Public health is local

Abstract

“Public health is local, and similarly local information is required to increase awareness among residents and policy makers alike of the unique challenges facing communities”, conclude Laura Dwyer-Lindgren and colleagues in an Article published in this issue of The Lancet Public Health. In their study investigating variation in life expectancy and mortality by cause among neighbourhoods in King County, WA, USA, between 1990 and 2014, the Global Burden of Disease Study group applies latest small area estimation methods to mortality data in King County—a county that includes the city of Seattle, 2 million individuals, and where life expectancy is among the highest in the USA. What is hidden behind this high life expectancy at county level is an astonishing gap of more than 18 years for men and more than 14 years for women between communities. Subdividing the county into 397 census tracks and examining cause-specific mortality and years of life lost from 152 causes of deaths has allowed Dwyer-Lindgren and colleagues to unravel not only these huge life expectancy differences between neighbourhoods, but also to identify areas where the burden of specific cause of death is substantially higher. Such patterns of health disparity can reveal or suggest important underlying determinants. The granularity of outcomes and possible causes reported redefines the meaning of public health and offers new opportunities for action. For Sandro Galea, who has written an accompanying Comment, if Dwyer-Lindgren and colleagues' data are a reminder of the health divides within the USA, more important still are the stark, geographically adjacent differences that illustrate the heterogeneity in population health. Because population health is usually measured at a national or regional level, governments and public health agencies aspire to measure health successes at these levels, notes Galea. “Unfortunately, the easiest way to improve overall county health is through efforts that reach those who are easiest to reach, improving overall health by targeting the so-called already health haves. This approach stands to improve overall county health while widening intra-county health divides.” Dwyer-Lindgren and colleagues' detailed mapping of variability in life expectancy and mortality by cause opens avenues for further research and could lead to an equally detailed micro-level mapping of the determinants of health and health needs of communities. The findings could also guide local interventions to tackle inequalities and improve the health of local populations. Is it time to think about public health more locally? Mayors of cities around the world increasingly seem to believe in the power of acting locally. Former New York City Mayor Michael Bloomberg has been considered the “first public health mayor” when he took a series of controversial positions to improve the health of New Yorkers. Writing in The Lancet last year, his successor, Mayor Bill de Blasio, recognised the part cities can play in public health: “the way we design our cities can help build healthy lives”. To support Mayors and local authorities designing their cities and their future, WHO's Healthy Cities programme has been promoting policy and urban planning with health at its core. The four guiding principles they recommend are the need to address inequality in health and urban poverty, the needs of vulnerable groups, participatory governance, and the social, economic, and environmental determinants of health. While the centrality of public health for sustainable urbanisation will be key to tackle health inequalities and improve social justice, Helen Cole and colleagues note in a Comment that the development of healthy and equitable cities has proven more difficult than anticipated. They warn of potential risks for increasing rather than reducing social inequities—in particular, when investments lead to gentrification of neighbourhoods and exclusion of the most marginalised. In a Letter reflecting on the health and safety of the most vulnerable in UK cities, in the aftermath of the Grenfell Tower disaster in London earlier this year, Faheem Ahmed and colleagues point out that “smart city plans have so far been led by the private sector, which has been reluctant to prioritise the importance of public health”. Public health science is now reaching a degree of precision that could provide us with street-level health outcomes and determinants of health. New disciplines, such as urban health, offer new opportunities for research and potential interventions. With cities and local communities becoming the new unit of public health, it is it time to think and act much more locally. Health haves, health have nots, and heterogeneity in population healthThere is approximately an 18-year difference in male life expectancy between Japan (80·5 years) and Sudan (62·4 years).1 The study by Laura Dwyer-Lindgren and colleagues2 in this issue of The Lancet Public Health shows that there is also an approximately 18-year difference in male life expectancy between the census tracts with the highest and the lowest life expectancy in King County, WA, USA. There is approximately a 14-year difference in female life expectancy between the UK (83·0 years) and Senegal (68·6 years),1 which is similar to the gap in the female life expectancy between the census tracts with the highest and lowest female life expectancy in King County. Full-Text PDF Open AccessCan Healthy Cities be made really healthy?Strategies such as the Healthy Cities project aim to place health at the centre of urban interventions.1 Such programmes seek to create cities with adequate housing and public transportation, quality health care, and safe places to exercise and play. However, these common transversal approaches also carry a risk of perverse effects, especially when the effect of market-oriented regulatory processes and uneven dynamics of policy formation are not considered. As a result, the Healthy Cities project and similar approaches, such as the WHO's promoted Health in All Policies,2 might in some cases bolster rather than reduce established trends toward urban social and health inequities. Full-Text PDF Open AccessSmart cities: health and safety for allOn June 14, 2017, a tragic fire decimated the lives of hundreds of Grenfell Tower residents, prompting a public enquiry into how a man-made disaster of this scale occurred in one of the world's wealthiest cities.1 The burnt out skeleton of the tower now stands as a symbol of growing inequality and injustice in the UK, casting a shadow over government policies towards the quality and availability of social housing.2 Although almost £20 billion has been spent on essential repairs to social housing since 2002, 10% of these buildings continue to pose inherent health and safety risks to residents in substandard accommodation. Full-Text PDF Open AccessVariation in life expectancy and mortality by cause among neighbourhoods in King County, WA, USA, 1990–2014: a census tract-level analysis for the Global Burden of Disease Study 2015This census tract-level analysis of life expectancy and cause-specific YLL rates highlights important differences in health among neighbourhoods in King County that are masked by county-level estimates. Efforts to improve population health in King County should focus on reducing geographical inequality, by targeting those health conditions that contribute the most to overall YLLs and to inequality. This analysis should be replicated in other locations to more fully describe fine-grained local-level variation in population health and contribute to efforts to improve health while reducing inequalities. Full-Text PDF Open Access