of
recommendations and strategies for implementing the recommendations.


Identify and Advocate for Healthy Public Policies

Because public policy in multiple areas within and beyond the
conventional health sector have significant effects on the health of
Minnesotans, the SCHAT suggested that the public health community
educate itself and the larger community on the types of policies that
support or undermine health and to advocate accordingly.

The SCHAT identified several specific strategies for accomplishing
this goal. First, the SCHAT asserted that MHIP should take actions
necessary to develop and pilot health impact assessment (HIA) tools
and methodologies in Minnesota. HIA was seen as a valuable method for
explicitly injecting health objectives into the various areas of
policymaking that have unacknowledged health consequences (for
example, housing, transportation, and economic development). The SCHAT
believed that by developing these tools, MHIP could do all of the
following, among other things:

* Begin to model the health implications of programs and policies in
other sectors

* Spur collaboration with related state and local agencies

* Assess and provide testimony on the health implications of pending

* Identify political and organizational barriers to HIA and strategies
for overcoming these barriers

* As a long-term goal, establish a foundation for requiring use of
these tools in policymaking and propose appropriate legislative
language for doing so

The SCHAT believed that a more general strategy for implementing this
recommendation is to create opportunities to turn the growing body of
knowledge around health and social conditions into action through
policies and programs.

Team members placed a strong emphasis on moving beyond a description
of the determinants of health to pushing healthy public policy. Based
on current evidence, the report lists several broad examples of the
kinds of policies that are necessary to create a healthy environment
and reduce health inequalities, including the following:

* Increasing opportunities for optimal early childhood development
through affordable and high-quality child care, appropriate family
support services, and employment practices that increase paid family

* Increasing opportunities for people to meet their basic needs by
increasing the supply of affordable, accessible housing, boosting
family income, and providing the support services that people need to
obtain and retain employment

* Linking economic and community development policies and practices
with health improvement goals as a way to foster sustainable
development that makes planning in areas such as housing,
transportation, and economic development mutually supportive and

* Generating local policies and practices that serve broader regional
interests and in doing so expand access to resources and opportunities
for all communities

As initial first steps, the SCHAT recommended that MHIP and MDH work
with appropriate partners to develop policy briefs that present
evidence on the relationship between social conditions and health and
articulate healthy policy approaches. They also recommended that these
partnerships identify barriers to moving a broader agenda forward and
strategies for overcoming these barriers.

Build and Use a Representative and Culturally Competent Workforce

As noted earlier, the SCHAT found that the health needs of communities
of color and foreign-born populations in Minnesota are unmet, in part,
because the health community is not prepared to address unique health
needs that arise in areas such as language, culture, and religion.
Consequently, team members decided that all sectors of Minnesota's
health community should create and maintain a workforce that is both
representative of the populations that it serves and able to
understand and address the needs that arise from their
characteristics. In order to accomplish this goal, the SCHAT asserted
that MDH and MHIP member organizations will have to "establish and
adhere to practices to recruit, retain, and promote personnel who
reflect the cultural and ethnic diversity of the communities served."

The Call to Action includes several strategies designed to achieve
these goals.

First, health organizations and agencies need to create an environment
that welcomes, accepts, and values all employees and community
residents by making workforce diversity a core value and by explicitly
demonstrating that harassment and discrimination are intolerable.

Another strategy identified by the SCHAT is to ensure that
organization functions are accessible to all employees through
measures such as providing ongoing multicultural competency training
for all employees and by assessing all policies and procedures to
ensure equality of opportunity and cultural responsiveness. The SCHAT
also indicated that organizations ought to take measures to create
diverse applicant pools now and in the future through targeted
recruitment, creation of internship and fellowship opportunities, and
inclusive hiring processes and that organizations work to retain
people of color who do enter the workforce through measures such as
building support systems and networks and conducting retention

Finally, the Call to Action recommends that organizations develop
measures for assessing progress in achieving these goals and build
these measures into assessments of organizational success and the
success of supervisors and managers.

Increase Civic Engagement

A critical recommendation included creating public health models that
engage the communities that they serve and increase the assets of
these communities.

Based on research in the area, the SCHAT believed that interventions
that engage and build relationships with the communities they serve
will better equip them to address the full range of conditions that
affect health in a manner that is "comprehensive, flexible,
responsive, and enduring." In doing so, they hoped to avoid past
problems with fragmented services and programs and address underlying
causes that drive multiple health outcomes.

The SCHAT recommended that the Department of Health convene a group
"charged with identifying opportunities, as well as barriers, and
solutions to broadly support the implementation of health improvement
programs that use principles of community development, civic
engagement, and participatory research and evaluation." It also
suggested that this group develop recommendations for implementing
such programs, coordinating health improvement activities with efforts
and initiatives outside of the traditional health sector that
favorably affect the social and economic environment, and transforming
the health communities' systems and institutions to make them more
accessible and responsive to community-based health improvement
initiatives and to allow for mutually beneficial relationships between
the two.

Reorient Funding

For public health programs to adapt to new understandings of the role
of social and economic conditions in creating health outcomes, members
of the SCHAT strongly believed that it is also necessary to rethink
approaches to funding. Most grant programs at the federal and state
levels have been disease- or issue-specific and competitive, based on
the assumption that structuring funding in this manner makes it more
effective and more efficient.

Resulting programs have been similarly narrowly focused. In the
aggregate, fragmented health programs often leave gaps in fulfilling
health needs. Such funding structures impede the development of
comprehensive health programs responsive to the relationships between
health outcomes and the conditions that contribute to them. They also
make it difficult to develop sustainable, community-based initiatives
and to invest in building community assets. Moreover, although funding
had been available to communities of color in the past, team members
believed it necessary to increase funding targeted specifically for
reducing health disparities.

The SCHAT recommended strategies for accomplishing this goal,
including that MDH reorient its grant programs to involve people and
organizations more broadly in proposal evaluation, ensure the
inclusion of community of color-based organizations on funding
notification lists, and make grant application processes accessible.
They further supported building goals to eliminate health inequities
into funding formulas and requiring prospective grantees to include
organizations representing underserved communities in proposal
planning and implementation.

To make funding more effective, they also recommended that health
agencies build collaborations with institutions and agencies outside
of the health sector as a way to focus on social and economic
conditions by linking disparate funding streams to provide for more
comprehensive programs and initiatives.

The team also recommended that MDH, MHIP, and SCHAT members inform
legislators of the shortcomings of categorical funding and seek to
strengthen links with local and national foundations that address
social and economic conditions or health.

Strengthen Assessment, Evaluation, and Research

Just as the SCHAT sought to modify and strengthen funding in order to
address the social conditions that affect health more effectively, it
also argued for modifying and strengthening the measurement of health
and the evaluation of health activities. The team supported better use
of population health data and development of measures and indicators
that include the factors that affect health and the interrelationships
among them.

Specific strategies recommended for accomplishing this goal include
requiring that local public health agencies (community health service
agencies) incorporate social and economic factors into the required
community health assessment plans every four years. The SCHAT also
recommended that these agencies conduct their assessments with
significant involvement from all community members, including people
of color, foreign-born populations, and low-income populations.

The report urged the commissioner of health to work with MHIP, MDH's
Minority Health Advisory Committee, and MDH's Population Health
Assessment Work Group to conduct a comprehensive baseline assessment
of the social and economic factors that affect health and health
disparities. The report further suggested that these groups also work
to strengthen the capacity of state and local actors to link
traditional health measures with measures such as income, education,
and race/ethnicity and with research on the distribution of and access
to resources and opportunities for Minnesota's various communities.

The report concludes a charge to MDH, MHIP, and the action team
members to become responsible for communicating the findings of the
report and championing its recommendations. Similarly, it urges these
actors to create opportunities to engage individuals, organizations,
and communities in dialogue around these findings and recommendations
and to identify opportunities to mobilize and collaborate with
individuals and groups outside the health community already committed
to improving the social and economic conditions of all Minnesotans.


Since submitting the Call to Action to the commissioner of health,
several significant activities have occurred in Minnesota's public
health community in direct response to its recommendations or
consistent with and influenced by its analysis and findings. In
particular, the Minnesota Health Improvement Partnership adopted
"workplan objectives" for 2001-2002, two of which are specific
recommendations found in the Call to Action. MHIP decided to
"identify, pilot test, and disseminate civic engagement tools that can
be used by communities in addressing disparities in health status"
through the work of the Civic Engagement and Health Disparities Work
Group and to "develop and pilot test health impact assessment
methodology" through the work of the Health Impact Assessment Action
Team.[8] In response to the efforts of Minnesota's health community,
the Minnesota State Legislature also enacted legislation in 2001 to
create and fund the Eliminating Health Disparities Initiative.
Minnesota's public health planning framework has also been modified to
encourage local agencies to incorporate social and economic conditions
and an explicit focus on health disparities into their assessment of
local health needs and planning to address them.

The Civic Engagement and Health Disparities Work Group

In 2001, MDH and MHIP convened the Civic Engagement and Health
Disparities Work Group with a threefold charge:

* to explore models of civic engagement for engaging communities and
institutions in addressing health disparities;

* to identify, pilot, and disseminate tools for increasing civic
engagement and community involvement in addressing health disparities;

* and to recommend ways to integrate these approaches into state and
local public health efforts.[9]

The work group defined civic engagement as a process involving the
"participation of members of a community in assessing, planning,
implementing, and evaluating solutions to problems that affect them."
To be effective, the work group found that such engagement demands
trust, two-way communication, and meaningful collaboration. To aid
public health actors in Minnesota in efforts to address health
disparities through civic engagement, the group placed a number of
resources on the World Wide Web, including: an articulation of key
principles for designing, implementing, and assessing civic engagement
efforts; several models of engagement and participation, including
asset-based community development (ASCD) and cultural complementarity;
and lists of specific strategies and tips useful for increasing the
engagement of communities in general and communities of color in

The Health Impact Assessment Action Team

Pursuant to the Call to Action, the Health Impact Assessment Action
Team was created and charged with the following:

* To develop a shared understanding of HIA and its potential
applications as a tool for developing healthy public policy and
illuminating the potential effects of policy decisions on health

* To identify potential pilots for HIA in Minnesota and oversee their

* To describe the potential utility and feasibility of HIA in
Minnesota based on findings from pilot projects.[11]

As discussed earlier, HIA was seen as a promising tool for ensuring
that policymaking in areas traditionally viewed as beyond the health
sector occur in a manner that acknowledges and accounts for health
consequences in general and the need to remedy health disparities in

Although the work of the HIA Action Team is ongoing, thus far the team
has developed preliminary screening tools for assessing the potential
utility of applying HIA to a given project or policy.[12] The team has
also worked, with mixed results, to identify potential pilot projects
and provide oversight and support for the implementation of HIA in
these projects. While potential partners for these pilots have
generally understood the value of considering the health implications
of their policymaking or programming, efforts to pilot HIA have been
hindered by the limited resources of the HIA Action Team and partner
organizations, limited understanding of how to implement the
assessment process, and difficulties in demonstrating the benefits of
doing so in a given situation. The work of the action team should
conclude by 2005 and will include an assessment of lessons learned
from efforts to pilot HIA and the implications of these efforts for
the long-term goal of broadly integrating health impact assessment
into policymaking processes in Minnesota.

The Eliminating Health Disparities Initiative

As discussed earlier, members of the health community have become
increasingly aware since the early 1990s of significant, and in some
cases growing, racial and ethnic health disparities in Minnesota.
Addressing them has been a priority of MDH and MHIP over the past
several years, reflected in the focus of the Call to Action on the
role of social and economic conditions in generating health
disparities and methods of eliminating them.

In response to the advocacy efforts of the health community and of
communities of color around the issue of disparities (though not
directly in response to the recommendations of the Call to Action),
the Minnesota Legislature in 2001 created the Eliminating Health
Disparities Initiative (EHDI) and provided it with $12.7 million to
fund EHDI grant programs in the first two years of its existence.[13]
The legislature established the EHDI to decrease health inequities in
infant mortality and immunization rates by 50 percent by 2010 and to
narrow health disparities in breast and cervical cancer, HIV/AIDS and
other sexually transmitted diseases, cardiovascular disease, diabetes,
and accidental injury and violence during the same period. MDH is
responsible for implementing the initiative, and the primary vehicle
for achieving these goals is through Community and Tribal Grant
programs that provide planning or implementation grants to
organizations working to address disparities in these areas. Planning
grants are short-term, designed to help communities assess their needs
and assets and develop strategies for addressing these needs as they
relate to the EHDI's target areas. To some extent, these grants have
been used to help local public health organizations and communities of
color develop stronger, sustainable relationships.

The legislation establishes several priorities for MDH to consider in
awarding grants. Priority is to be given to applications and
strategies supported by their target community that complement related
activities within the community they will serve, have a positive
effect on multiple priority areas, and embody racially and ethnically
appropriate approaches or are to be implemented by organizations that
reflect the race and ethnicity of the communities that they serve. MDH
is creating a comprehensive plan for evaluating the effectiveness of
the EHDI. By means of a participatory research partnership with
community-based organizations, community research experts, the
University of Minnesota, and others, it will develop measurable
outcomes for the initiative's overall goals and identify the types of
intermediate outcomes that will affect the health of diverse
individuals and communities in Minnesota.[14]

Public Health Planning at the Local Level

To receive some forms of state funding, local public health agencies
in Minnesota must submit a community health services plan to the
Minnesota Department of Health every four years.[15] In these plans,
local agencies must conduct an assessment of public health in their
community and develop a community health plan that details actions to
be taken. MDH issued guidelines for the next round of planning
(covering the period from 2004 to 2007), and although the mandated
planning requirements have not changed, the guidelines recommend that
local agencies adopt a number of the recommendations and strategies
discussed in the Call to Action and developed by the Civic Engagement
Work Group and HIA Action Team.

The new guidelines urge local agencies to engage their communities in
the needs assessment process, in setting public health priorities, and
in establishing public health plans. Although agencies are legally
required to conduct public hearings, the guidelines consider these
steps the bare minimum and urge that more significant efforts be
undertaken to create more comprehensive, sustained community

The guidelines also acknowledge growing evidence that social and
economic conditions affect health, and they reference "key aspects" of
the social and economic environment that drive health outcomes,
including income, education, housing, and employment conditions. The
guidelines state generally that "these social and economic factors
should be considered in the assessment and prioritization steps and
incorporated into the plan." At the same time, the guidelines also
identify twelve "categories of public health" -- such as alcohol,
tobacco, and other drug use; mental health; unintended pregnancy; and
violence -- that community assessment and planning should use to
structure activities.

Although planning to address social conditions and categorizing public
health needs and objectives in this manner are not mutually exclusive,
this method of categorization reflects some of the pitfalls of funding
identified in the Call to Action and may impede efforts to get local
agencies to focus on underlying conditions that drive multiple health


In a relatively short period of time, Minnesota's public health
community has made significant advances in addressing the role that
social and economic conditions play in generating health outcomes and
health disparities. Any critique of this community's efforts must
acknowledge the important and unprecedented (at least for the United
States) vision and scope of this work on a statewide level. As the
foregoing discussion makes clear, significant efforts are under way to
use this knowledge to inform current and future public health work.

Many of the greatest challenges for this work, however, lie ahead. As
the SCHAT realized, a focus on social and economic conditions means
that many of the strategies for addressing health needs transcend
conventional notions of what constitutes appropriate public health
practice. This suggests that for the public health community to be
responsive to evolving understandings of health, it will need to
transform itself in significant ways. To some extent, public health
actors will need to educate themselves in a variety of policy and
programmatic areas beyond the scope of their work and make difficult
decisions about allocating resources among established and emerging
public health priorities.

As the Call to Action observes and experiences with the Eliminating
Health Disparities Initiative and community health services planning
demonstrate, fully realizing the implications of this new approach to
health will also require a restructuring of funding and implementation
methods for health initiatives. Setting discrete goals in narrowly
defined areas will impede efforts to address broader health
determinants and limit successes even in priority areas. Advancing
health through social and economic change will also require an
examination of the ways in which public health agencies work with
organizations and agencies in other fields.

As the Call to Action makes clear, healthy policy spans a multitude of
issues, including economic development, housing, and education. As
discussed earlier, MHIP and MDH have deliberately included
representatives of agencies that deal with such issues as planning,
housing, welfare, and employment within MHIP itself and on the work
groups and action teams charged with identifying effective strategies
for the public health community to pursue. Thus revamping the public
health sector in response to the effects of social and economic
conditions on health outcomes cannot one remedy the health inequities
that exist in Minnesota. Pursuing these strategies will require that
the interaction between these agencies and the health community become
bidirectional and that health considerations inform policymaking. To
be successful, the public health community must develop a strong case
for why such collaborations are mutually advantageous.

Ultimately, to maximize effectiveness and to create sustainable change
will require that these new focuses and new relationships become
institutionalized. Pursuing this end will require Minnesota's public
health community to consider its role as an advocate for health and
for healthy public policy. Although the goals established by the
Minnesota Health Improvement Partnership are explicitly designed to
"inspire voluntary action," the work of the Social Conditions and
Health Action Team and the recommendations that it made question
whether voluntary action will be sufficient. To a large extent, the
persistence of racial disparities is not the result of a lack of
information about how to remedy them but rather the result of a lack
of political will and commitment.

If remedying racial and ethnic disparities in health is a priority
that requires action in areas such as housing, education, and
employment, experiences in addressing racism in the United States also
cast doubt on the sufficiency of voluntary efforts. Voluntary attempts
to remedy affordable housing shortages, desegregate neighborhoods and
schools, and address discrimination in the workplace and other areas
do not have a successful track record in general or when compared to
policies and programs that mandate racially just actions.

The future of the Call to Action will depend in large part on how we
meet these challenges. At the time of this writing, some immediate
obstacles and uncertainties exist in Minnesota, including a budget
crisis. Accomplishing the goals of the Call to Action is a long-term
effort that must transcend immediate impediments, requiring continued
labors over many years. It will also require winning new converts and
developing new allies at the local, state, national, and even
international levels. If we succeed, our initial efforts described in
this chapter will have played a small role in a much larger story.


[1] I was a member of the Social Conditions and Health Action Team and
of one of its progeny, the Health Impact Assessment Action Team. I am
one of the parties outside the conventional health sector who has been
engaged in this work. In writing this chapter, I have attempted to
capture the broader context in which these groups fall but feel the
need to acknowledge that this narrative and my criticisms are informed
and perhaps limited by these perspectives.

[2] A list of the members of MHIP is available at Accessed April 20, 2006.

[3] Minnesota Health Improvement Partnership Accessed April 20,

[4] Urban Coalition and Minnesota Department of Health. Populations
of Color Health Status Report, 1997. Accessed April 20, 2006.

[5] Minnesota Department of Health. "Healthy Minnesotans: Public
Health Improvement Goals 2004." Accessed April 20, 2006.

[6] Ibid.

[7] So far as we can tell, general information on the SCHAT seems
unavailable on the web as of April 20, 2006. -- Rachel's News editors.

[8] Accessed April 20,

[9] Accessed
April 20, 2006.

[10] The materials developed by the work group can be found at Accessed April
20, 2006.

[11] Accessed April
20, 2006. Accessed April 20, 2006.

[12] The literature review, annotated bibliography, and screening
tools can be accessed at Accessed April 20,

[13] Minnesota Statute 145.928. For general information on the
initiative, go to
Accessed April 20, 2006.

[14] Accessed
April 20, 2006.

[15] Minnesota Statute 145A. Completion of this plan is mandatory
for local agencies receiving community health services subsidies from
the state. Accessed April 20, 2006.