MetroDoctors Winter 2022: TCMS is now Advocates for Better Health

Dr. Crutchfield Sees All Patients Personally. Specializing in all hues of skin, including skin of color. Experience counts. Quality matters.

Recognized by Physicians and Nurses as one of the best Dermatologists in Minnesota for the past twenty years.

“YOUR PATIENTS WILL THANK YOU FOR REFERRING THEM TO DR. CRUTCHFIELD”

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Metro MetroDoc tors

Doc Winter Index to Advertisers

ABH Officers

President: Zeke McKinney, MD, MHI, MPH

Secretary: Cora Walsh, MD

Editor-in-Chief: Thomas E. Kottke, MD, MSPH

Managing Editor: Nancy K. Bauer

Editorial Board Members:

Clare Buntrock, Medical Student

Carol Coutinho, Medical Student

Dennis Cross, MD

Peter J. Dehnel, MD

Edward P. Ehlinger, MD, MSPH

Robert R. Neal, Jr., MD

Lynne Ogawa, MD

Richard R. Sturgeon, MD

Production Manager: Sheila A. Hatcher

Advertising Representative: Betsy Pierre Cover Design by Amber Kerrigan

MetroDoctors (ISSN 1526-4262) is published quarterly by Advocates for Better Health, 2355 Fairview Ave, #139, Roseville, MN 55113. Periodical postage paid at St. Paul, Minnesota. Postmaster: Send address changes to MetroDoc tors, Advocates for Better Health, 2355 Fairview Ave, #139, Roseville, MN 55113.

To promote its objectives and services, Advo cates for Better Health prints information in MetroDoctors regarding activities and interests of the society. Responsibility is not assumed for opinions expressed or implied in signed articles, and because of the freedom given to contributors, opinions may not necessarily reflect the official position of ABH.

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Non-members may subscribe to MetroDoctors at a cost of $15 per year or $3 per issue, if extra copies are available. For subscription information, contact Nancy Bauer at (612) 623-2893.

Treasurer: Alex Feng, MD, MBA

Past President: Sarah Traxler, MD, MSPH

At-large: Ryan Greiner, MD

ABH Executive Staff

Becky Timm, MA, CEO (612) 362-3715; btimm@metrodoctors.com

Nancy K. Bauer, Associate Director, and Managing Editor, MetroDoctors (612) 623-2893; nbauer@metrodoctors.com

Lucy Faerber, MPH, Program Manager (612) 362-3739; lfaerber@metrodoctors.com

Patrick Jones, Director of Finance and Operations (612) 362-3705; pjones@metrodoctors.com

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Kate Feuling Porter, MPH, Senior Program Manager (612) 362-3724; kfeuling@metrodoctors.com

TRIA Physician Recruitment

Outside Back Cover

This annual scholarship is provided to a University of Minnesota Medical Student, with a focus on those currently underrepresented in medicine, for excellence in leadership, service, and advocacy in health care.

Meet the 2022 ABH | The Foundation Medical Student Scholarship Recipient Amarachi Orakwue, MS1

ABH | The Foundation CEO Becky Timm presented Amarachi Orakwue with the 2022 Medical Student Scholarship Certificate at the scholarship luncheon sponsored by the UMN Foundation.

5 IN THIS ISSUE Safety is Privilege

By Thomas E. Kottke, MD, MSPH 6 ABH: Where Physicians Can Pour Their Passion for Doing Good Beyond the Clinic

By Becky Timm, MA, CEO 8 Decriminalization of Poverty: A Potential Tool to Improve Public Safety

By M. Etienne Djevi, MD, Guest Co-Editor

THE INTERSECTION OF PUBLIC SAFETY AND POVERTY 10 • COLLEAGUE INTERVIEW: A Conversation with Jennifer DeCubellis 14 • A Public Health Approach to Public Safety By Gretchen Musicant, RN, MPH 16 • Simply Acknowledging Missing and Murdered Indigenous Women is Not Enough We Need Action By Senator Mary Kunesh 18 • “Do No Harm” Amidst Cycles of Structural State-Sanctioned Violence and Adverse Pregnancy Outcomes

By Yusra Murad and Kene Orakwue, MPH 20 • Healthcare’s Role in Firearm Violence Prevention

By Bjorn Westgard, MD, Kentral Galloway and Danny Givens

• Homelessness is Not Having a Stable Place of Peace By Khalique Rogers

• PAID EDITORIAL: Is Mohs Surgery Right for You? By Joseph Shaffer, MD

• ENVIRONMENTAL HEALTH: Highways, Urban Farms, and Housing Density: The Connection Between Health, Poverty, Racism, and the Environment

By Holly Swiglo

FUTURE PHYSICIAN LEADERS

It’s Time to Reimagine Public Safety and Medicine’s Role

By Ayomide Ojebuoboh, MD-PhD Year 2

Twin Cities Medical Society is now Advocates for Better Health, a place where physicians can pour their passion for doing good beyond the clinic walls. See article on page 6.

By Thomas E. Kottke, MD, MSPH Editor-in-Chief, MetroDoctors

Safety is Privilege

A homicide rate that is eight times that of non-Hispanic whites. A many-times higher risk of being shot by police while unarmed. Unemployment. Poverty. This is what young Black men in America are facing. In Between the World and Me, Ta-Nehisi Coates tells his 15-year-old son that, growing up in Baltimore, he was in constant fear of violence at the street corners and from the police. The experience of youth and young adults in North Minneapolis makes clear that this same fear permeates the lives of Black, brown, and Indigenous people in our own community. On top of the violence, stack inadequate educational opportunity, unemployment, and poverty. In response, we’ve focused this issue of MetroDoctors on the intersection of poverty, race, and public safety.

When the editorial board decided on this theme, we immediately asked Dr. Etienne Djevi to co-edit the content with me. Dr. Djevi, in addition to providing infectious disease consultation in the Allina Health system, is deeply engaged in promoting equity in his community of Roseville. He both serves on and chaired the Human Rights, Inclusion, and Engagement Commission (HRIEC) and is a member of the Multicultural Advisory Committee (MAC) with the Roseville Police Department. In recognition of his contributions, he was nominated to be Grand Marshal of the 2022 Rose Parade. I cannot think of a better person to curate a discussion of public safety, particularly as it intersects with race and poverty.

Mentorship matters. Its positive impact on the lives of young people of color surfaces repeatedly in the literature. A personal story that is close to home proves this point: Over the past several years I’ve had the pleasure and privilege of knowing Dr. Dennis Cross, a colleague at work and a member of the MetroDoctors editorial board. Dennis grew up in Milwaukee and Mississippi, and after Dennis returned from his tour of duty in Viet Nam and Cambodia, he went to college because he could use some of his GI Bill money to pay for his car. Failing in his humanities and social science courses because of his Black Panther politics, he met Helen Kittsley. I want to share (I have his permission) what he wrote:

I will never forget Helen Kittsley, “…Dennis I used to be a racist, but I’m not anymore” (Student advisor/counselor) at the University of Wisconsin 1972. This was before it was “fashionable” (my words) to ally with Black Men...She knew the lay of the land... meaning she understood the white male teacher mentality and gave me specific tools to navigate structural racism inherent in the delivery and teaching of college courses. “Take all Science and Math courses. I will help you register for them.” Fast forward 24 months and she asked me one day. “Have you ever thought about going to medical school?” I said “What?”

The ”What?” became a long and successful career in the practice of nephrology and general internal medicine in a southern suburb of Minneapolis.

I hope you appreciate the articles in this issue of MetroDoctors, and the real-time stories of the violence being experienced today by the members of our Black, brown and Indigenous communities.

Over the summer, TCMS became ABH: Advocates for Better Health. Our mission is focused on creating a healthy, equitable, and thriving state by engaging physicians and medical students in community-driven public health initiatives. Join us in using your skills and resources in mentorship and advocacy. And, if you see a young person of color who would benefit from mentoring, don’t just say something, do it! Mentor. Advocate. Join me. Join us. Advocate for better health.

1853

Minnesota Medical Association formed 1855 Hennepin County Medical Society (HCMS) founded 1870 Ramsey County Medical Society (RCMS) founded 1883

Passage of the Minnesota Medical Practices Act raises the qualification standards for physicians to practice 1888

University of Minnesota Medical School founded 1897 Eduard Boeckmann, MD donates medical and research library to RCMS

1900s

HCMS/RCMS offer free lectures on public health issues at libraries

1952 Charles Bolles Bolles-Rogers Award established 1950s

Group practices emerge. HCMS/ RCMS provide business consultation 1957

HCMS/RCMS sponsor a mass chest x-ray survey in which more than 300K persons are examined 1970s

HCMS/RCMS launch philanthropic foundations; HCMS sponsors Mass Rubella Immunization Project in which 737K children are immunized 1971

HCMS establishes Foundation for Health Care Evaluation (now known as Stratis Health) 1975

HCMS launches Physicians Health Plan (PHP, now Medica) 1977

HCMS develops 1st in nation Centralized Hospital Medical Staff Credentialing Program 1980

HCMS/RCMS establish Senior Physicians Assocation. HCMS founds MN Medical Insurance Exchange (precursor to Midwest Medical Insurance Co, now Constellation) 1990s

HCMS establishes a scholarship for medical students and RCMS creates physician recognition award for community service

ABH: Where Physicians Can Pour Their Passion for Doing Good Beyond the Clinic

Building on the Past ABH traces its earliest beginnings to the 1850s, and much has changed in medicine over the past 170 years. We know that long-lasting organizations need to evolve or become extinct.

I had the opportunity to learn from our past physician and staff leaders, who like us today, also served during times of organizational transition. By diving into past issues of MetroDoctors, I read about these leaders as they responded to demands for change rising from physicians. With each transition, these forerunners laid out a new vision and the next service model for the many iterations of county medical societies which served the Twin Cities area since 1855. Together, we are the new generation of leaders to respond to the call and begin designing the next framework for serving our community.

As the first medical societies were founded, we can make some safe assumptions about the general composition of the leadership and membership. White, male, upper-class, with few family and household responsibilities, and many who were independent practitioners. This organizational composition has been relegated to the dustbin of history by the rapid changes in medicine, and by today’s physicians and the ever-changing healthcare work environment.

In 2022, the incoming class at the University of Minnesota Medical School Twin Cities Campus has a majority of female students and students of color. Many students come from families in which they are the first college graduates and medical students. More students are immigrants or second-generation immigrants. Household and child-raising responsibilities are more equitable but continue to fall primarily on the shoulders of female physicians, residents, and medical students.

As of 2019, more than 84% of Minnesota physicians are employed, and that number will likely increase after the COVID-19 pandemic. Unfortunately, the escalation of stress and moral injury experienced by physicians, residents, and medical students has led to corresponding poorer health outcomes and a higher incidence of suicide for physicians. Clearly, former ways of operating a professional medical organization no longer work.

A New Kind of Medical Society

In the tradition of volunteer leadership, in 2021 the physicians, residents, and medical students serving on the Twin Cities Medical Society (TCMS) Board of Directors knew it was time again to make bold and strategic organizational changes. The Board stewarded a year-long process for TCMS to design the next iteration of organized medicine. Our data collection process included conversations with physicians, residents, medical students, educators, healthcare leaders, public health professionals, community members, and donors, along with trend analysis for membership organizations, and a review of emerging issues in medicine and public health.

Grounded in these findings, the Board approved the updated branding and name change to Advocates for Better Health to better reflect our future. Our Board and staff are developing the newest model of service for ABH to continue to support our physician community and to expand our impact for better public health.

By BECKY TIMM, MA, CEO

ABH Mission

We are dedicated to creating a healthy, equitable, and thriving state by engaging physicians and medical students in community-driven public health initiatives.

ABH Vision

To be the organization where individuals or communities can turn to for physician-led expertise and engagement, and where physicians can pour their passion for doing good well beyond what they may be able to do within their everyday work.

Your Passion can Make a Difference

In conversations with many of you, I have heard you say you need more support to continue as physicians, residents, and medical students. In a recent study from the Mayo Clinic, one in five physicians plan to leave medicine altogether and one in three doctors plan to reduce their work hours. Working conditions and on-the-job realities for physicians are changing and you need an organization which is adaptable, informed, and passionate enough to meet you where you are today.

We at ABH are evolving our holistic service model to help meet your professional and human needs. We commit to asking for your input and responding with innovative programming. We commit to providing opportunities for you to work together to pour your passion into making substantive and community-collaborative changes in public health. We commit to creating means for you to serve as physician mentors and to be connected to a physician mentor we know this re-energizes your work. And lastly, we commit to supporting your wellbeing through the physician-centered programs offered by the Physician Wellness Collaborative. ABH is listening and laying the foundation for the professional organization you need now.

Make Real Change by Being an ABH Member

Supporting physicians, residents, and medical students, in ways informed by your needs and interests, is the reason for evolving into Advocates for Better Health. Our organization is powered by members like you.

From COVID-19 to climate change to public safety, the last three years have thrust public health into the spotlight. It is abundantly clear that realizing our vision of healthy, whole patients will require physicians to make significant changes not just within our clinics, but within our communities as well. Support ABH’s ongoing and future public health initiatives by joining Advocates for Better Health or renewing your membership.

ABH | The Foundation

Our physician-led philanthropic organization is ending another successful year striving to improve the health and wellbeing of the community through strategic initiatives. With generous support from donors like you, the Foundation supported eight organizations with grants totaling more than $64,000 in 2022.

Since 1989, the Foundation has awarded an annual scholarship to a University of Minnesota Medical Student traditionally underrepresented in medicine in cluding Black, Indigenous and people of color, LGBTQ+, and students with disabilities for excellence in leadership, service, and advocacy in health care.

Since 1952, the Foundation has awarded the Charles Bolles Bolles-Rogers award to a physician of excellence. Two physicians received this honor in 2022 Ellen Coffey, MD, an internist at Hennepin Health, and William Wheeler, MD, pediatric pulmonologist from Children’s Respiratory and Critical Care Specialists.

To continue this philanthropic work, we invite you to make a tax-deductible donation at metrodoctors.com/foundation. Your contribution will support the Foundation’s mission to help local organizations improve the health and wellbeing of the community. After making your donation at metrodoctors.com, learn more about opportunities to serve on the Foundation’s Board of Directors.

1999

HCMS/RCMS publish a merged membership journal MetroDoctors Early 2000s

HCMS/RCMS connect with medical students: particiating in the White Coat Ceremony, coordinating the Shadow a Physician Program, and hosting lunch and learn presentations 2004

RCMS becomes Accredited CME Provider

HCMS and AMA publish Abuse-Free Medical Workplaces 2008

2005

HCMS/RCMS advocate for Secondhand Smoke Prevention ordinances and Clean Air in metro counties and cities

HCMS/RCMS become West Metro and East Metro Medical Societies (WMMS and EMMS) 2009

WMMS begins partnership with BCBS focused on healthy eating. EMMS launches Honoring Choices MN 2010

WMMS/EMMS merge to create Twin Cities Medical Society - a society wholly focused on public health 2012

TCMS expands BCBS-funded work to include reducing harms of commercial tobacco 2015 WMMF and EMMSF Foundations merge, establishing TCMS Foundation 2018

TCMS launches the Dr. Peter Dehnel Public Health Advocacy Fellowship. 117 students and 73 physician mentors participate to date 2019

TCMS contracts with Physicians Serving Physicians / Physicians Wellness Collaborative to provide administrative services 2022

Advocates for Better Health and ABH | The Foundation are launched as the successors to TCMS and TCMSF

Decriminalization of Poverty: A Potential Tool to Improve Public Safety

“I’m sorry I am late again, Doc,” were the words I heard in the hallway as I was headed out of the clinic. I decided to honor the appointment and started walking back to him and the clinic. During the appointment, my patient told me that he had to take three different buses, then walk about 20 minutes from the last bus stop to get to the clinic. With this context, I was happy that I made the effort to see him. As we continued to talk, I learned that at the root of my patient’s hardship was a suspended driver’s license due to unpaid fines. He didn’t contest the fines or dodge his responsibility. He simply couldn’t afford to pay the fines.

When I accepted to write this article, I wondered how I could approach it. I could go academic with tons of articles to reference, or I could just share how I found myself into community advocacy against poverty. I decided to not go academic for simplicity and reproducibility reasons. Many of today’s challenges are known and well-defined. Solutions are what we need. I believe if I look to ensure that my input is simple and reproducible, then anyone can replicate it and optimize it for a better overall impact.

I was born to farmers in Benin, West Africa. Besides fresh food that we had in abundance, we were poor. I owe everything to the hardworking character that my poor parents instilled in me and to the poor Beninese Government that supported me through free public school and universities. This is the reason why I am a strong believer in wellrun government as a means to lift the poor out of poverty.

Conversely, there are governments throughout the world that have created second-class citizens through policies and practices that, unless undone, perpetuate poverty for generations.

In the United States, the legacy of slavery; redlining; discrimination in educational, housing, and employment opportunities; and mass incarceration through the failed

By M. Etienne Djevi, MD

war on drugs, represent some of the ways the government continues to perpetuate poverty.

We are not all born under the same circumstances and we do not start the game of life with the same opportunities. However, we all aspire to a life where we can meet our basic needs such as feeding ourselves and our families, putting a roof over our heads, and being able to seek medical care when we are sick. For poor people, these basic needs are often unavailable or perhaps better described as unobtainable.

The world’s resources are not expanding to meet the needs of a growing world population. For the survival of our species, humans will have to find different ways of sharing the resource pie. The wealthy, used to having the largest portion of the pie, will eventually need to share with the less fortunate amongst us. This means paying the working poor a livable wage.

Each of us, as individuals and as institutions, will have to do some introspective work and frankly answer the question When will we understand poverty, its root causes, and the potential solutions?

While we wait for systemic solutions to poverty, we can continue to make small changes where we live. It starts with trying to understand the challenge.

A child who is facing food insecurity and is acting out at school needs not be suspended from school. Rather, the child needs access to food. A child whose father has been incarcerated for years could be acting out in class because he misses the love of his father; or perhaps his mother is over-whelmed and unable to provide guidance. How does a suspension from school help this child or the child’s family? Have we tried to understand any root causes of said behavior or is punishment an easier default response to behavioral disruptions?

During this election season, when a focus was placed on crime and public safety and two mutually-exclusive positions seemed to arise, it is important for us to pause and

ask ourselves a question: Do fines and prison time address criminal behavior across the socio-economic spectrum? As a society, I think we have work to do with poverty-associated public safety issues. We need to identify ways to address crime and public safety that do not perpetuate poverty through fines, license suspensions, and other punishments that limit a person’s chances to work, earn money, and support themselves or their family.

An individual operating a vehicle with a broken taillight, because he cannot afford to fix it, does not need a fine. They need assistance with fixing it. An unpaid fine in that instance can lead to a suspended driver’s license. Unable to drive, they cannot drive to work, or drive their children to school, or drive to a doctor’s appointment. His poverty in the system of punishment makes him poorer, contributing to the perpetuation of poverty with him and his offspring. Should the police even conduct traffic stops for equipment violations, or is the traffic stop itself beyond the scope of policing for public safety? Recognizing this cycle, my local police department has stopped equipment fines. They are currently enrolled in a program that provides coupons to fix broken motor vehicle equipment, and the County Attorney’s Office has discouraged traffic stops related to equipment violations. We are grateful for this concrete action being taken by Roseville Police and Ramsey County not to punish poverty.

Individuals and families who are experiencing homelessness deserve to be connected to a social worker and resources. Recognizing that police officers aren’t experts in social work, housing navigators and social workers are now embedded in my local police department and are trained to connect individuals who are experiencing homelessness to resources. The department has representation at many community advocate and social service meetings and continues to cross-train staff to identify certain indicators related to homelessness, mental health, and substance abuse.

Improving the relationship between police departments and communities, especially communities of color, is critical because officers are the first line of interaction

between communities and the justice system. How do we get police officers to see the humanity in all of us regardless of race, gender, socioeconomic status? Conversely, how do communities accept the fact that police officers are humans who have a challenging and often dangerous job? This is the reason why for years I have worked with my local police department to get officers and people of color, especially Black people, to celebrate Juneteenth together. This dream became a reality in 2022.

Black people in attendance were grateful to see police officers serving and being humans. Officers and community members shared a meal during the event. Some expressed their gratitude for officers being at the event, with incidents like what happened in Charlottesville still fresh on our minds.

I encourage you, as my colleague and reader of this article, to find time to get involved in some aspect of your community and to better understand a challenge or challenges that your community is facing. For me, working toward solutions for challenges of social justice, public health, and climate change bring additional purpose to my life. I have found access points into these efforts through my local government, co-workers, and an ever-growing list of people and organizations who, like me, want to contribute and make positive changes.

In hindsight, my response to my patient should have been, “thank you for all that you did to get here despite all the challenges you are facing.”

To understand or at the least, to try to understand, is a good first effort and a solid step toward finding solutions to the challenges we face as a community.

M. Etienne Djevi, MD is a partner at Saint Paul Infectious Disease Associates. He is a member of the Roseville Human Rights, Inclusion, Engagement Commission (HRIEC), and a member of the Roseville Police Department Multicultural Advisory Committee (MAC). He can be reached at djevi001@ umn.edu.

Colleague Interview:

A Conversation with Jennifer DeCubellis

Jennifer DeCubellis is the Chief Executive Officer (CEO) for Hennepin Healthcare System (HHS), a 484-bed academic acute care hospital, as well as a clinic and specialty care system located in Minneapolis and across Hennepin County. Prior to this role, Jennifer was the Deputy County Administrator for Hennepin County, responsible for Health and Human Service operations, which included over 4,000 employees and a budget of over $1 billion. In addition, she oversaw business alignment with Hennepin Healthcare System.

Jennifer has a master’s degree in Clinical Psychology from the Illinois School of Clinical Psychology and a bachelor’s degree in Special Education (emotional and behavioral disorders) from the University of Wisconsin, Madison. She has more than 25 years in public program administration working across all areas of Health and Human Services with an emphasis on program redesign, system transformations, and quality improvements to ensure positive resident outcomes alongside prudent financial management.

Hennepin Healthcare System (HHS) is a statewide resource for many things particularly trauma care, hyperbaric treatment, poison control, and medical education. What kind of support does HHS receive from the state for these services?

Our system is an incredible resource for the whole state. We op erate like other hospitals in that we get paid for the services we provide based on insurance contracts. This includes our special ization in trauma and hyperbaric treatment, which serves patients from across the state and region. We are also a specialized state resource, for instance with the poison control duties we take on for the State of Minnesota a ser vice operated under grant funding from the state. Graduate Medical Education gets paid through State and Federal programs, and graduates of our programs work in hospitals and clinics across the state today. In 2021, the State legislature recognized Hennepin Healthcare as a state safety net resource and authorized specialized funding through directed pay ments to support the care we provide, regardless of payer source,

to all Minnesotans. Hennepin County also augments funding to ensure access to health care is available to all of its residents.

HHS was one of nine organizations to receive NCQA accreditation for health equity. The ap plication process is arduous. Briefly explain the process and why this program is important for your organization.

Like all accreditations, this takes time and commitment to demon strate that core requirements are built into our health system and standardized in how we do our work. HHS was one of only two provider systems in the nation to receive this accreditation. The other seven are payers. It is easy to say we are working on health equity but it’s critical to truly demonstrate it in all the work we do and to embed it into the core of our organization as demonstrated with this accreditation. Health care won’t change at the root of systemic racism unless those very roots change. We

believe this is a start. Embedding health equity into our policies, procedures, and practice means it will have staying power beyond any one leader or initiative. Our intent is to truly transform how we show up and how we provide care, and we knew that would take a deeper commitment.

HHS has received some negative news coverage related to its use of medications for “excited delirium” and for the relationship between EMS and police. How have you responded to the issues raised?

We used the opportunity to take a close look at our values and our core functions and we made a couple of critical decisions in response to conversations with our community. First, to clarify our role, we ended the practice of allowing dual employment with law enforcement. We had a couple of physicians who were also law enforcement officers and we asked them to choose one or the other. Most chose to be physicians only and one left to work in law enforcement. We also had conversations about the use of the term “excited delirium” as a condition description and made the decision to stop using it. It was being misused by others, so now we use more precise language about specific symptoms. We also made it clear that the evidence-based use of medications for specific conditions would continue. We trust our caregivers and provide the education and information they need to make treatment decisions and then we support them. They are trained to respond to some of the most difficult medical emergencies and they do so every day. Shift after shift, they provide lifesaving care. We also leverage research to ensure we stay at the forefront of best practices and deploy emerging treatments that benefit our patients.

Since HHS is the major trauma center in Minnesota, victims of violence and others associated with the violence frequently show up in the Emergency Department (ED). What are you doing to keep your ED staff physically safe and how are you addressing the staff mental health issues that are often associated with these kinds of stressful situations?

There is nothing more important than keeping our team members well. They cannot perform the lifesaving care we rely on them for if they themselves are not feeling safe and well. This has proven an increased challenge over the last three years as trauma care demand has drastically increased. We focus on safety and well-being every day across the organization. This includes our daily tiered huddles that recognize team members within departments and across

the organization to acknowledge their efforts, their teamwork, and their commitment. We have on-demand supports for team members’ own mental health. Whether it is following an EMS response or a stabilization event, our team members see trauma every day and they feel it too. They would not be the incredible healers that they are if every case did not demand their very best and that can be exhausting, emotional, and heart-breaking. No matter how many lives are saved, when any one is not, they feel it. We have created response teams internally, we have outside resources available, and we have peer supports. Everyone is on alert to look out for team members who may need to tap out for a bit or need additional support, and our goal is to make that not just ok but encouraged. We moved from “healthcare hero” language to the “Humans of Hennepin” recognizing our team members in their humanity, their reality, their incredible gifts and emphasize that it cannot come at the price of self-sacrifice, that their health matters and that healers also must have a chance to heal. This will be on-going work. It is exciting to see the culture our residents are bringing in right now a culture of support, of mental health, and of normalizing self-care.

As the only public hospital in Minnesota, HHS serves many people who are uninsured, homeless/ housing insecure, in mental health crises, and experiencing substance use issues. These factors put these individuals at risk for numerous safety-related problems. What are you doing to go beyond the clas sic “treat and street” approach to one that addresses some of the core societal issues that underlie many of these problems?

We know all too well that safe housing, mental health, chem ical health, and health care in general are a significant part of well-being. And if we are not well, it makes everything else we need to function that much harder. We are working with many community partners to create a true ecosystem of care in an effort to create access to supports and pathways to stability for those we serve. One example of this is at our new East Lake clinic where we are working to bridge social services and health care in a single setting, so there is seamless access to medical benefits, mental health, work and education supports at one site. It ensures that wellness is not just physical but takes into account spiritual care, financial health, cognitive health, and builds a system of support when people need it most.

Poverty affects not only the individuals who cannot work for diverse reasons, but it also affects those who work full time for very low wages the work ing poor. How can you and your organization assist in improving the quality of life of the working poor? Joining the movement of increasing the wages for workers?

We all need to do our part, whether it is helping individuals get healthy enough to work, or as an employer making sure we pay livable wages with benefits and provide career pathways for our team members so they can afford to live in the communities they serve, afford benefits to keep themselves well, and have the supports they need to maintain employment. We have created many of our own training programs to assist people in moving into health care, gaining the training they need while being paid. There are examples of this in our paramedic academy, in our medical assistant/healthcare assistant programs, etc.

What relationships and partnerships does HHS have with state, county, and local agencies who are also focused on enhancing public safety, e.g., Metro Transit, BCA, MPD, DOJ, DOC, Legal Aid, etc.?

As first responders we work closely with other agencies. Whether it is providing medical training for the National Guard responding in Minnesota, covering immunization and vaccination events for the County, or training local fire depts in medical response we all have a role to play to ensure readiness to respond to what our communities need. We partner with the State to meet health needs and make sure we are ready as a state to respond in case of a state emergency such as a natural disaster, a pandemic, or other mass accidents/traumas.

We work with local responders (police/fire) on emergencies that have a medical need such as water rescues, acts of violence, or accidents. We train many local departments on specialized rescues to ensure capabilities exist in the community.

With all your past healthcare experience, what advice would you give medical students and residents as they complete their training in relation to the intersection of public safety and poverty? How can student doctors help now?

Understanding what trauma does to your physical health, your interpersonal interactions, and your response system is important.

The worst thing we can do as healers is respond to only a present ing symptom or issue without seeing the whole person, identifying underlying concerns, and helping create response plans that reduce the many barriers people face in accessing care and provide the supports they need to truly realize optimal health. We will get better outcomes for lower costs by being more comprehensive. This is smart government in action.

What excites you the most as the leader of HHS?

What is possible when we work together as a community. The mission of Hennepin Healthcare inspires me. It is not about a business model, it is about doing right for and with others so we realize health and wellness together. And I see that in action every day team members working on transforming health care and providing exceptional care without exception. They inspire me, they motivate me because they dream big, see no limitations, and are committed to being the change that health care needs to see right now!

What are the greatest challenges for the future of HHS?

Creating new care models to meet the needs of our community in new ways, whether it is on-demand care, new staffing models to address workforce changes, or technologies to elevate wellness for everyone. We also are looking at our downtown inpatient facilities and will be making big decisions about the future of our facilities in the coming years as we reinvest in downtown Min neapolis. There is a lot of positive movement and opportunity, and I believe we are well positioned to transform health care. It will be a heavy lift and we need to move fast. I have no doubt we will get there together!

What didn’t we ask that you would like our readers to know about you and/or HHS?

People work at Hennepin Healthcare for the right reasons: they are here for the mission and the community we serve. That pas sion for this work has carried us through the pandemic, through civil unrest, and into dreaming for the future. It is what creates our “team” here. That will carry us through changing times as we invest in the wellness of our community.

A Public Health Approach to Public Safety

Since the murder of George Floyd, there has been an amplified public discussion about how we improve our collective public safety. The term a “public health approach” to violence and safety has gained more widespread use. As with many terms used in our public conversations about public safety, there may not be a common understanding of that term. As Commissioner of Health in Minneapolis, I had 15 years to explore what a public health approach to violence entails and how to put that notion into action.

How we talk about and describe an issue has a powerful impact on the types of actions and solutions that seem possible. If we conceive of public safety as solely a matter for police and the criminal justice system, then our ideas for action will be limited to that focused policy area. On the other hand, if we think of public safety more broadly, including a public health approach, then the range of strategies can encompass more of the underlying factors that contribute to the risk of violence. Research has shown that community risk factors like living in areas of high concen trations of poor residents and diminished economic opportunities increase the like lihood of community violence.

In 2006, Minneapolis was experienc ing a spike in community violence and the term “Murderapolis” was being ap plied to the City. It was clear to leaders in Minneapolis that while the police were an important element of a public safety strategy, they were insufficient to address all the underlying issues that contribute to violence. The Minneapolis Health

By Gretchen Musicant, RN, MPH

Department convened a small group rep resenting the major cultural groups in the city to identify strengths and gaps in the city’s approach to preventing violence. The group concluded that an important first step was to ask the City Council to declare that youth violence was a public health issue, which they did. As part of that action, they put in motion a yearlong indepth community driven process to flesh out the concept and recommend action.

That work led to the development of the initial Blueprint for Action that has since been revised as knowledge, experi ence, and community needs have evolved. The Blueprint identified three levels of prevention that need to be addressed: pri mary, secondary, and tertiary.

Primary prevention includes those efforts directed at lowering the risks across an entire population. For a physical health issue like diabetes, that might mean im proving access to healthy food and exercise opportunities for most people. Applied to violence, it includes strategies like making sure that all youth have access to caring adults beyond their immediate families through sports, afterschool

programs and organizations like Big Broth ers/Big Sisters.

Secondary prevention includes the ef forts directed towards preventing a health problem among a population with height ened risk. Again, for diabetes, this might include working with people diagnosed with pre-diabetes to develop a personalized diet and exercise plan. When the health challenge is youth violence, the at-risk population might include youth who have violated curfew or who are missing school often. Strategies include intensive youth outreach and case management for young people brought to the City’s Ju venile Supervision Center and engaging more people in diversion activities that bring together the community, perpetra tors of low-level infractions and those who have been harmed by those infractions to reconcile the parties and oversee a plan for restitution.

Tertiary prevention includes ap proaches to limit further harm to those who are already affected by a health prob lem. For the care of those with diabetes this might include efforts to control A1C levels. When applied to violence, there are a number of tested programs that have shown their positive impact. Perpetrators of violence and victims of violence are often very similar in their risks and needs and are both regarded as people included in tertiary prevention programs. One ex ample is a hospital-based program called Next Step, now operating in several Min neapolis hospitals. A staff person who is well steeped in the community and knowl edgeable about resources connects with the person injured through violence before they are discharged and stays connected after discharge. The program has reduced

hospital readmissions and positively im pacted retaliatory violence. Another pro gram is an employment program for gang affiliated young people. The program’s im pact is measured not only in the amount of job training and employment but also in whether the participants are involved in a violent incident while participating in the program.

Many of the strategies to prevent vi olence are relationship based and include helping young people access help with the most fundamental of needs: housing, education, and employment. The fact that most young people impacted by violence need help in this way is a painful example of the inequity in our community. Creat ing more equity across our community will certainly impact the amount of violence that we see.

A public health approach to violence looks at the individual and collective risk and protective factors, and works to en hance resilient factors and address risk fac tors. Community violence perpetrators and victims are statistically likely to be adolescents and young adults, therefore

a focus on assuring positive youth devel opment is closely connected to violence prevention. This includes working to as sure that youth have: positive relationships with adults outside the family; mastery of skills and accomplishments that are valued; and a sense of self-worth and purpose. Unfortunately, there has been a signifi cant, steady, measurable decrease in the investment of public and private funds that help young people achieve these youth development milestones at the local, state, and national levels since 2003.

An important violence risk factor is exposure to and experiencing trauma. Re search is showing that trauma has a clear impact on the nervous systems, affecting how future events are responded to and the risk to one’s health overall. Addressing immediate and long-term trauma should be integrated into health care.

As community safety is reimagined, an important component of improving our current situation requires us to work pro actively to prevent violence and not simply respond to it after the fact. There is a role for each of us in this: as professionals in our

work; through community involvement; and as citizens influencing public policy.

Healthcare providers can screen their patients for trauma and discuss the issue with their patients. They can make sure that they are aware of community resources and are able to refer their patients to them. Healthcare providers can also use their trusted voice to advocate for investments in youth development and violence pre vention efforts.

Link

to Current Blueprint

http://www2.minneapolismn.gov/govern ment/departments/health/office-violence prevention/blueprint/

Gretchen Musicant, RN, MPH, is the re cently retired Minneapolis Commissioner of Health. She received both her nursing and public health degrees from the University of Minnesota and was a Mondale Fellow at the U of M Humphrey School. She is a recipient of the Gaylord Anderson Leadership Award from the University of Minnesota. She can be reached by email at gretchenmusicant@ gmail.com.

Simply Acknowledging Missing and Murdered Indigenous Women is Not Enough — We Need Action

In the past decade, the longstanding problem of Missing and Murdered Indigenous Women (MMIW) is fi nally beginning to get the attention and acknowledgement it deserves. A growing awareness of this historic violence and injustice in Minnesota and across the United States and Canada is pushing lawmakers, nonprofits, and officials in Indian Country to finally acknowledge that the problem has not only imperiled the lives and safety of generations of Indig enous women and girls, but also trapped them and their families in a repeating cycle of violence and poverty.

But simply acknowledging decades of violence means nothing without action, and Minnesota has become a leading force in building national awareness and im plementing lasting, intentional, systemic change.

Indigenous Women Far More Prone to Violence in Minnesota

In Minnesota, Indigenous women and girls are far more likely to experience violence, be murdered, or go missing compared to other demographic groups. Making up just 1% of the state’s population, 9% of all murdered girls and women between 20102019 in Minnesota were Native Indian.

In 2019, the National Indigenous Women’s Resource Center interviewed 105 Native women in prostitution and reported that 79% of the women had been sexually abused as children by an average of four perpetrators, 92% had been raped, 48% had been used by more than 200 sex buyers during their lifetimes, and 16% had been used by at least 900 sex buyers.

By Senator Mary Kunesh

The group’s report, Garden of Truth: The Prostitution and Trafficking of Na tive Women in Minnesota,1 also found that 84% had been physically assaulted in prostitution, 72% suffered traumatic brain injuries in prostitution, and 52% had PTSD at the time of the interview, a rate that is in the range of PTSD among combat veterans. Seventy-one percent had symptoms of dissociation.

Recognizing the horrific data from this report and hearing the generational family stories of loved ones who had gone missing or were murdered with little to no investigation or media attention, Minne sota joined the movement in 2018 with the introduction of legislation,2 intent on creating the Missing and Murdered Indig enous Women’s Task Force. In 2019, the task force was established with unanimous bipartisan support of the Minnesota Legis lature. Completed in 18 months, the pan el’s report3 was presented to the legislature in 2021. That same year, the Missing and

Murdered Indigenous Relatives (MMIR) office4 was created the first permanent, comprehensive office of its kind in the nation.

Centuries of Prejudice, Unfair Systemic and Legal Practices are Root Causes

Findings of the MMIW task force con firmed what Indigenous communities already knew the root of the MMIWR pandemic is racialized and gender-based violence directly resulting from centuries of prejudice and unfair systemic and legal practices. It points directly to the gov ernmental policies of forced removal5 of Native children and separation of families, creation of a predatory and racist child welfare system,6 and the use of police7 and surveillance agencies to criminalize and intimidate Native peoples. Decades of laws prohibited Native people from engaging in cultural and religious ceremony or speak ing tribal languages while perpetuating the social-psychological myth8 that Indig enous women and girls exist to serve white men’s sexual needs. Not to be forgotten is the violence that follows the extraction industry which has directly contributed to the extreme rates of violence toward Native women in Minnesota9 and across North America.

These root causes have led to increased systemic risk factors of violence and abuse among Indigenous women and girls, along with poverty and lack of housing, involve ment in the child welfare system and crim inal justice system, as victims of domestic violence, and involvement in prostitution and trafficking.

According to the U.S. Bureau of La bor Statistics,10 AIAN (American Indian

Alaskan Native) people have the highest poverty rate (23%) and are among the lowest in labor force participation com pared with any other major racial group in the United States. So, it is not surprising that the results are cycles of generational poverty with the poorest of health and economic outcomes. For the past 30 years, child poverty rates11 in AIAN communities have exceeded 40%.

November 30 marks Native Women’s Equal Pay Day,12 designated to highlight the pay gap for Native women, under scored by a long history of racism, sexism, and pay discrimination that continues to devalue the contribution of Native women in the workforce. Native Women work ing full-time year-round, and part-time earn approximately 51 cents on the dollar compared to white, non-Hispanic men. This wage gap perpetuates the genera tional roadblocks that chain too many Native American women and families to poverty a political outcome, not a per sonal choice, keeping them vulnerable to predators and those intent on harm. Nevertheless, stronger pay equity on its own is not sufficient to ensure longterm personal safety and economic mo bility. The intersection of poverty and Minnesota’s missing and murdered Indigenous women cannot be ignored. When equal pay measures are enacted alongside other social safety net and work support policies such as public safety supports, access to health care, paid family and med ical leave, quality and affordable child and elder care, and an increased minimum wage Native women would not only gain pay equity but would also build last ing economic and personal safety for their families.

Wide-Ranging Action Needed to Prevent Further Violence

Violence against Indigenous women is preventable and requires commitment across all systems and sectors of our com munities including the public (governmental), private (business/corporations), nonprofit, educational, military, religious, health care, and mainstream media sectors. Beyond that, health systems need to take

this current awareness and movement to commit to addressing social determinants of health within healthcare delivery sys tems and policy. They need to develop programs, policies, and innovations to prevent and address MMIW and thereby improve the health of communities.

While historic distrust of health pro viders, police, and governmental agencies has prevented many Native family mem bers and survivors from seeking services at a domestic or sexual violence program, they might come into contact with various healthcare systems. Thus, it would be hoove health and public health workers to recognize MMIW as a major public health crisis, acknowledge that the violence caus es grave and lasting harm to individuals, families, and communities, and engage in violence prevention and other solutions that support survivors and families of miss ing and murdered Indigenous women.

Minnesota has been a leader in ac knowledging the history and causes of MMIW; now we all need to act to end the historic injustices of this violence.

Senator Mary Kunesh, Standing Rock Lakota descendant, was elected to the MN House of Representatives in 2016 and elected to the Senate in 2020. She is the first woman of Native descent to be elected a Minneso ta Senator. Mary retired from her role as a public school library media specialist after 25 years’ service and is the Chair of the Missing and Murdered Indigenous Women Task force in MN, as well as the first in the nation, Missing and Murdered African American Women Task force. She also established the permanent office of Missing and Murdered Indigenous Relatives in state government. She has served as an Assistant Majority Leader for the DFL House Caucus and currently holds the role of Assistant Minority leader in the MN Senate the first Native American to hold that role in the legislature. Mary is a founding member of the Minnesota Native American Legislative and POCI (People Of Color Indigenous) caucuses.

References

1. Farley, M., Matthews, N., Lopez, G., Stark, C. and Hudon, E., 2022. Garden of Truth: The Prostitution and Trafficking of Native Women in Minnesota | NIWRC. [online] Niwrc.org.

Available at: <https://www.niwrc.org/resourc es/report/garden-truth-prostitution-and-traf ficking-native-women-minnesota> [Accessed 14 October 2022].

2. HF 3375 (2018) HF 3375 Status in the House for the 90th Legislature (2017 - 2018). Available at: https://www.revisor.mn.gov/bills/bill.php?b= House&f=HF3375&ssn=0&y=2018 (Accessed: October 17, 2022).

3. Office of Justice Programs (no date) Learn more about DPS, Divisions, Programs, Boards and Committees. Available at: https://dps. mn.gov/divisions/ojp/Pages/missing-mur dered-indigenous-relatives-office.aspx (Ac cessed: October 17, 2022).

4. Martin Rogers, N. and Pendleton, V. (2020) Legislative Reference Library–Minnesota Leg islature, Missing and Murdered Indigenous Women Task Force: A Report to the Minnesota Legislature. Minnesota Legislature. Available at: https://www.lrl.mn.gov/docs/2020/mandat ed/201198.pdf (Accessed: October 17, 2022).

5. Pember, M.A. (2019) Mary Annette Pember, The Atlantic. Atlantic Media Company. Avail able at: https://www.theatlantic.com/author/ mary-annette-pember/ (Accessed: October 17, 2022).

6. Renick, C. (2018) The Nation’s First Family Separation Policy, The Imprint. Available at: https://imprintnews.org/child-welfare-2/ nations-first-family-separation-policy-indi an-child-welfare-act/32431 (Accessed: October 17, 2022).

7. Marina Mileo Gorzig; Deborah Rho, P.D. (2019) Police stops and searches of indigenous people in Minneapolis: The roles of race, place, and gender 20 19 update, Federal Reserve Bank of Minneapolis. Available at: https://www.minneapolisfed.org/article/2019/ police-stops-and-searches-of-indigenous-peo ple-in-minneapolis-the-roles-of-race-placeand-gender-2019-update (Accessed: October 17, 2022).

8. Nîtôtemtik, T. (2018) Myth: Sexualization, violence, and Indigenous women, University Alberta Law. Available at: https://ualbertalaw. typepad.com/faculty/2018/09/myth-sexualiza tion-violence-and-indigenous-women-.html (Accessed: October 17, 2022).

9. American Indians and Alaska Natives in the U.S. labor force: Monthly Labor Review (no date) U.S. Bureau of Labor Statistics. U.S. Bureau of Labor Statistics. Available at: https://www.bls. gov/opub/mlr/2019/article/american-indiansand-alaska-natives-in-the-u-s-labor-force.htm (Accessed: October 17, 2022).

10. Mary Dorinda Allard and Vernon Brundage Jr., “American Indians and Alaska Natives in the U.S. labor force,” Monthly Labor Review, U.S. Bureau of Labor Statistics, November 2019, https://doi.org/10.21916/mlr.2019.24.

11. Akee, R. (2022) How does measuring poverty and welfare affect American Indian children? Brookings. Brookings. Available at: https:// www.brookings.edu/blog/up-front/2019/03/12/ how-does-measuring-poverty-and-welfare-af fect-american-indian-children/ (Accessed: October 17, 2022).

12. Native women’s equal pay Day 2022 (no date) Equal Pay Today! EQUALPAY@EQUALRIGHTS. Available at: http://www.equalpaytoday.org/ native-womens-equal-pay-day-2022 (Accessed: October 17, 2022).

“Do No Harm”

Amidst Cycles of Structural State-Sanctioned Violence and Adverse Pregnancy Outcomes

On April 11, 2021, hardly 11 months after the murder of George Floyd sparked a glob al uprising anchored in Minneapolis, four Brooklyn Center police officers murdered Daunte Wright less than 10 miles from 38th and Chicago. Wright one of 1,054 peo ple killed by police in the United States in 2021 was Black, 20 years old and a father.

In the immediate aftermath of his mur der, hundreds flocked to the city, convening on a lawn situated between the Brooklyn Center Police Department (BCPD), and a small, two-story apartment complex. With in hours, BCPD unleashed brutal crowd control tactics, kettling protesters and fir ing tear gas that quickly ballooned around the apartment building, exposing residents and Brooklyn Center community members residing within blocks of the BCPD. The coming days saw news reports of Brooklyn Center residents moving to hotels, with the help of a community-led mutual aid group, to shield their families from flash bangs and chemical irritants, photos of toddlers pressed against the window, watching chaos unfold from behind a film of gas.

While less than 7% of Minnesota’s pop ulation is Black, Brooklyn Center, a first-ring suburb whose population is majority nonwhite, is 31% Black. Within census tract 202, which includes the BCPD, more than half of renters are Black. Eviction filings in Brooklyn Center between mid-September and mid-October 2022 fell well above the national average, by as much as 121% in some areas. Median household income in census tract 202 is $52,000 annually, 31% below the statewide median. One in five

By Yusra Murad and Kene Orakwue, MPH

households lives under the poverty line (an nual household income of $27,750 for a family of four).

Myriad instruments of structur al racism police violence, residential segregation, criminalization, and pover ty converged on the lawn outside the BCPD. Policing and property ownership in the United States are inseparable from their brutal origins of colonization, land theft, enslavement, and exploitation, and thus inseparable from one another. Research ers at the University of Minnesota’s Center for Antiracism Research for Health Equity (CARHE) and others have found the crowd control tactics deployed by the BCPD, in cluding less-lethal weapons and firing tear gas, to be harmful for health. That this haz ardous and traumatic police response, on the heels of yet another murder of a Black man by police, occurred in a predominantly Black, low-income, renter neighborhood is no coincidence, but rather a microcosm of past and present systematically arranged violence.

As the field of public health looks deep er into the intersection of police contact, neighborhood context and health outcomes, physicians must understand racism, housing policy, and carceral expansion as mutual re inforcers, and central drivers of poor health. There is no shortage of research suggesting that the vestiges of racial covenants and redlining are very-much alive in our cities, although modern-day tactics to maintain racial segregation and protect white property interests go by different names: surveillance, policing, gentrification, and eviction. Each of these tactics has documented impacts on our physical and mental health. In a recent study of almost three million births across

5,924 counties, evictions were associated with increased odds of low birth weight; and the association between living in a coun ty with a high eviction rate and low birth weight or preterm birth (birth occurring before 37 weeks gestation) was strongest for Black women.* Evictions are concentrated in low-income neighborhoods, where families earning poverty wages become severely-cost burdened, forced to make choices between rent, nutritional food, childcare and health care. It is in these neighborhoods that re search suggests police-related death rates are highest.

It is no surprise, then, that in a study of Black women’s perspectives on structur al racism across the reproductive lifespan, “housing,” “law enforcement” and “policing Black families” were identified as three of nine major domains of structural racism. The downstream effects of arrest and incar ceration are often catastrophic and genera tion-altering, creating permanent challenges for renters in getting approved for housing, pushing families deeper into poverty and highly policed and surveilled neighborhoods, reigniting the vicious cycle.

These cycles of violence churn from generation to generation. In 2021, one in 11 Minnesotan babies were born prematurely. Black women were twice as likely to have

Kene Orakwue, MPH Yusra Murad

a preterm birth baby as compared to their counterparts. This has dire consequences: preterm birth can lead to a range of compli cations, including underdeveloped organs; breathing, vision and hearing problems; and long-term conditions such as cerebral palsy. Research infers that chronic exposure to stress, namely structural racism and an ti-Black racism, leads to inequities in adverse birth outcomes. A recent study conducted by CARHE’s Dr. Rachel Hardeman found an association between living in highly-po liced neighborhoods and elevated odds of preterm birth, particularly for Black preg nant people. Importantly, Hardeman et al. concluded that because neighborhoods with more Black residents were more likely to be policed, “the higher incidence of PTB among Black pregnant people than white pregnant people may be attributed to racialized expo sure rather than a differential effect of po lice contact between racial groups.” Another study concluded that any encounter with law enforcement, positive or negative, was associated with increased medical mistrust. Repeated interaction with law enforcement is detrimental to the lives of Black people.

The long-term sequela of chronic stress resulting from persistent exposure to struc tural racism has devastating intergenerational effects. When high levels of stress contribute to an array of maternal health disparities, such as preterm birth, Black children are at increased risk of adverse health outcomes, creating a lifetime and generational cycle

of weathering and worse health statuses. Preterm birth and low birth weight also gen erate exorbitant costs: one study estimated the excess cost associated with babies born prematurely in 2016 was $25.2 billion. Rac ism leads to health and economic inequities, and is a function of white supremacy.

Physicians and healthcare providers have long considered themselves absent from this cycle of place-based structural racism, ex ploitation, violence and poverty, up until the point of clinical intervention. In recent years, the field of medicine has embraced the concept of social determinants of health; physicians are quick to note the effect of housing, environment, and income on pa tients’ health outside the four walls of the clinic. But unapologetic willingness among physicians to name structural racism as the fundamental root cause and commit to disrupting it in day-to-day practice is na scent yet. It is not enough for physicians to step forward at the point of preterm labor, or the great many complications that may follow, and make hollow statements about “ending health disparities.” To intentionally ignore the structural conditions that enable such deleterious outcomes for Black birth ing people is an act of great harm, a direct violation of the first oath every physician recites.

A healthy Minnesota, where all people cannot just survive but thrive, is possible. It is imperative for physicians, who hold the responsibility of caring for us at our most

vulnerable moments, to understand the breadth and depth of community-centered investments that are needed. A significant proliferation of public housing, with rent capped at 30% of income, is crucial in less ening the magnitude of eviction and dis placement affecting working-class families. Racialized policing that prioritizes property over health and well-being will exacerbate racial inequities in preterm birth and other health outcomes, and represents one of the most pressing public health issues of our time.

Yusra Murad (she/her) is a PhD student in Health Services Research, Policy, and Admin istration at the University of Minnesota School of Public Health. She is also a research assistant with the Collaborative on Media & Messaging For Health and Social Policy. Her research in terests are at the intersection of housing, health care and journalism, with a focus on how me dia narratives can and must contribute to the ongoing work of establishing housing as health care; identify structural racism as a driver of the housing crisis and subsequent poor health outcomes; and ultimately compel policy change that is grounded in collective well-being.

Yusra received her Bachelor of Arts in Psy chology and Global Health from the University of Wisconsin Madison. She was previously the health policy reporter at Morning Consult. She can be reached at: murad011@umn.edu.

Kene Orakwue, MPH (she/her) is a reproduc tive justice and health equity scholar. She is currently a Health Services Research doctoral student at the University of Minnesota Twin Cities. She is also a research assistant at the Center for Antiracism Research for Health Eq uity (CARHE). Kene’s research focuses broadly on racism, maternal health, and their inter sections. She strives to apply her findings to real-world initiatives to improve the outcomes of Black birthing people.

Kene received her MPH with a concen tration in Health Policy & Management, her B.S. in Public Health Sciences with a focus area in Global Women’s Health, and a certificate in Reproductive Health, Rights & Justice from the University of Massachusetts Amherst. She is also a Mama Glow Doula Trainee. She can be reached at: orakw005@umn.edu.

References available upon request.

Healthcare’s Role in Firearm Violence Prevention

A teenage male is brought in by ambu lance to the emergency department after being shot several times. He is resuscitat ed, his injuries are surgically repaired, and he is admitted to the trauma ser vice. During admission, it becomes clear that he lives with issues of poverty, low education, mental illness, and substance use. Standard hospital consultations are made. Upon discharge, this young victim retaliates against the initial perpetrators. Another teenage male is brought in by ambulance to the emergency department, and a cycle continues…

The American epidemic of interper sonal violence involving firearms has wors ened across the United States during recent years. According to the Centers for Disease Control, there was a 35% increase in the firearm homicide rate during the first year of the COVID pandemic with the rate in 2020 reaching 6.1 per 100,000, the highest level in over 25 years. The largest increases occurred among Black or African Ameri can males ages 10-44, American Indian or Alaska Native males ages 24-44, and in communities with higher rates of poverty. Meanwhile, the firearm suicide rate has remained persistently high, at around 8 per 100,000.

Minnesota has not been immune from the increasing trend in firearm violence. In June of this year, the CEOs of Allina Health, CentraCare, Children’s Minneso ta, Essentia Health, Fairview Health Ser vices, Gillette Children’s, HealthPartners, Hennepin Healthcare, North Memorial Health, and Sanford Health released a joint statement declaring that gun violence has

By Bjorn Westgard, MD, Kentral Galloway and Danny Givens

“reached epidemic levels and represents a significant threat to public health.” They also pledged to develop solutions and push for gun reform. Locally as well as nationally, there is, therefore, a need for proven strat egies that address the economic, physical, and social conditions that contribute to the risks for violence. More than a few cities have established violence interruption pro grams, where workers from neighborhoods experiencing crime and violence identify and mediate disputes in their communities and follow up with all involved to ensure that conflicts do not escalate.

Hospital-based violence intervention programs (HVIPs) offer one increasingly promising avenue for prevention where health care can play a critical role in inter rupting the cycle of violence taking place in the communities we serve. Conceived in the 1990s, HVIPs are multidisciplinary programs that bring together trauma-in formed medical care and community part ners to provide support and services to the victims of violence who are at risk of be coming perpetrators. Those interventions can help patients as they reintegrate into their community, altering the patterns of behavior that led to these patients being hospitalized and preempting recidivism and

retaliation by providing patients with a sup port network of outpatient care and services once they are discharged from the hospital. In the Twin Cities, LifeTeam, Next Steps in Hennepin County, and now Healing Streets in Ramsey County are striving to do this critical work in and outside of metro area hospitals, funded largely by county, local government, and philanthropy.

HVIPs begin with intervention at the patient’s bedside in the hospital or the emergency department. Many victims of violence are young and distrustful of systems that have not historically treated them well. However, the time that victims spend recovering in the hospital provides a “teachable moment” when patients are particularly receptive to interventions to promote positive behavior change. Cultur ally-competent violence prevention special ists, coming from similar communities and experiences as the clients whom they serve, can break through patients’ distrust. Front line HVIP workers can then work directly with victims and their families to develop short- and long-term goals to help with behavior change and the healing process.

For victims of violence to begin to heal, they need support in developing coping strategies to help them understand what

Bjorn Westgard, MD

Danny Givens Kentral Galloway

has happened to them and to move forward with the changes that have become perma nent in their lives due to the violent event they experienced. After violence prevention workers have connected with victims in the hospital, case managers can work to connect patients with community resources to provide whatever intensive services they may need in the months following violent incidents and injuries: mental health cri sis resources, mentoring, home visits, and assistance with follow-up appointments.

Both the road to recovery and the re silience necessary to break the cycle require holistic strategies in order to heal and foster the resilience of the predominantly young victims of violence. Young people may need job training and education develop ment to complete their high school degree/ GED, attend higher learning institutions, or learn job skills to be able to work. Of ten, victims’ families may need short-term financial assistance to pay for rent/mort gages, food, and clothing while they try to support patients in their recovery. It is therefore critically important for HVIPs

to have relationships with partners in the community, in the schools, in the legal system, and in outpatient health care who all can help youth that have been deemed at-risk change their behavior and begin to heal from the trauma they have experienced in their lives.

While the hopes for violence inter ruption and intervention efforts are high, front-line workers experience high rates of burnout, particularly when faced with disparate funding and inconsistent back ing. If these programs are to achieve their promise, there is a need for ongoing in frastructure and support, both social and financial, within communities, healthcare institutions, and government. Hospitals and communities are engaged, but broader support and standardization are needed. If we support them, hospital-based violence intervention programs have the potential to halt the revolving door of trauma while addressing the inequalities that lead to atrisk behaviors. HVIPs have the potential to heal the survivors of violence by building relationships and partnerships between

hospitals and emergency departments and the communities they serve.

Bjorn Westgard, MD is an emergency physi cian, medical anthropologist, and commu nity health researcher at Regions Hospital, the HealthPartners Institute, and Hennepin Healthcare. Through his clinical work and research, he searches for community solutions to the health and social issues that show up in the emergency department.

Kentral Galloway has worked in child protec tion and youth shelter and treatment services, always seeking to serve those most in need, to fight for those without voice, and to work for change to address systemic, racial issues in society. He is the director of Hennepin County’s Next Steps program serving survivors of violent crimes.

Danny Givens is a heartfelt and experienced activist, orator, pastor, and advocate for racial justice in Black, brown, and Indigenous com munities in Minnesota who has worked with many congregations and communities and who now works to deliver Ramsey County’s Healing Streets program to those who need it most.

Homelessness is Not Having a Stable Place of Peace

Founder of Good Riddance Consulting, Khalique is a social entrepreneur who works on social impact initiatives in the State of Minnesota. He focuses on ampli fying the voices of youth and community using a data-driven human approach. Having first-hand experience with home lessness at a young age, he recognizes the importance of having the people who are facing the problems contribute to designing the solutions.

As healthcare organizations develop programs to combat youth homelessness, understanding the conditions that lead to youth homelessness, the experience of homelessness itself, and the resources that youth need to achieve stable hous ing will be critical if the programs are to meet youth needs. The responses of the 32 individuals I surveyed and inter viewed in homeless camps during the height of the COVID-19 pandemic in 2020 might help them achieve this understanding.

In addition to being currently home less, these individuals also experienced homelessness during their youth, ado lescence, or early adulthood. As might be expected from national data, most identified as Black, American Indian, Asian, or as a combination of multiple races. Half of the respondents first expe rienced homelessness before the age of 18 and three-quarters of the respondents had experienced homelessness for a year or more. Many had left home because of violence or sexual exploitation. As one young woman explained to me, “My

By Khalique Rogers

adoptive dad was sexually inappropriate with me and very religiously abusive and got full custody of me in the divorce, so I left.” A young man told me he left home because of “fighting with mom [sic] boyfriend.”

My respondents emphasized their sense of loneliness: “Nobody cares,” and “Understanding your [sic] in this posi tion alone. All year long. No one to offer help.”

Homelessness was interfering with their educational aspirations: “I’m not able to go to school because I have no place to live. No food to eat so I have no way of studying or focusing on school,” and, “Ended up in jail. Had to get a GED.”

Being caught up in the criminal jus tice system was also a barrier to finding housing: “Sometimes you can get put in situations you never thought you would be in. You can end up with a felony and there isn’t any real help when it comes down to housing with a felony.”

In addition to describing the prob lems they experienced because of home lessness, the survey respondents offered solutions. For example, one respondent suggested, “teach how to find help.” Another suggested, “bring them to a center, not jail.” Yet another asked to “[give us] a second chance.” Regarding physical, mental, and behavioral health service, a respondent advised, “promote treatment, they are kids without help.”

Healthcare providers need to know that youth homelessness is prevalent and increasing: In Minnesota, the number of homeless youth counted by Wilder Research on their single-night count

in 2018 exceeded the total number of homeless they counted in 1991. Some counts find that one in 10 young adults ages 18-25, and at least one in 30 ad olescents ages 13-17, experience some form of homelessness unaccompanied by a parent or guardian over the course of a year. Rather than being on the street, many youth “couch surf” with friends or relatives. Failure to find a safe place to sleep opens the door to sexual predators.

The needs identified by the indi viduals I interviewed mirror the Unit ed States Interagency on Homelessness (USICH) framework. This framework describes four core outcome goals for youth: stable housing, permanent con nections, education/employment, and social-emotional well-being. It recom mends seven actions to prevent and end youth homelessness:

• Prevent youth from becoming homeless by identifying and working with families who are at risk of fracturing.

• Effectively identify and engage youth at risk for, or actually experiencing,

homelessness and connect them with trauma-informed, culturally appropriate, and developmentally and age-appropriate interventions.

• Intervene early when youth do be come homeless and work toward family reunification, when safe and appropriate.

• Develop coordinated entry systems to identify youth for appropriate types of assistance and to prioritize resources for the most vulnerable youth.

• Ensure access to safe shelter and emergency services when needed.

• Ensure that assessments respond to the unique needs and circumstances of youth and emphasize strong con nections to and supported exits from mainstream systems when needed.

• Create individualized services and housing options tailored to the needs of each youth, and include measurable outcomes across key in dicators of performance, including education and employment. (Unit ed States Interagency Council on Homelessness, 2015)

Interventions that healthcare orga nizations might sponsor with success include: prevention programs for youth transitioning out of juvenile justice or foster care; family strengthening; transi tional, supportive, and subsidized hous ing; individual or group counseling or treatment; non-housing case manage ment and support; economic and em ployment programs; and outreach and service connection. These interventions have been found to reduce substance use and generate positive connections,

education, employment, and social-emo tional well-being. Healthcare organizations benefit when they reduce youth homelessness because doing so reduces hospitalization rates.

In addition to describing the needs of homeless youth, the USICH web site advises interested parties to “pay attention to factors that contribute to youth homelessness specifically.” Among the most powerful social determinants of youth homelessness are persistently high unemployment and low wages as sociated with racialized organizations; disparities and discrimination in educational opportunity; an inadequate stock of affordable housing, “redlining,” and predatory extraction of value from Black communities; and, particularly for young Black and Latino men, a criminal justice system that “hyper-criminalizes” their lives, brands them for a lifetime as a criminal, and disrupts the structure and lives of Black families. Until these “causes of the causes” of youth homelessness are addressed, the system will continue

to pump youth, particularly Black and Latino males, out onto the street.

When developing programs to elim inate youth homelessness, it is essential to develop with the youth rather than for the youth. Healthcare organizations might consider following my example of promoting the work of youth advisory councils. I start with a youth led steering committee of five to seven young people who then identify 2-3 key issues they want to amplify to the greater commu nity. I strive to give youth the tools to address systemic and structural barriers and create upward mobility opportunities for African American and Native youth. Fighting injustice and striving for justice while working within systems, my goal is to create a generation of youth change leaders who will build a sustain able framework and move the culture toward a brighter future for generations to come.

Khalique Rogers, Good Riddance, LLC, Minneapolis, Minnesota.

Some counts find that one in 10 young adults ages 18-25, and at least one in 30 adolescents ages 13-17, experience some form of homelessness unaccompanied by a parent or guardian over the course of a year.

Is Mohs Surgery Right for You?

Contributed by Joseph Shaffer, MD, Dermatology Consultants

You may have heard of a specific type of surgery called Mohs Surgery, named after its founder Dr. Frederic Mohs. Mohs Surgery is a procedure used to treat the most common skin cancers basal cell carcinoma and squamous cell carcinoma. Mohs Surgery is designed to completely remove the cancers while preserving as much of the normal skin around it.

Mohs Surgery is most used for people with the following:

• Skin cancers on the face, neck, or hands.

• Aggressive types of cancer.

• Recurrent cancer at any site.

• A predisposition to multiple skin cancers.

• Rapidly growing or large tumors.

Mohs Surgery offers the highest cancer cure rate while minimizing removal of the surrounding healthy tissue. The cure rate for Mohs Surgery has been reported as high as 99%, making it an important choice for many skin cancer patients.

The Procedure

During Mohs Surgery, layers of cancer-containing skin are progressively removed and examined by the surgeon under the microscope until all the cancer is gone. Once the cancer is removed, the area is typically repaired with stitches.

Mohs Surgery is performed under local anesthetic, adding to the safety of this procedure. The four steps are:

1. Tumor removal After the skin has been numbed, the visible tumor is surgically removed. This is called the first stage.

2. Mapping The removed skin is processed and marked with ink to maintain orientation under the microscope. A map is drawn reflecting the inking and its relationship to the surrounding structures. The tissue is then processed in the surgeon’s lab and turned into a microscope slide.

3. Analysis The surgeon then acts as the pathologist as well and examines the tissue under the microscope. If any of the tissue sections demonstrate that additional cancer cells exist, the physician will return to that specific area and remove an additional thin layer. The mapping process will once again take place, and the entire process will continue as needed until all cancer cells are completely removed. Most cancers are removed in one or two stages.

4. Reconstruction Reconstruction is designed to repair your skin and provide the best cosmetic results with minimal if any scarring. Mohs Surgeons are specifically trained in facial and other body part reconstruction. Your physician will usually discuss the repair options after the cancer is completely removed.

Recovery Period

It is recommended that you take it easy after surgery to help with healing. With most reconstructions, stitches are removed one or two weeks later, and over a period of months you’ll experience continuing cosmetic improvement in the scar.

Today most Mohs Surgeons are trained as part of a one-year Mohs Surgery Fellowship Program after their Dermatology residency. For more information, patients can visit MohsCollege.org for more details on this procedure.

Remember

Dr. Joe Shaffer is a board-certified Dermatologist with Dermatology Consultants, one of the largest private dermatology practices in the Twin Cities. He has performed more than 33,000 Mohs surgeries in his career and is consistently named to Minnesota Monthly’s lists of Best Doctors for Women and Top Doctors. He reminds people to schedule an annual full-skin exam with a board-certified dermatologist to catch skin cancer in its earliest, most treatable stages.

QUARTERLY

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2355 Fairview Avenue #139 Roseville, MN 55113-2724

TWIN CITIES MEDICAL SOCIETY 2355 Fairview Avenue #139 Roseville, MN 55113-2724 NANCY BAUER NANCY BAUER

Environmental Health

Highways, Urban Farms, and Housing Density: The Connection Between Health, Poverty, Racism, and the Environment

In the Twin Cities, great disparities exist between communities when it comes to toxin exposure and health, and these differ ences are usually associated with race and socioeconomic status. A study from the Center for Earth, Energy, and Democracy illustrates the extent of such environmental injustice by comparing two neighborhoods in Minneapolis less than two miles apart. One is mostly Black, Indigenous, and people of color (BIPOC) while the other is mostly white, and the white community’s median household income is over 4.5 times as high as the BIPOC neighborhood’s. The BIPOC community has about 556 acres of industrial and highway land use within a one mile radius and 44 contaminated sites, while the white community only has about 102 indus trial/highway acres and eight contaminated sites. Sites such as these increase the risk of asthma, cancer, and other health issues. The BIPOC neighborhood has only 6.4 acres of parks and 3% tree cover, while the white neighborhood has 80 acres of parkland and 44% tree cover. Additionally, Minneapolis communities that were historically redlined, such as the BIPOC neighborhood in this study, are an average of 11 degrees hotter, due to less vegetation and more concrete and asphalt. As our climate changes, these communities will face the greatest impacts. Fortunately, there are many local ini tiatives working to address these disparities. One of the most ambitious projects in the Twin Cities right now is the Twin Cities Boulevard project, which seeks to remove a portion of the I-94 highway and rebuild a community-centered neighborhood. The original construction of I-94 demolished parts of several BIPOC neighborhoods, in cluding along Rondo Avenue. Today, the life expectancy in these communities is five years less than the Twin Cities average, due in part to pollution created by the highway, and many residents are trapped in poverty

By Holly Swiglo

because their family’s homes and businesses were destroyed. The Twin Cities Boulevard project will help combat these problems by reducing air and noise pollution, adding parks and trees, and improving safety by decreasing high-speed traffic. It will also boost the economy by creating space for new businesses and affordable housing and providing new jobs.

Another local initiative is the East Phil lips Indoor Urban Farm project. East Phillips is a neighborhood in Minneapolis with over 70% BIPOC residents and almost one-third living below the poverty line. It is also one of the most polluted areas in the Twin Cities. Lead poisoning, heart disease, and asthma are common, and much of the area is con taminated with arsenic from an old factory. To help solve these problems, community members created a plan to turn a warehouse into an urban farm. This farm would in clude aquaponic and hydroponic gardening, a farmers’ market, local small businesses, and 28 affordable housing units. It would provide access to healthy, locally-grown food, and is expected to create 1,000 jobs and hundreds of millions of dollars worth of economic development over the next decade.

Creating denser housing, such as multi-family homes, is another great way to work toward environmental justice. BI POC people often face barriers to housing, so creating more affordable homes helps combat both poverty and racial injustice. It also limits the need to develop more land, reduces driving time, makes public transpor tation more realistic, decreases home energy usage, and limits polluted stormwater runoff. The Minneapolis 2040 plan, which propos es how the city should develop, includes denser housing and other environmental initiatives, such as restoring contaminated areas to their original states, increasing tree cover, promoting energy efficiency and re newable energy, improving soil quality, and encouraging landscapes that filter water and provide heat reduction benefits.

I am grateful to live in a community with plentiful parks and trees, few pollut ants, and clean air. However, not everyone is this fortunate, and it is our responsibility as people with privilege to help our neighbors facing injustice. We need to support and encourage our leaders to pursue these initia tives and vote for politicians who promote them too. Everyone, no matter where they live, how big their platform is, or how busy they are, should use their voice to push for what is right.

Holly Swiglo is a youth climate activist in her senior year at Roseville Area High School. She led a school climate walkout with almost 600 participants last March, and since then has been working to increase her city and school’s sustainability. Holly was published in Eco systemic, an environmental magazine based in Washington DC, and is a member of the Environmental Stewardship Institute, a youth program led by the local nonprofit Friends of the Mississippi River. She plans on attending college next year to major in environmental studies and continue her activism. Email: hswiglo@ gmail.com.

Sources:

• https://storymaps.arcgis.com/stories/c0f 510c3948846a99db5ec27884ceec1.

• https://climate.state.mn.us/disproportion ate-heat-risks.

• https://www.twincitiesboulevard.org.

• https://sahanjournal.com/climate/east-phil lips-pollution-urban-farm-proposal/.

• https://fmr.org/updates/land-use-planning/ minneapolis-2040-plan-good-environ ment-yes.

FUTURE Physician Leaders

By Ayomide Ojebuoboh, MD-PhD Year 2

It’s Time to Reimagine Public Safety and Medicine’s Role

“Have you heard from your brother? I’ve been trying him since last night.” As I woke up in the morning, I began reading these worried messages from my mother. As our concern slowly grew, we began trouble shooting all the possible ways to find my brother who was living in another state. My mother was so anxious that she left work in the morning and many concerned questions began spinning in my mind:

Should we call the police? Well, if we call the police, they may arrive and then shoot him since he’s a Black man.

When I find his address, who could I get to check his place? My friends are working and busy in NYC but calling the police is not an option.

We felt like we were reaching a dead end but finally a little over an hour later, we received a phone call from my brother who mentioned that he slept early the night before and simply overslept that morning. We were relieved but this situation was a sad reminder that the current systems for public safety continue to fall short when it comes to caring for Black, brown and Native individuals because in reality, if a loved one is missing, we have nowhere to go.

During this frantic moment with my family, I began thinking about the stories shared by Black women and informants while I was working as a research assistant in Dr. Brittany Lewis’ Research in Action firm. That summer, I helped with the Missing and Murdered African American Women project which was focused on examining the violence against African American women in Minnesota. During this experience, it was evident that public safety systems were more violent than beneficial and the women were bringing up similar concerns that I had when my mom and I were trying to find my brother. However, it was extremely telling that during these interviews, although individuals were bringing up the violence of the police department, they were also bringing up the violence of another system the medical system.

From Black women more than 3.5 times likely to die giving childbirth to the presence of law enforcement in the hospital increasing emotional distress for patients in

combination with the stories from the research interviews, it’s evident that the violence from police officers are no different than nor separate from the violence of the medical system. This makes me wonder: What would it look like for those of us in medicine to reimagine what it looks like to support public safety initiatives supported by and created for the community? For example, in Minnesota, how could hospitals connect with individuals at Relationships Evolving Possibilities which provides emergency care to community members like conflict de-escalation and mental health crises and support or Men in Black Security, a de-escalation organization run by Black people that provides security services instead of allowing the default to be partnering with the Minneapolis Police Department? These are the questions that those of us in medicine need to ask because although medicine is not under the scope of public safety it is still complicit with violence from departments of public safety.

Overall, public safety is far from being a place of “safety” for many Black, brown, and Native individuals. So, my question for those in medicine is the following: Will we continue to turn a blind eye to the violence of these systems of public safety or will we choose to reimagine public safety and be honest regarding our association with these systems of violence in order to truly be a healing profession for the people?

References

1. Marian F. MacDorman et al., “Racial and Ethnic Disparities in Maternal Mortality in the United States Using Enhanced Vital Records, 2016-17,” American Journal of Public Health 111, no. 9 (2021): 1673-81.

2. https://healthydebate.ca/2021/08/topic/police-presence-in-health-care/.

3. https://www.pnas.org/doi/abs/10.1073/pnas.1516047113 the medical system is not the main space of healing for Black patients.

Nicholas Weiss, MD Orthopedic Surgeon “My