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.
​
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
​
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.
​
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.

​
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.