Life in the big city: building a culture of health.

In 2012, the Robert Wood Johnson Foundation (RWJF) teamed up with the de Beaumont Foundation to cofund the Big Cities Health Coalition (BCHC), which now comprises 20 city and county health departments across the country, including in the 10 largest metropolitan areas. Two additional large metropolitan health departments were invited to join the BCHC in 2014. Together, these 20 health departments promote and protect the health of 46 million people, or almost 15% of the US population. The BCHC is based at the National Association of County & City Health Officials, with which RWJF has a long history of partnership. Why did RWJF choose to support the BCHC? Big city health departments have a powerful ability to create healthy living opportunities on a large scale. The actions of these departments are more visible, the number of people impacted by these actions is large enough to fairly rapidly document improvement, and when an agency is supported by a mayor or council, its innovations and policies can send a clarion call across the nation. This is particularly true when the big cities can act in concert—and the role of the BCHC is to enable exchange of innovations and united voices on policies that protect and promote health. At the same time, big city health departments face daunting challenges. All BCHC departments have an urban core and are constantly confronted with the effects of poverty and other social determinants of health. There is no hope that they can solve the health issues of their cities unless they work collaboratively with other sectors of government, the health care sector, and business. They also must be able to engage diverse community groups operating in different neighborhoods in prioritizing and implementing action, and must appropriately adapt strategies to the context while still seeking alignment across the jurisdiction. Their multiethnic populations signal the increasing diversity of the national population. RWJF made the commitment to support the BCHC because big cities provide an opportunity to create a Culture of Health for millions of people at a time, and because big city health departments have developed innovative solutions to overcome the challenges. The RWJF vision of a Culture of Health is of an expectation about the value of health shared among individuals and organizations with the capacity to promote widespread well-being, and of healthy lifestyles and access to high-quality health care for everyone. Our work with the BCHC has shown that the courageous and innovative leaders of the big city health departments share the vision that all people must have the opportunity to lead long and healthy lives. The RWJF vision of the Culture of Health has 4 dimensions: The first is the development of a shared value of health and social cohesion. This is illustrated in many of the big cities through their collaboratively developed health plans involving numerous partners, such as HealthyChicago. An example of fostering social cohesion is the effort to develop community resilience by the Los Angeles County Health Department. The second dimension emphasizes multisectoral collaboration. The San Francisco Health Department has a long history of bringing a health lens to decisions made in housing, transportation, land use and planning, juvenile justice, and other sectors through the use of health impact assessments, leading to the development of robust collaborations among different sectors. The San Antonio Health Department actively collaborates with the dental faculty of the University Health System in San Antonio to bring oral health care to public elementary schools in neighborhoods of concentrated poverty, whereas the Philadelphia Department of Health partnered with schools on multiple programs and achieved a reduction in childhood obesity. The third dimension emphasizes improved and equitable opportunities for healthy choices. Many big city health departments work with partners to establish changes that promote walking, biking, and recreation to increase physical activity; reclaim parks, making them safe for families; and reduce the number of food deserts, improving healthy eating. The big cities are forerunners of policy changes that include extending smoking bans to reduce exposure to secondhand smoke and raising cigarette taxes to decrease tobacco use. The fourth and final dimension of the Culture of Health encompasses the improved quality, efficiency, and equity of health and health care systems. Several big city health departments, including the Boston Public Health Commission and the San Diego and Seattle–King County Health Departments, emphasize health equity in all their work. Many of the big cities are actively pursuing national accreditation to improve the quality and efficiency of their organizations, with Chicago being the first big city to be accredited. For more than a decade, RWJF has supported health departments, including those in the big cities, in activities to achieve readiness for national accreditation and to apply quality improvement for increasing efficiency and effectiveness.1 The Denver Department of Environmental Health has created a culture of quality through continuous quality improvement. Enabling access to quality health care is a priority for every big city health department. In some cities, this is accomplished by providing high-quality safety-net clinical services, connecting people to children's public health insurance or Medicaid, or monitoring and reporting the quality of health care in the jurisdiction. The Houston Department of Health and Human Services actively promoted and assisted people to enroll in the health insurance exchange. In all 4 dimensions, big city health departments are leading efforts to establish a Culture of Health. It is particularly important to partner with and learn from the big cities and large metropolitan areas at this time in our nation's history. As our federal government and many state governments have been restricted from taking bold action because of partisan gridlock, the cities and the metropolitan areas have come to take the lead in pioneering disruptive innovation, risk-taking, and pushing boundaries. The big cities and metropolitan areas are “positioning themselves at the cutting edge of reform, investment, and innovation” and “act as engines of social transformation.”2 At the level of big cities and large metropolitan areas, “boots are on the ground” where those agencies feel accountability to their constituents daily. Big city leaders seek pragmatic solutions, and collaboration is the clear way to take action that will result in tangible success. We have already seen firsthand the power that big cities can have when they band together to promote health. For example, Los Angeles, Chicago, New York, and Philadelphia all implemented laws in April 2014 that forbid e-cigarettes in places where smoking is prohibited—following the lead of Seattle–King County and Boston. This kind of collaborative action builds a groundswell of support for a Culture of Health in our nation. We have no doubt that the big city and large metropolitan health departments are critical partners in creating a national movement for a society that places emphasis on prevention of disease and promotion of health—a national Culture of Health.