By Peter Manetta

​Health care reform debates will continue to swirl around cost. The most vocal participants across the political spectrum rail about the chunk of our GDP dominated by health care, the bills that bankrupt families, and the lack of affordable coverage options. Whether they believe in private or public-sector solutions, they all recognize that changes must be made. But such debates rarely include discussions about the demand-side, namely the role of preventable chronic diseases as both adriver and amplifier of costs. If fewer people develop these conditions, demand will go down.  Public healthneeds to be making this point loudly. Every time there is a politically divisive argument over single-payer vs. private insurance, or market self-correction vs. regulation, public health advocates need to be there saying “there is a better way to make this system manageable.”
 
While economists will tell us that it is difficult to predict exactly what effect demand reduction would have on our incomprehensible health care “marketplaces,” economic theory indicates that this would reduce costs. What’s more evident is that demand reduction would be immediately beneficial for public and private payers. Most importantly, preventing chronic disease will dramatically reduce the economic burden for consumers themselves, freeing up their resources for other life essentials. The prevention argument is simple to make: “let’s focus on not needing so much health care in the first place.” It is an obvious point that appeals directly to core American values of thrift and common sense.  So why isn’t it a part of the debate?
 
Pundits don’t talk about demand because the experts they listen to also don’t talk about it. A February 2018 report from the Network for Regional Healthcare Improvement (NRHI) comparing cost drivers across five states is a great example. Entitled Healthcare Affordability: Untangling Cost Drivers, the authors do not even mention chronic diseases as a cost driver. The report is entirely focused on factors they see as within the health care system, despite the absurdity of considering anything external to an industry that dominates nearly 20% of our economy. The closest they come to mentioning demand is discussing disparities in use patterns, for which there is not yet a clear explanation:
 
“Outpatient resource use in Colorado was 25 percent above the benchmark, the highest percentage above the average in any category in any participating state. Coloradans also had the highest utilization of prescriptions, at 23 percent above the benchmark.”
 
It might be important to find which structural inefficiency is causing this disparity, but the burden of preventable disease that is likely behind most of this pattern is undeniably the more critical factor. The authors seem to be ignoring this. Also, what guarantee do we have that the cost reductions resulting from increasing efficiency in health care delivery will be passed on to consumers or even payers?
 
Pundits aren’t the only people paying attention to such reports. Policymakers rely on them when planning reform efforts. An alliance of seven governors, including Colorado’s, just released their new plan called the Blueprint for Improving Our Nation’s Health System Performance.  Most solutions they propose are also limited to similar within system factors found in reports like NRHI’s that realign incentives and increase efficiency. The plan contains only the vaguest nod to the demand-side, suggesting that reforms should “encourage responsible              choices by empowering      consumers with useful information and incenting healthy lifestyles.” This statement at least hints at more demand-side considerations, but it certainly does not reflect current thinking in primary prevention. It echoes sentiment from public health 1.0, which prioritized individual behavior change over addressing systemic factors.
 
As a hopeful if not substantive gesture, both approaches do claim to be considering many factors at once. The NRHI references the “health care cost balloon” metaphor, which describes how squeezing one side just moves air to another. As one of its core beliefs, the Blueprint states that “the best strategies to improve our health care system address multiple objectives simultaneously.” This indicates that both pundits and politicians perhaps are open to a more systems-thinking approach that at the very least doesn’t ignore the obvious.
 
How do we meaningfully enter the conversation? To start, we can openly criticize reports like NRHI’s. Public health can directly answer their myopic conclusions with op-eds and articles in academic journals. Public health can also join politically charged debates in the mainstream press on health care reform. Our message is simpler and saner, and for most people it will be a breath of fresh air. Concurrently, public health can continue to demonstrate its value at the local level by involving more community members in its programs and planning, so they can recognize and celebrate its successes. If they are involved in community health prevention efforts, then such efforts will no longer be invisible to them. 

By Peter Manetta

​Multi-sector community health partnerships are critical for building local capacity to address upstream determinants of health. This is a key takeaway from CALPHO’s exploration of local-level Health in All Policies. Moving upstream requires long-term planning, systems thinking, sustained funding, and political support – areas that challenge many partnerships and may limit their scope to addressing specific outcomes. I am not suggesting that more narrowly-focused partnerships are a waste of resources. There are certainly benefits to focusing on proximal health causes that participants feel empowered to address, and a history of successful collaboration and the resulting collective efficacy are powerful glues. But collective efficacy is just one of the necessary ingredients for moving a partnership upstream toward effecting local, systems-changing policies. What are the others?
 
A recent study published in Health Affairs helps to answer this question. Noting a lack of objective data on multi-sector partnerships, the authors designed a thorough study to identify facilitating characteristics for a partnership to engage in “regional health system transformation.” They developed a four-part conceptual framework to evaluate a partnership’s readiness for this kind of engagement: stewardship, strategy, financing, and environment (meaning health system market and policy environment). Within this framework, they set a list of readiness expectations adapted from a body of collaboration literature and past partnership assessments by ReThink Health. Finally, they compared these expectations to analyses from an extensive interview and site visit process. This resulted in a list of the most mature partnerships (which included the North Colorado Health Alliance), and a snapshot of how most partnerships compare to their expectations. Perhaps not surprisingly, most did not meet those expectations. (if you are interested in learning more about the expectations and maturity lists, email me)
 
This framework and its embedded expectations are valuable assessment tools, and when combined with operational knowledge of local context, can help guide partnerships' strategic direction. But the authors' vision for systems change, while extensive, is not comprehensive. From the outset, it limits the concept of "multi-sector" to sectors with power – power often originating from and sustained by inequitable systems. Under this framework, a mature partnership includes governmental public health, health care entities, business interests, elected leaders, and economic development entities. It does not account for groups whose power must grow – and whose voice must be heard – in order for the entire system to change equitably. In other words, this framework may help community partnerships develop relationships with the powerful, which is necessary, but it misses the critical importance of engaging affected populations and sharing leadership with community members. This absence limits the contribution that more grass-roots organizations like Lake County Build A Generation can add to our understanding of community health partnerships, and especially how they can help foster understanding and unity between groups at different ends of the power spectrum.
 
ReThink Health’s most recent Pulse Check on Multi-Sector Partnerships does a better job of including this factor in its analysis, noting that “less than half report that their authority comes from broad-based grassroots support.” ReThink also noted the lack of engagement of sectors like media, faith, and health insurers. Some of Colorado’s partnerships offer rich examples of why these sectors are important. For example, Healthy Mesa’s overarching focus on community connectedness places family, faith, the arts, and local recreation at the center of Mesa’s health ecosystem (as opposed putting efficient health care provision in the center). This aligns the partnership with the values of its community and may increase its clout with local leaders.
 
CALPHO will continue to support LPHA’s partnership efforts, especially opportunities to learn from each other. Along with CDPHE’s Office of Planning, Partnerships and Improvement, Trailhead Institute, the Rocky Mountain Public Health Training Center, and County Health Rankings & Roadmaps, CALPHO is developing a workshop on partnerships for the community health assessment/improvement plan process, and we hope to extend learning opportunities on that topic. If you have suggestions for this workshop or other ways we can help, please email us.  

by Shannon Kolman

In his book Collaborating with the Enemy: How to Work with People You Don’t Agree With, Like or Trust, Adam Kahane presents an unconventional type of collaboration and offers ways to think about collaboration when the situation is increasingly desperate and contentious. Most people’s conventional understanding of collaboration is that it requires everyone in the group to be on the same team and headed in the same direction. The Stretch Collaboration that Kahane presents abandons the assumption of control, gives up unrealistic fantasies of harmony and compliance, and instead embraces messy realities of discord, trial and error, and cocreation. “Stretch Collaboration looks like martial arts practice”.  Because this type of collaboration, which is needed for complex and contentious situations, requires flexibility, patience, and discomfort, we must realize that collaboration is only one of four options available.
 
Before looking at those options though, we must first face the fact that we all “enemify”; we label those who are different than ourselves as others, rivals, adversaries - enemies. We try to simplify complex realities into black and white, us and them.  The conundrum is that we need to work with “others” to move forward yet we also feel we must not work with them to avoid treachery. Because of this challenge, Kahane suggests that we first understand when to collaborate before deciding how to collaborate. 
 
There are four basic paths we can take when trying to change a situation or make a transformation: 1) forcing our will; 2) adapting or getting along; 3) exiting the situation; or 4) collaborating. We use each of these options all the time and it can be helpful to be clear about what choice we are making.  For example, we force through laws, regulations, money, and weapons. We also often adapt because we can’t change the situation yet we must find a way to go on with our lives.  And we exit, such as in divorce or quitting a job. When making the choice to collaborate, it’s important to understand that there are risks with collaborating, especially in complex and untrusting situations, such as the risk of producing too little too slowly, or compromising too much, or betraying what matters to us most. If we decide to enter into collaboration with those we don’t trust, agree with or like we must not take the decision lightly.
 
Stretch Collaboration requires us to stretch in at least three ways: 1) stretch away from a focus of coming to agreement on collective goals and to move toward embracing both conflict and connection, which seem dichotomous but are necessary for complex, contentious situations; 2) stretch away from insisting on clear agreements about the problem, the solution and the plan and move toward experimenting systematically with different perspectives and possibilities; and 3) stretch away from trying to change what other people are doing and move toward action. The first of these three requirements, embracing both conflict and connection, seems to me to be the most difficult. People generally do not like conflict. Yet to collaborate with those you don’t agree with you have to allow for conflict. It’s also difficult to connect or engage with people you don’t trust or like, yet in Stretch Collaboration we need to connect with those others to expand our awareness, allow for new possibilities, and keep conflict from becoming degenerative.
 
I can see that for public health professionals, accepting the idea that social problems do not have definitive or objective answers like math or science problems may be challenging. Many in public health have been trained to use conventional problem-solving models which start with the assumption that there is one right answer. Stretch Collaboration requires that each person reveal their perspective so that the group can have a fuller picture.  It doesn’t mean that they agree though. The author suggests that some of the most robust actions are those that different players support for different reasons. He notes that President Lyndon Johnson succeeded in landmark civil rights legislation because he attended to the interests of individual legislators while harnessing the individual “wholes” into a collective whole.  We cannot just revert to the “good of the whole” because there are multiple wholes.
 
Conventional collaboration assumes we can control the focus, the goal, or plan to reach the goal.  Stretch collaboration offers a way to move forward without being in control – think more of multiple people rafting a river together.  Kahane suggests that we need to get good at alternately connecting with others, or engaging, and conflicting with others, or asserting.  We will each have a tendency to move toward engaging or asserting and we must learn to do both, and know when to move from one to the other.  It’s similar to the job of a good manager reconciling the drive toward self-realization of his individual team members and the need to unite the team to achieve collective realization.  It’s not one or the other, it’s both. 
 
Secondly, in order to Stretch Collaborate, we must also be willing to experiment – take a step and then see what happens. If people don’t like, trust, or agree with one another then they may only be able to try short-term, modest, low risk actions. It is more important to act than to agree. Success means we can get unstuck and take a step. I can think of instances of this in our public health work: most recently, the action to support legislation that would pilot a supervised opioid injection facility in Denver as a pilot project. This goes against ideals around the “war on drugs,” however it is an action that may produce results of saving lives and gain lessons to inform the next step. We can’t hold on to cherished ideas at the expense of the emergence of something new. Kahane points out that artists do not manifest already-finished mental pictures. Picasso destroyed images on his canvas covering them up with new images over and over again.
 
Lastly, to use Stretch Collaboration, we must step from the sidelines into the game of engaging with our “enemies” and then alternately conflicting with one another. This means we must see ourselves at part of the situation. Are we late getting home because of “that darn traffic” or because we are part of the traffic? If you’re not part of the problem, then you can’t be part of the solution.
 
I have no illusion that this will be easy. I know for the collaborations I currently participate in, Stretch Collaboration would mean inviting people that have contradictory ideas to those we currently have in the group. It would mean throwing away the group norms, values, and agreements we came up with. It would be a painful process of listening to those I don’t agree with, truly listening, and arguing my point when necessary while allowing them to argue their point. It would mean taking an action without a complete plan. And mostly it will require me to be uncomfortable as I become part of the traffic and stop blaming the traffic jam.

By Peter Manetta
The idea of “advancing health equity” is a powerful mission or vision, but makes a lousy action-oriented goal. That’s why I was excited to spend an afternoon during our recent Health Equity Advocacy Cohort convening discussing the lack of affordable housing, a major health determinant and pressing equity issue for every Colorado community.
 
We participated in round-robin discussions with mostly Denver-based housing advocates, and one advocate from Grand Junction who provided a more rural perspective. One of the groups, Denver Homeless Out Loud, described how the metro’s recently enacted camping ban, which they refer to as a “survival ban,” has affected their lives. They feel that this ordinance puts them in the position of choosing safety and shelter over obeying the law. And as Homeless Out Loud frequently points out, there is nowhere for most folks to go once the police kick them out of a camping spot. Affordable housing is unavailable, and these advocates described shelters as being no safer than prisons, with thin mattresses on the floor spaced inches apart, violence, drug use, and the resulting increased rates of infectious disease transmission.
 
But there’s a small bright spot for a handful of Denver’s homeless in a pilot-project of tiny-home communities. These small “villages” of a few homes each can be erected quickly on undeveloped lots and have a low environmental footprint. City leaders nominally support these villages, and the mayor leveraged their promising start as a public relations success story (you can follow the tiny-home village project here). But the city had nothing to do with funding, organizing, or building the homes. That was accomplished by a coalition of advocates and private funders. Also, the village zoning permit is temporary, and the villagers will be forced to move every 6 months unless there are permanent zoning changes. Village and other homeless advocates are pushing for more permanent zoning exemptions, but it is unclear why city leadership would so openly support something while allowing policy barriers to impede it.
 
It’s perhaps too easy to blame property developers’ political influence over city government, though this may well be the main barrier. Another major factor might be old policies challenged by new, unanticipated situations. If this is the case, then a thorough examination of our communities’ land use and zoning rules could reveal opportunities to incent affordable housing development and advance housing-first policies with a win-win approach. Some smaller changes demonstrate this possibility. Homeless advocates have been asking for more trash cans, public restrooms, and storage lockers. These won’t solve the affordable housing problem, but such changes would benefit the homeless population while creating cleaner, healthier public spaces. These are bite-size policy changes that, if successful, could build trust and good will between opposing groups, perhaps paving the way for closer collaboration on more comprehensive efforts.

By Shannon Kolman

Although I missed the Colorado Health Symposium last month, I did catch some of the recorded presentations. One that caught my attention was a keynote talk by the columnist and political commentator Sally Kohn. She put forth a call to action to stop hate. Her fundamental belief is that there is too much hate in the world today, that it is spreading like a virus, and that it will keep spreading if we each don’t do something about it. 

Sally touched on the fact that there is a human tendency to define “us and them.” The human brain is wired to make distinctions and to note differences. It is part of our survival mechanism. I recently attend the Center for Health Progress luncheon which featured Rinku Sen, an activist and former president and of Race Forward and publisher of Colorlines.com. She spoke about the fact that although the idea of being “racially color blind” (e.g. disregarding racial characteristic, or saying race doesn’t matter as a way to address discrimination) sounds like a good thing, it isn’t possible. Our brains are not wired that way. In researching this idea of being color blind, I ran into an old (2011) Psychology Today article that suggested rather than being color blind, what if we became more multicultural by recognizing and valuing difference, by learning about differences, and by fostering alliances. Sounds good, but how do we do that?

This suggestion is similar to the three tools that Sally Kohn noted for becoming aware of and putting a halt to our own hate. The word hate seems harsh, and an easily Googled definition states that hate is an intense or passionate dislike for something or someone. So, I would have to agree with Sally that we all hate in varying degrees; we all have implicit and explicit biases, especially given the current political climate, that cause us to feel intense dislike toward certain groups of people or ideas. Sally suggests we use 1) counter networks, 2) counter speech, and 3) counter spaces to bridge the divides hate creates and to breakdown the “virus of hate”. So how do we do that?

Sally gave concrete examples of how we can break down our hate barriers. She is calling for each of us to become extremely self-aware of how we perpetuate our own thinking and ideas, and to step out of our comfort zones to at least consider the ideas of other groups we hate. She gave some compelling statistics such as the fact that three-fourths of white Americans have no black friends, and that most Americans do not have friends on the opposite end of the political spectrum. She also noted that we use “narrow-casting” with our own news stations to reinforce our own beliefs. What we need, Sally says, are real life social networks that counter our in-group out-group divides – and that doesn’t happen by accident, we have to make it happen. Just by getting to know the people you hate, stereotypes start to be challenged and the divisions we’ve created start to break down.

Counter speech requires us to respond to ideas and people we hate by being nice – listening, connecting, and humanizing. When we hate we dehumanize people and counter speech can help to humanize those with disagree with. The idea of counter spaces challenges us to not only build networks of people unlike ourselves, but to step into spaces with people who have ideas and beliefs unlike our own. This is supported by research that shows that children who go to racially integrated schools do not exhibit unconscious racial bias, much less conscious bias. These kids are not color blind they just don’t dislike or hate the other kids who look different than themselves because that has become an accepted difference in their minds.
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Sally’s suggestions are no easy task. Stepping outside of our comfort zones is uncomfortable and our survival parts of the brain do not like being uncomfortable. She is not the only one offering this challenge though. The August 28th edition of Time magazine featured a collection of articles by leading thinkers called Hate in America. In one portion of the article, Ilhan Omar, a Minnesota state representative and first Somali-American Muslim lawmaker, says “when we interact with those we fear and hate, we will find commonality.” He suggests that to bridge the divide that hate creates we must: 1) realize that most of our differences are exaggerated nuances exacerbated by uncompromising ignorance; 2) see others’ struggles as our own, and their success as our success so we can speak to our common humanity; 3) build a more connected society, using our resources to uplift one another so we collectively benefit. There’s certainly a challenging theme here. The question is, are we up to the challenge?

By: Peter Manetta

​Sixteen CALPHO directors and executive committee members attended last Friday’s Funding and Financing Symposium, hosted by the Center for Public Health Practice. Below are some thoughts from Rio Grande Director Emily Brown and Tri-County Executive Director John Douglas:

• “The Public Health Funding/Financing Summit was a valuable opportunity to talk about this topic with a broad range of public health partners.  There was time to reflect on how far our public health system has come since the 2008 act, as well as learn more about the history and timing behind the act.  We were reminded of articulating the importance of public health's value and finding ways to communicate this in a language, and with a direct "ask", that resonates with our legislators, commissioners, and the public.  For me, this discussion also further highlighted the continuing disparities between large and small health departments.  The answer is not as easy as just increasing funding. I look forward to the next phase of this discussion so we can be prepared, when the timing is right, to take the next step towards improving our public health infrastructure.  (Also - the CU South Denver campus was a beautiful location.  I appreciated the opportunity to see a new facility in our state!)”                                                                         -Emily Brown, MPH, CPH

• “The symposium did a great job of diving into the unsexy but critically important topic of how to do a better job of funding core public health services. I learned a lot of important history about this topic in Colorado, and, more importantly, gained a renewed understanding of the essential importance of better ‘telling the public health story.’”                                                                                                                                                     -John Douglas, MD

While funding and financing public health was the symposium’s topic, the conversation was dominated by how we communicate the value of public health. This challenge is an old one. We have long recognized the difficulty behind demonstrating the value of public health when success is often defined by nothing happening. It is important to continue the branding-messaging-value-proposition conversation, but it might be more productive to consider communication tactics as a supporting element of a larger funding reform strategy. The specific funding and financing reform effort we choose to pursue will directly inform how we communicate our value. Each potential strategy has different audiences, timing considerations, channels, stakeholders, and opponents. For instance:

• Convincing county commissioners to contribute more than the minimum per capita contribution to their LPHA. The direct audience for this effort would be the commissioners, but we would also consider the voters who put them there and organizations they listen to as potential campaign targets. This could be a multi-pronged strategy: LPHAs and their partners making direct appeals, presentations at CCI, development of messaging frameworks for local policymaker and community engagement, and op-eds in local papers. Recruiting the National Association of Counties (NACO) to support our message might also be part of the effort.
  
• Reforming the Public Health Act. Communication tactics for this strategy would primarily target state legislators with direct education and testimony. We could also develop messaging guidelines for advocacy and activist partners, leveraging their communications clout to amplify our own. Such partners could also engage in direct advocacy with legislators’ constituents and such an effort would probably require campaign-style communications tactics, including traditional and social media.
  
• Initiating a Wellness Trust. This strategy, like Massachusetts’ Prevention and Wellness Trust, is a method of financing prevention with funds from the health care sector. So far, wellness trusts funds have been applied categorically to chronic disease prevention programs both in and outside of governmental public health, but one can imagine a version that bolsters long-term, operational public health funding streams. Their justification is based in language of health care cost reduction, the triple aim, and “population health.” Whether we would choose a ballot or legislative avenue for this, communications tactics would probably focus on the likely opposition: hospitals and other large providers. Hopefully this would not be a contentious effort, but would instead attempt to strengthen current public health-health care partnerships to build consensus around the concept of a wellness trust. We might use the “population health” language they recognize, stressing that a trust would support their payment and delivery reforms already under way. Something like a wellness trust might only happen with the health care partners as an ally, with their better-resourced communications leading the advocacy effort. Learn more about wellness trusts here.

During the symposium, Senator Irene Aguilar, one of the legislative panelists, and Boulder County Public Health Director Jeff Zayach pointed to the 800-pound gorilla riding the elephant in the room: TABOR. Overcoming this obstacle would obviously be bigger than public health. This effort would be about the philosophy of government funding in general, and messages about public health’s value would be just a small part of a large, coordinated campaign. Such an effort would also remind us that we are not alone, that our country’s dwindling social investments has hurt many other sectors like education, human services, and transportation. 

From this perspective, there is collective approach to communicating our value, using the concept of infrastructure. Lee Thielen, former Executive Director of CALPHO and part of the symposium’s opening plenary, hinted at this concept by quoting a recent blog in Health Affairs: “At the end of the day, we must acknowledge that public health is part of the vital infrastructure of a modern, secure, economically competitive, and just nation.” Perhaps this simple message can guide us until we have a specific funding-financing reform strategy to support.

By: Peter Manetta

The National Academies recently hosted a rural health equity summit with panels on the role of philanthropy, community organizing, economic prosperity, and issues around health care access. Among the economic development panelists was Brian Lewandowski, an economics professor at CU Boulder and the main author of a rural community resiliency study released last year. This study compared Colorado rural communities on different demographic and economic indicators. As you might expect, factors like industry diversity, strong leadership, and solid infrastructure tend to increase a community’s economic resilience. But just as impactful are forces that we in public health refer to as the social determinants of health: quality affordable housing, educational achievement, social connectedness, and collective efficacy.  

This alignment of economic resiliency measures with social determinants could be a useful messaging concept for local health equity champions who might be struggling to engage business interests (or folks who share their ideology). The typical economic justifications for advancing health equity focus on the same factors as primary prevention in general: deferred health care costs for governments, employers, and insurers. But reducing health care costs might not be as strong a motivation for some rural business leaders. Unless you are a large employer, rural business communities may be too far removed from the direct benefits of reduced health care costs and other macroeconomic indicators. But successfully tying health equity to economic resilience at the local level could result in its inclusion as both a desired outcome and a driver of economic development. This focus on economic growth also aligns with the WHO’s Rio Political declaration on SDOH, which includes a resolution asserting the importance of “delivering equitable economic growth through resolute action on social determinants of health across all sectors and at all levels.”

Part of CALPHO’s work in Phase 3 of the Trust’s Health Equity Advocacy Cohort is developing this kind of messaging. Along with our Cohort partners and with assistance from consultants at the Center for Social Inclusion and Seigel Public Affairs, we are exploring health equity communications strategies for all types of audiences. We expect these efforts to be quite fruitful, but just as valuable is input from local public health professionals with frequent experience discussing public health concepts in their communities. We would love to hear about strategies that have been effective for you or ideas you may have, so please email us!

Peter Manetta (CALPHO Project Coordinator) and Ashley Gallegos attended this conference, organized by the Haas Institute, from April 30 – May 2. Below of are some of their thoughts on this exciting conference:
 
Ashley:
The time I spent at the Othering and Belonging conference was tremendously meaningful, I am thankful to have had the opportunity to attend. The combination of current worldly topics dissected by scholars and activists with the weaving in of art and expression created a powerful experience. The Haas institute created a safe place to have difficult conversations and to challenge each of us to  acknowledge our own barriers, our own judgements and to reduce the othering that we engage in personally and in our work. We were encouraged to create spaces of belonging, meaning practicing consideration and inclusion even with those that hold different views than our own. My biggest take away is the understanding that belonging isn’t one size, no one person or group determines its contents, it is instead, the result of giving space, valuing differences and making decisions based from an understanding of our deep interrelationship.
 
 
Peter:
Othering and Belonging brought together luminaries and pundits who are leading national conversations on race equity and social justice, and it was certainly exciting to hear from the vanguard of a snowballing movement. Perhaps more illuminating were the informal table discussions that followed the expert panels, where I found comfort in the realization that our peers in other states feel many of the same frustrations. One issue we all seem to struggle with is finding the right balance between educating ourselves and our peers (convening, fostering open dialogue, capacity building) and taking more direct action (policy advocacy and development, legal action, nonviolent protest).
 
I felt this most strongly after hearing the most energetic speaker of the conference, an Oakland-based labor activist who had only 5 minutes to speak because she was on her way to lead a May-day protest. After the standing ovation subsided and she had rushed off, the distinction between her day of action and our day of dialogue could not have been in greater contrast. As she headed out to the street with a raised fist, we sat in a soporific conference hall discussing how to move forward!
 
Obviously, we must act, and I think working in public health qualifies as a basic level of action. We and our partners are carefully planning how to move beyond the basic, but of course we cannot wait for equity concepts to reach a saturation point in our field. There are windows of opportunity to exploit and urgent needs to address. But those future actions will be more effective, inclusive, and informed because we participated in convenings, trainings, and open dialogues. Bay area communities started their dialogues decades ago and continue to sustain them, and their progress on some equity outcomes is evident (albeit slow). I don’t think it’s a stretch to say that their community’s sustained dialogue and education strengthened the Oakland labor leader’s activism and broadened her reach.
 
I could go on for pages about other inspiring and thought-provoking elements of the conference, so I’ll stop with one clear takeaway: we must create and sustain similar experiences for our own communities. We can certainly learn from other states’ successful initiatives, but Colorado is so different from the Bay area, from the pacific northwest, and from New York – our movement must be homegrown.
 

By Shannon Kolman, CALPHO Project Manager
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Health equity has become a popular and widely used term in recent years, however if you ask a group of people what health equity is you’re likely to get a variety of definitions. The definitions that I prefer the most talk about health equity as a state in which all people, regardless of race, ethnicity, religious beliefs, income, or address have the opportunity to attain their full health potential. This requires valuing all people and addressing inequalities.

Staff at CALPHO have been intimately involved with health equity work over the past few years through participation in The Colorado Trust Health Equity Advocacy (HEA) Cohort, which includes 18 organizations from areas throughout Colorado. The work of the Cohort is not easy, in fact it’s darn hard. Health inequities stem from centuries of policies, systems, and beliefs that were often intentionally designed to result in more opportunities for some and less for others. As Nelson Mandela said, “poverty is not an accident. Like slavery and apartheid, it is man-made and can be removed by the actions of human beings.” The same is true of health inequities. However, addressing the insidious and deeply rooted nature of health inequities requires looking at infrastructure in our society, and this is no small matter. There is no easy fix. There isn’t one program that will make even a large dent, only many seeds, planted one by one, that eventually lead to a different landscape.

As groups like our HEA Cohort start to emerge among local public health agencies (LPHAs), we have heard an all too familiar tune. It goes something like this: “our health equity team is only talking, we’re not doing anything”, and “health equity work is much too process oriented, we want action”.  We know the feelings well. Our HEA Cohort struggled for years with the process of understanding what health equity really is, with developing enough trust to talk about really difficult issues, and dialogue that was necessary to lift up underlying issues.  Unfortunately, this process cannot be skipped if we truly want to work toward health equity.  Fortunately, the talk is more than just talk.
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I recently heard a presentation about using dialogue as a vehicle for change. The presentation helped me understand that, if done properly, dialogue is action. To conduct effective dialogue, it’s important to understand: 

• Dialogue is not a conversation. A conversation is more casual and often includes focusing on differences or taking sides. Dialogue is directed and channels energies to provide a context from which new associations and ideas can be presented.
• Dialogue is not a didactic type of discussion which focuses on a unilateral exchange of information. Dialogue is a mutual exchange of information in an environment that encourages everyone to learn and embrace what is not known.
• Dialogue is not a debate which has an emphasis on persuasion.
• Dialogue emphasizes listening. This includes listening to others, with respect of their views and experiences, as well as listening to ourselves through reflection.

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If these ideas about dialogue are interesting to you, take a look at the book Dialogue: The Art Of Thinking Together by William Isaacs, who presents these and other concepts to get people talking together for real change.  In the meantime, enjoy the ride, sprinkle some seeds and see what grows.

By Kim Gonzales, Executive Director of Las Animas-Huerfano Counties District Health Department

​Las Animas Huerfano Counties District Health Department (LAHCDHD) was contacted in fall of 2015 by Colorado Department of Public Health and Environment (CDPHE) about ASTHO’s (Association of State and Territorial Health Officials) Million Hearts learning collaborative. The primary focus was high blood pressure and community-clinical linkages relating to the condition. As a public health department serving the unique needs of two rural/frontier counties, we already viewed the creation and maintenance of these types of linkages as our duty in enhancing public health. Our mission statement starts with “In partnership with the community.” This was a perfect fit. 
 
Since accepting the opportunity to work on a learning collaborative under the guidance of CDPHE, we have implemented a standardized blood pressure measurement guideline, a protocol for identification of hypertension and referral to primary care, and a bi-directional referral process. This has all been in partnership with primary care clinics and other community agencies. Community members are identified with high blood pressure, and we are now asking their permission to send a referral to be seen at their primary care provider’s office. Primary care clinics then make a phone call to schedule an appointment. Getting high blood pressure treated will go a long way towards achieving the Million Hearts goal of reducing heart attacks and strokes by 1 million.
 
We were excited to leverage worksite wellness deliverables as we scheduled worksite blood pressure screenings. Not surprisingly, there were a number of community members shocked to find they had high blood pressure. We shared the collaboratively developed referral list with these folks and recommend referral to resources. From now on, each agency can make same-day referrals for primary care, exercise classes at Mt. Carmel Health and Wellness Center, tobacco cessation classes at the health department, diabetes workshops at Mt. San Rafael Hospital Clinic, or Chronic Disease Self-Management workshops at Spanish Peaks Outreach Clinic. As referrals are received and phone calls are made, each agency provides feedback regarding the referral status. Our communication has improved tenfold with the effort we’ve put into the Million Hearts Initiative.
 
Our biggest success has been a newfound strength in collaboration. We never knew how much we had available until we worked together for a few months developing the referral system. We cannot go back to the way things were before joining the Million Hearts Initiative. The referral forms we’ve created are in use at various agencies across both counties, and awareness is increasing regarding available resources. Our counties are growing and changing. The Million Hearts Initiative and ASTHO learning collaborative have positioned us and our Million Hearts Partners to walk forward together into a new and hopeful future for the bi-county region; a future in which medical establishments are aware of what is available to their patients for them to lead healthy, productive, happy lives. One day it will be as simple as the click of a button. And all this was made possible through ASTHO’s learning collaborative and our participation in the Million Hearts Initiative.