Connecting state and local government leaders
COMMENTARY | Health departments fight for policies that make it easier for all people to live their healthiest lives: safe schools and communities, livable wages, affordable housing and healthy food.
Earlier this year, the Philadelphia Department of Public Health began providing free air purifiers to early childhood education facilities. The initiative checked multiple important boxes: The better air quality and updated ventilation systems improved students’ health and helped them academically. It proved so popular—in February and March alone, the health department distributed nearly 400 purifiers to 280 education centers citywide—that the program was expanded to the city’s K-12 schools.
As executive director of the Big Cities Health Coalition (BCHC)—which comprises 35 of America's largest metropolitan health departments serving a combined 61 million people—I see every day how local public health departments take similar steps to help their residents enjoy longer and healthier lives. With national surveys showing that Americans strongly support cities taking action to address issues like housing, equity and education, the popularity of initiatives like Philadelphia’s is not surprising. It is also a much-needed counterpoint to popular pandemic sentiment that the public health officials who protect and serve our communities deserve scorn rather than support. More funding and resources from Congress, along with additional investments from state and local governments, would allow local public health departments to be even more responsive to community needs. The impact on our nation would be transformational.
There’s no sugarcoating it: Public health institutions were hit hard in the court of public opinion during the pandemic, with poll after poll showing a precipitous decline in trust. This all too often manifested as threats, harassment and even outright violence against health leaders, resulting in resignations and retirements. Since 2020, more than half of states have passed laws that restrict health departments from doing their jobs. This happened despite the fact that public health officials took the lead on distributing and administering vaccines that saved at least 3 million lives, prevented 18 million hospitalizations and saved more than $1 trillion in health care costs. Any public health official will say that the COVID response was by no means perfect. But the circumstances were unprecedented, and the belief that public health deserves such vitriol is simply wrong.
The debate over the pandemic response also obscures the broader and critically important point that addressing emerging infectious disease threats is only one component of a public health department’s portfolio. Plus, the general public strongly supports cities taking action to make sure residents have an opportunity to be healthy in their day-to-day lives. Support from leaders—elected, community-based and others—is essential as the nation seeks to not just return to “normal,” but learn from this experience and strengthen the public health system for the future.
In 2023, BCHC conducted focus group and survey research with residents across all 35 of our member cities. Our goal was to better understand how certain groups of people felt about the role that public health departments and leaders can play in their communities. We focused our efforts on Black and Hispanic residents who have not always been treated well by medical and public health systems as well as self-identified moderates and conservatives who have also historically been skeptical of government intervention. Participants were “policy influencers,” defined as news-attentive and civically engaged voters.
We found that respondents share our broad view of public health’s role and responsibilities and that there is strong alignment between residents’ priorities and those of public health leaders. For example, two-thirds of respondents believe cities should increase access to affordable housing, and more than 70% believe cities should address homelessness. We concur. Safe and secure housing is strongly connected to health and well-being, while substandard housing and evictions can cause both physical and mental illness. That’s why local health departments in the nation’s most urban areas are taking action. In Boston, for example, the health department led an effort with a dozen city agencies to move 150 people experiencing homelessness into new shelter and housing sites between January and April 2022. They also worked to connect those individuals to programs designed to reduce substance abuse and improve mental health.
An even higher number of respondents (81%) believe reducing crime should be a top priority for cities—in fact, it was their highest priority. This isn’t surprising: Gun violence deaths surged during the pandemic in BCHC cities, becoming a leading cause of death for young people and disproportionately affecting Black residents. But treating crime solely as a law enforcement matter is not enough; a public health response that addresses the root causes of violence amid underlying health disparities is essential. For these reasons, BCHC not only urges Congress to reinstate the federal assault weapons ban and enact a series of additional gun safety initiatives, but also to commit more funding to gun violence prevention research and investments in programs that have proved to make communities safer.
Housing and community violence prevention are just two of the many health priorities revealed by our surveys and focus groups. Substance use, obesity, air quality and mental health are also top of mind in various parts of the country. A strong, well-resourced public health system is necessary to address all of these needs. But even as the U.S. spends trillions of dollars on health care each year, life expectancy is declining, our health outcomes are worse than many other wealthy nations and prevention funding pales in comparison to dollars spent on medical treatments.
We don’t have to choose between funding medical care or funding prevention. We can and must do both. States should follow the lead of Indiana, which recently—thanks to a push from its Republican governor, Eric Holcomb, and with support from a GOP-controlled legislature and local business and community leaders—increased state funding to local health departments from $7 million a year to $75 million this fiscal year and $150 million next year. As Holcomb put it in his State of the State address advocating for these additional dollars: “Nearly all of these dollars will be deployed locally … tailored to the unique circumstances of each community partner.” That’s exactly how the process should work, with collaboration across state and local agencies.
At the federal level, instead of regularly short-changing public health, Congress should provide higher and sustained investments. That must include building on recent funding provided directly to large local health departments so they can respond quickly and effectively to their residents’ needs as well as support for rebuilding the public health workforce at the local level.
So much of what affects our health happens outside the hospital or a doctor’s office. Indeed, as Philadelphia’s air purifier initiative shows, sometimes safer schools are the best prescription for children’s health. It is clear the American people understand the nuance, as do public health officials across the country. We need policymakers at all levels of government to make this connection as well.
Chrissie Juliano is executive director of the Big Cities Health Coalition (@BigCitiesHealth).