Philadelphia got tired of being known for cheesesteaks.
The city, which had among the highest rates of obesity, diabetes, and high blood pressure in the United States, wanted its calling card to be something healthier.
In 2008, under a new health commissioner and with some federal funding, Philadelphia started to look for explanations and interventions for its worsening public health crisis.
A detailed map of the City of Brotherly Love showed that the problems were not equally distributed. In a string of neighborhoods along Philly’s western edge, people were dying 10 years earlier than those in the city’s affluent areas. Among black Philadelphians, obesity reached past 40 percent and nearly 20 percent had type 2 diabetes.
So, the city launched a program called Get Healthy Philly in 2010. It has been so successful that public health experts and policy wonks across the nation are abuzz.
While childhood obesity has continued to go up nationally, it has fallen by 6 percent in Philadelphia. The decline has been even more pronounced among African American and Asian American youth, who historically have been harder to reach.
The number of people cycling to work doubled and soda consumption fell 30 percent. Rates of diabetes, which is slow to develop, also ticked down slightly.
So what is Philadelphia’s secret? It stopped looking at the obesity and diabetes epidemics as a long list of individual failures and started viewing them as problems woven in the fabric of city life.
“Instead of trying to change behaviors, we’re trying to make the default setting easier,” Dr. Cheryl Bettigole, MPH, who recently stepped in as head of Get Healthy Philly, said. “It’s almost like a tagline: make the healthy thing the easy thing.”
Philadelphia arranged trainings for Chinese restaurants to make popular dishes with less salt, because high sodium consumption is a leading cause of high blood pressure. It built support for walking and cycling into transportation planning. It launched a bike sharing program and put bikes in lower socio-economic neighborhoods. It trained corner stores on how to stock and market healthier foods. It also reduced junk foods in schools.
The city encouraged farmers markets to operate in lower income neighborhoods and gave perks to people who receive public assistance for shopping at them. For every $5 in federal food assistance benefits used at a farmers market, shoppers get a $2 coupon for fresh fruits and vegetables.
Spending at farmers markets by people who qualify for federal assistance has ballooned. From 2013 to 2014, total spending from federal assistance and the Philadelphia bonus programs rose 40 percent to more than $275,000.
The success of Get Healthy Philly doesn’t hang on the adoption of just one component; rather it’s the combined elements that make it successful, according to Bettigole.
“Everything is what it takes to make that kind of change,” she said.
Elaine Waxman, a senior researcher at the Urban Institute, agreed.
“That’s the kind of progress you can see when you use multiple strategies,” she said. “We just have to remind people that these issues are inherently complex, so we have to be patient. You have to be in it for the long haul.”
Philadelphia isn’t backing down. As municipal districts update their planning blueprints, health goals are now part of what was once purely land-use documents. City streets and infrastructure will have to support access to healthy food, open space for walking and biking, and mass transit across the city.
If there’s a single city in the United States, whose planning has contributed to poor health for its lower-income and non-white residents, Los Angeles takes top honors. During its development, Los Angeles relied heavily on housing covenants that corralled people of color into undesirable parts of the city.
But this spring Los Angeles added health outcomes to its general plan, taking what Philadelphia started to another level. The city recognized that its layout greatly contributes to health disparities.
“You’re undoing things because a lot of bad decisions were made in the past,” Claire Bowin, the city planner who leads the project, said. “Let’s own up to those errors and make sure we’re investing in these communities. We’re not going to continue to spend equally across the 15 different council districts when [one] area has a lot more problems.”
The Healthy Los Angeles plan focuses on prevention and narrowing the gap in outcomes between affluent whites and everyone else in part by “mak[ing] the healthy choice the easiest choice.”
The effort began by measuring each of those outcomes by neighborhood across the sprawling metropolitan area in a painstaking set of maps.
In the string of neighborhoods stretching south from downtown L.A. toward the port and, to a lesser degree, those that border downtown to the east, residents are less healthy by a range of measures: asthma, low birth weight, pedestrian deaths in traffic accidents, heart disease, mental health hospitalizations. Many of the sickest areas also lack primary care doctors.
“When you have some people who have a relative overflow of resources and some people who have no resources or poor resources, then you build your inequalities — poor quality schools, poor quality parks, and poor quality sidewalks, and poor quality transportation — it builds up into a very unhealthy scenario,” Tamara Dubowitz, Sc.D., a senior policy researcher at the RAND Corporation, a centrist think tank, said.
L.A. now wants to see 75 percent of its residents living within a quarter mile of an urban park and everyone living within a mile of a farmers market. The city will encourage walking and biking and attempt to bring more doctors offices to poorer parts of town.
It won’t be easy to get there, though. For the moment, there’s no funding designated to make the city’s ambitious health benchmarks a reality.
Los Angeles, like Philadelphia, initially counted on funding from the Centers for Disease Control and Prevention (CDC). What was supposed to be a three-year grant was abruptly curtailed when the budget sequester imposed by Congress cut the CDC’s own funding.
Bowin expects to make some progress without dedicated funding. For instance, the city requires new housing developments to set aside land for open space. The open space has traditionally gone alongside new condominiums. But L.A. is now pushing for those the open space set-asides to go where they’re most needed.
The planning department will look for other incentives to offer developers of construction projects that include medical offices or grocery stores. The beauty of folding public health goals into transportation projects is that those plans usually get their funding.
Currently, taxpayers pay around 4 cents on the dollar for healthcare spending. Even if such policies forces more funding to be put toward public health and prevention, most argue it will save money in the long run.
“The economic case is actually really easy to make,” Bettigole said. “We can’t afford diabetes and premature death from heart disease. If you look at the cost of all the chronic disease, putting in a few miles of paths and trails and a farmer’s market is cheap.”
Other cities are considering similar approaches, putting a local spin on a model first advocated several decades ago by the World Health Organization. Called Health in All Policies, California began to encourage local governments to embrace the approach in 2010.
“It’s not caught on in a more systematic way in the United States because we spend a lot of time focusing on individual agency in health behaviors,” Waxman said. “We just don’t think naturally about the ways that context affects the choices people make.”
In New York City, for example, then-mayor Michael Bloomberg’s ban on supersized sodas was met with scorn. But the focus on individual behaviors has led us into a vicious cycle of poor health and exorbitant healthcare costs.
“One of the ways we’ve often dealt with health in United States is we’re very focused on the backend, on all the sophisticated technologies and medications and therapies. But despite being world leader in that, our health outcomes tend to be worse than in much of the rest of the developed world,” Waxman said.
It’s too soon to say for sure how a multipronged focus on prevention will play out beyond Philadelphia’s early successes. But a smattering of local governments will be watching.
“I think it’s one of the most interesting things that’s going on right now,” Dubowitz, of the RAND Corporation, said. She led one of a handful of studies that shows city policies can better bring health outcomes.
The study, published last month, compared two similarly troubled Pittsburgh neighborhoods that lacked full-service grocery stores, communities characterized as containing food deserts. In one of the neighborhoods, where community leaders had long identified access to healthy food among their top list of demands from local government, city incentives spurred a store to open.
The situation offered a rare opportunity to include a control group in an analysis of the effects of bringing access to healthy produce to a known food desert.
Nutrition rates improved markedly in the neighborhood that got a new store, but there was an interesting twist in the findings. Residents’ nutrition improved whether or not they shopped at the new store.
“We found that people in this neighborhood had dietary changes regardless of how frequently they used this grocery store. It wasn’t the mechanism by which these changes were occurring,” Dubowitz said. “The neighborhood went through a major economic infusion and some of the unmeasured elements include community hope, optimism, and pride.”
Waxman worries thought that cities will fail to address the entirety of challenges that weigh on health outcomes in neglected neighborhoods.
“If you don’t have income, it doesn’t matter if somebody puts a supermarket next door. You’re in a food desert of one if you don’t have the money to buy groceries,” she said, citing feedback from teens in an ongoing study she’s conducting on families without reliable access to food.
It’s fair to say that adding citizens’ health to the foundational documents of city governments won’t stop Americans’ downward health spiral, nor will it quickly bridge the gap in outcomes between affluent white people and everyone else.
But since health — good and bad — takes root in daily life, communities are a good place to sow the seeds of healthier habits.
“I do think these strategies are important interim steps because they force communities to get down into the specific barriers that people face,” Waxman said. “They just won’t get us all the way.”