Health System Transformation Lecture Series
Centers for Disease Control and Prevention (CDC)
Atlanta , Georgia
Monday, March 24, 2008

Thank you very much.

For me it is a big honor to come to the CDC to talk about health and strong communities, since these are topics very dear to my heart.

I am extremely excited about our King County Equity and Social Justice Initiative. Most of all I’ve been heartened and inspired by the response we have received from our community and partners since our recent launch. They are ready to get their hands dirty and work with us.

As a politician, I’m sure you can imagine I usually start my talks by turning down the lights and showing PowerPoint slides full of data. But my crack staff has informed me that this style of presentation would be highly unusual for CDC, so instead I will do something not common for me and just give a speech.

I am an admirer of public health and its significant accomplishments, in particular in the 20 th century. Two of my favorite accomplishments, which you reference in MMWR, are immunizations and decline in tobacco use.

Through multi-pronged strategies, immunization rates have improved across wide sectors of society. Technological innovation, public health practice and political will have combined to achieve extraordinary results, including the drastic reduction in deaths due to infectious diseases nationally and the eradication of smallpox globally.

Tobacco use is a similar success story, where taxation, smoke-free policies, labeling and packaging, treatment, education campaigns and even public interest litigation have resulted in dramatic drops in rates and huge gains in health.

Today in the 21 st century, however, we have had a shift in our preventable disease burden. Our old public health approaches are not sufficient to address our most pressing challenge. I am talking about inequities.

In King County, we have tremendous wealth and opportunities. We have industry powerhouses including Microsoft, Boeing, Costco and Starbucks.

Nevertheless, our inequities in health mirror national and global trends. Today, in King County our leading actual causes of death – tobacco use and obesity – have also become leading causes of inequity-related death.

For tobacco, an adult in our county without a high school education is almost four times more likely to smoke than a person with at least a college degree.

With obesity, we recently collaborated with the University of Washington on a zip code study, and we found that the single best predictor of BMI was neighborhood assessed property values. Obesity rates reached 30 percent in the most deprived areas but were only around 5 percent in the most affluent ZIP codes.

These disparities are repeated for infant mortality, mortality from violence, HIV/AIDS and chronic diseases. In fact, we see them for almost all risk factors and diseases.

So even in my county, which is relatively well off, the color of your skin or your home address are good predictors of whether you will have a low-birth-weight baby, suffer from asthma, or die from diabetes – essentially how healthy you are and how long you live.

Your skin color, income, education level and home address are also very good predictors of many other important non-health outcomes, such as whether your children live in a single-parent household, are homeless or end up in jail.

Though we have made enormous strides as a society, and we have successes stories in public health and general well-being, in my county, like the rest of the United States, we have two groups of people: those with opportunities and who are briskly climbing up the ladder, and those who are not.

And we are paying the price, both in human terms and financially.

We are spending a significant amount of our dollars to pay for services to support those most affected by inequities. It’s alarming and it makes me outraged that 71% of my county’s local tax dollars goes to support and finance the criminal justice system.

In other areas of our budget, we are in large part filling holes, whether it’s in the area of mental health, homelessness or other crisis services. In my county, 17% of our local tax dollars goes to health and human services, which mainly consists of service delivery and treatment for our poorest communities.

Sure, we are instituting some creative ways to control our costs in our region, such as with the Puget Sound Health Alliance and the Children’s Health Initiative, both of which I launched to improve access and quality of health care for the region. But we can only do so much to control costs when so much money goes to “stopping the bleeding” and finances the services for those in dire straights.

We all absorb the costs when a significant portion of our population is faced with high rates of disease and lack of access to health insurance. We all experience the economic results when our workforce is not as productive as it might be in our increasingly competitive global environment. We all share in the lost productivity and the economic expense associated with criminal justice and other crisis services.

And these factors are linked: income, education, race and neighborhood on the one hand, and health and many other quality of life outcomes on the other.

Why are income, education, race and neighborhood determinant of not only your health but also numerous other outcomes and quality of life?

We must recognize that a person’s health and well-being are not just the product of individual characteristics – genetics, age and gender – but also of underlying, root conditions that are the determinants of health.

Determinants like income and other forms of wealth; employment; affordable, quality housing; transportation; quality education; safe neighborhoods and social networks.

And so to create health we need to create equity. I am talking about high-quality education; job availability and living wage; local ownership of businesses and homes.

We need to focus on people. People need local leadership; involvement in community organizations; political participation; strong social ties.

We need to focus on neighborhoods, because as you know, place matters: accessible parks; affordable ways to move people around, including public transit, walking and biking; safe and non-toxic water, soil, indoor and outdoor air.

For me, this is very personal. I was one of the “lucky” ones. At six years old, in Spokane, I watched the demolition of my family home after a mere 30 days notice. I spent my first years of school falling behind in my reading skills because that is what my teachers expected. But I also had a fifth grade teacher who believed in me and made an enormous difference in my life by helping me see opportunities, not obstacles.

We can continue to labor in providing crisis services in the areas of family support, health, child welfare, criminal justice and homelessness, or we can focus on building strong, resilient communities through “upstream” approaches that create opportunities and make healthy people and healthy communities.

We may never work full time on upstream approaches and will still need to attend to individuals affected by inequity. But the more we work upstream and do it effectively, the more likely we will make progress in eliminating the root causes of our problems.

For all these reasons, I have launched our Equity and Social Justice Initiative in King County.

I have asked, what if all residents of King County have the same opportunity regardless of race, ethnicity, gender, immigration status, sexual orientation, disability?

What if all residents had the opportunity to receive the same quality education, the same access to basic health care, the same opportunities to work for a living wage, the same access to affordable housing, the same ability to live in safe neighborhoods, and the same opportunity to enjoy the natural environment?

A new, better and very different King County would emerge. We, in partnership with our communities and local organizations, can be the catalyst for this change.

This vision may sound ambitious, but remember government can and should play a direct and influential role in services, developing policies, setting priorities, and making funding decisions in many critical areas that affect equity.

We are starting the overall initiative by changing the way we do business -- making equity and social justice central to our work. At the same time we will look for opportunities to gain traction and build momentum across sectors.

We are working at three levels with the King County Equity and Social Justice Initiative.

• First, the delivery of King County services: all King County departments have committed to specific actions to promote equity in 2008. For example, our Department of Development and Environmental Services will review and revise comprehensive plan policies to encourage vibrant, mixed-use neighborhoods that are diverse and integrated. Our Transportation Department will prioritize creating transit-oriented developments with close proximity to affordable housing, recreation and employment centers.

• Second, policy development and decision-making: King County will ensure that promoting equity is intentionally considered in the development and implementation of key policies and programs and in making funding decisions. We are developing and testing an equity impact assessment and review tool, and we will incorporate use of this tool in our decision-making processes.

• Third, community partnerships: Key opportunities to promote equity and social justice go beyond the boundaries of our government, and we need to listen to community voices. We are collaborating with partners from many sectors in the areas of community engagement and education. King County has an opportunity to address the historical lack of access to decision-making by involving community members in developing solutions to inequities. And all communities – not just some communities – must have a strong voice in shaping their future.

We are not reinventing existing wheels. Already we are using the new PBS series, “Unnatural Causes: Are Inequalities Making Us Sick?” as a tool for education and community dialogue. This powerful tool has proven to be an effective method to increase awareness about the significance of the determinants of health and to stimulate ideas for action, especially around policies.

 

If you look at our recent Equity & Social Justice Initiative Report (www.kingcounty.gov), you will see that one of the areas of action includes our children’s education. More than one person has told me, “But Mr. Sims, King County does not run the education system. Local autonomous school boards do that.”

Of course, that’s true, but I know that if we don’t move into the education sector as a key determinant – from early childhood development and school readiness to quality K through 12 education with pipelines to higher education – we will fail with our other efforts. School dropouts, including those precipitated by adolescent pregnancy, often are preceded by inadequate school readiness. Early childhood interventions are critical to reducing school dropouts over the long term. These programs are highly cost effective and may prove to be one of the most powerful tools for reducing upstream causes of inequities in adult health.

By linking a wide array of educational, health, and other interventions, we can promote both good health and educational achievement, and we can reduce the unconscionable socioeconomic and racial/ethnic inequities in both health and education.

I want to provide one expanded example of work that we have started in King County through our White Center Community Enhancement project, in one of our lowest income communities.

Our vision, for White Center and other depressed low-income communities, is to create communities that offer a mix of housing options, that are pedestrian-friendly with convenient access to shops, services and transit. It’s not only about providing affordable housing for our most vulnerable residents, but it’s about enhancing their environment through innovative polices and practices. I’m talking about creating an infrastructure for community health.

We created a cross departmental effort that integrates land use, transportation, air quality and health. In recognizing how community designs impacts individual and community health, we are creating a pedestrian corridor from the brand new housing development to the central business district of White Center.

We are creating a new Transit Oriented Development project along the new pedestrian corridor. We have just begun talks with a private bank, which owns the property, to establish a mixed use/mixed income development in conjunction with a transit facility. We hope this will become a catalyst for neighborhood economic development and improved quality of life.

Under a citizen-approved initiative to increase transit service, the first route we expanded was the off-peak service to this low income community, White Center. We know that regular service throughout the day – not just during typical commute times – will enable workers to get to swing-shift jobs and enable people to get to services and medical appointments during the day and on weekends.

We entered into private public partnership to improve a long-neglected park located in the heart of the White Center through a $550,000 grant. To become the community of tomorrow, today – we need community partners. I look for partners and change agents everywhere!

The change agents and partners are not just the disempowered communities, who live and feel the inequities every day, but the business, political and community leaders who hold the resources and the decision-making power.

Our success in the Equity and Social Justice Initiative is dependent on changing how we do business within King County government and moving out of our comfort zone, and working with other players. We will engage champions and change agents across sectors and disciplines -- from education, housing, community economic development and business, to name a few, who are committed to sustain this work.

In our local initiative, our local health department has been critical in its development and implementation. A similar effort can be advanced countrywide if our national health department took a similarly active leadership role. I believe there are actions that the CDC can take as our nation’s public health agency.

• CDC is a tremendous resource as a source of data. But the data is mainly focused on community health status of individuals. We need more robust measurement of characteristics of the social, physical and built environment that influence inequities in health.

• If we are to eliminate health inequities, public health programs funded by CDC and the CDC itself need to incorporate an equity lens in program interventions and evaluation.

• CDC has an opportunity to influence an agenda for equity and social justice in the Health and Human Services department.

• The same cross-department and cross-sector work we are beginning in King County should occur at the federal level. This means breaking down the silos within the Federal government and working in concert with Transportation, Education, Environmental Protection, Justice, Housing and Urban Development, Labor, Commerce and Agriculture.

In King County, we draw inspiration from our namesake, Dr. Martin Luther King, who in 1964 proclaimed, “I have the audacity to believe that peoples everywhere can have three meals a day for their bodies, education and culture for their minds, and dignity, equality and freedom for their spirits.”

The Equity and Social Justice Initiative is both inspiration and very concrete actions in communities such as White Center. We must have vision, but also provide bricks and mortar.

As I said, public health has made enormous strides during the last century in a wide range of areas, but the persistent problem that we have not been able to address are inequities. We have reached a plateau in much of our progress in advancing health and quality life, and in some situations, some communities are even losing ground.

In the Community Guide for Preventive Services, there is no blueprint – yet – for creating equity and social justice, but we do understand the problem, and we understand the characteristics of healthy communities. We need to continue our work to make sure all communities have the assets and opportunities enjoyed by some.

We are determined in King County to make great strides toward achieving equity, and I know many of you nationally share this same determination. Many efforts are already in places. But this is a complex undertaking that will require new approaches as well as consistency and dedication over the long run. We have no more important task.