Health and Social Justice, June 1, 2003
MINNESOTA'S CALL TO ACTION
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.
A CALL TO ACTION IN CONTEXT
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. The purpose of MHIP is to "develop coordinated public, private, and nonprofit efforts to improve the health of Minnesota residents." 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. 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 disparities.
MINNESOTA'S HEALTH IMPROVEMENT GOALS: HEALTHY MINNESOTANS 2004
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 diseases."
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." 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 health.
* 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.
A CALL TO ACTION. ADVANCING HEALTH FOR ALL THROUGH SOCIAL AND ECONOMIC CHANGE
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 inequalities.
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 consequences.
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.
RECOMMENDATIONS AND STRATEGIES FOR IMPLEMENTATION
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 legislation
* 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 leave
* 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 healthy
* 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 surveys.
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.
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.
PUBLIC HEALTH EFFORTS AFTER THE CALL TO ACTION
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. 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.
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 particular.
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 disparities.
* To identify potential pilots for HIA in Minnesota and oversee their implementation.
* To describe the potential utility and feasibility of HIA in Minnesota based on findings from pilot projects.
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 particular.
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. 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. 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.
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. 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 engagement.
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 outcomes.
FUTURE DIRECTIONS AND CHALLENGES
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.
 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.
 A list of the members of MHIP is available at http://www.health.state.mn.us/divs/chs/mhip Accessed April 20, 2006.
 Minnesota Health Improvement Partnership Accessed April 20, 2006.
 Urban Coalition and Minnesota Department of Health. Populations of Color Health Status Report, 1997. Accessed April 20, 2006.
 Minnesota Department of Health. "Healthy Minnesotans: Public Health Improvement Goals 2004." Accessed April 20, 2006.
 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.
 http://www.health.state.mn.us/divs/chs/mhip/ Accessed April 20, 2006.
 http://www.health.state.mn.us/communityeng/index.html Accessed April 20, 2006.
 The materials developed by the work group can be found at http://www.health.state.mn.us/communityeng/index.html. Accessed April 20, 2006.
 http://www.health.state.mn.us/divs/chs/mhip/#6 Accessed April 20, 2006. Accessed April 20, 2006.
 The literature review, annotated bibliography, and screening tools can be accessed at http://www.health.state.mn.us/divs/chs/mhip/#7 Accessed April 20, 2006.
 Minnesota Statute 145.928. For general information on the initiative, go to http://www.health.state.mn.us/ommh/ehdi.html Accessed April 20, 2006.
 http://www.health.state.mn.us/ommh/legrpt012103.pdf Accessed April 20, 2006.
 Minnesota Statute 145A. Completion of this plan is mandatory for local agencies receiving community health services subsidies from the state. Accessed April 20, 2006.