NYC Public Health as a Model: Kimberly Isett and Miriam Laugesen Q&A
As scholars together at the Columbia Mailman School of Public Health in New York City, public health researchers Kimberley Roussin Isett, PhD, and Miriam Laugesen, PhD, watched major policy changes unfold across the city over the past several years. They decided to look at New York City as a model for improving public health that other cities could replicate. “Things were happening in New York City rapidly, and in a health-focused way that really not seen before,” says Isett. Since then, other cities across the country have enacted similar, comprehensive smoke-free policies. Voluntary calorie postings on restaurant menus were also integrated as a requirement in the Affordable Care Act. The researchers decided to look at New York City as a model for improving public health that other cities could replicate. NewPublicHealth recently spoke with Drs. Isett and Laugesen about their research. Dr. Isett recently took a new position as an Associate Professor in the School of Public Policy at the Georgia Institute of Technology in Atlanta, and Dr. Laugesen is an Assistant Professor of Health Policy and Management at Mailman and a former Robert Wood Johnson Foundation Health & Society Scholar.
NewPublicHealth: Because of its large budget and powerful public leaders, New York City isn’t always seen as a model for other, particularly smaller, health departments. But your work shows some of their efforts to be important, maybe critical for other departments to study and replicate. How did you come to that conclusion?
Miriam Laugesen: In our research, one theme that kept coming across again and again was the scientific basis—the amount of research and data—that the Bloomberg administration and staff had collected to justify and design their policies. That was a very big component, we thought, of many of their policies and that New York City had many innovative, interesting examples of how policymakers can base their policies on evidence.
Kim Isett: Another thing they did was to effectively use structure. We think of city government as a system that’s not very flexible and is slow to move. What they did in New York City was that if they didn’t have the appropriate kinds of structures already in place in the system, they took steps to rearrange the bureaucracy to make sure those issues that they cared about had focus. So, for example, under Dr. Thomas Frieden [formerly New York City’s health commissioner, and now director of the Centers for Disease Control and Prevention] the city created a bureau of chronic disease and that ensures that somebody is paying attention to the issue of chronic disease. Organizationally, that’s huge.
One other thing the city accomplished was that [they worked across organizational divisions] when they were looking at certain issues. For example, when they looked at restricting the use of trans-fat in prepared foods, the focus was not just in restaurants, but in any organization or agency under the jurisdiction of the entire City that dealt with prepared food such as the Bureau of Prisons and the Department of Education. They created an umbrella organization [the Office of the Food Policy Coordinator] that coordinated food policy across all of those agencies so there was a consistent approach to food policy across the city government.
That’s really powerful to have consistency across all agencies because often policies and regulations are passed and they really only exist within that one silo. So instead of doing that, they really thought of this comprehensively.
NPH: Were there any other policy changes in New York City that you wanted to draw attention to?
Kim Isett: The extensiveness of the smoking policies have been the furthest reaching and most comprehensive of any city. I think that this was really controversial at the time. So public health reforms don’t have to be clinically interventionist, they can be things that help people stop at a decision point and make considered, alternative judgments.
NPH: And are these efforts replicable elsewhere? Especially in cities far smaller, and with far less planning infrastructure and funding than New York City?
Kim Isett: None of the things that they did are unreachable by other cities. I think the hard thing about it was that they were the first ones. And now they’ve established that these efforts can work and are effective. And it’s so much easier to replicate things than to be the entrepreneur, the first one.
New York City can fight the uphill battle because they have the money; the rest of the country just have to be good consumers of evidence. For example, reallocating staff explicitly to be tasked with a new effort [like New York City did with chronic disease] is actually very low cost and completely replicable.
Miriam Laugesen: I agree. I think this is something that we struggled with in the project initially. Are people going to be skeptical about this? Are people going to say it’s not possible elsewhere because there are too many advantages that New York has? And what we came to realize through our work is that it just takes one jurisdiction to step forward and to do something out of the ordinary. If you have a leader at that local level who’s prepared to think outside the box and to learn from these experiences, they don’t need all the resources and ground work that New York City uses. And that helps us answer the question: how much of it was the innovation and will of Mayor Bloomberg, and how much was it reshaping the bureaucracy to change things.
I think on balance, we found that the bureaucracy was a bigger part of it. Mayor Bloomberg provided the environment and the political backing for the policies. But we’re seeing other cities building on innovative models.
NPH: Which cities would you point to?
Kim Isett: Philadelphia has modeled three key New York City initiatives: clean air initiatives with idling buses and increased green space and bike lanes; a trans-fat restriction, though not as comprehensive as New York City, and [limits on] sugar-sweetened beverages.
Miami is trying to do a lot of these things and Los Angeles has some of these initiatives as well.
In the northeast and northwest, the cities tend to be a little more left of center and so it may be easier to get these kinds of things done as early adopters. But, we’re also seeing other kinds of political jurisdictions working at this. We did a real quick analysis of who is adopting trans-fat restrictions across the country. And when we looked at that, we actually found it is upper-income suburban places [across the political spectrum] that tend to be more likely to try to adopt trans-fat restrictions—places such as Needham and Brookline [Mass.], San Francisco, Nassau and Duchess Counties in New York.
Miriam Laugesen: I think looking at ideology instead of conservatism and liberalism is important. I also think that part of this new public health agenda that Bloomberg has been pushing actually has political appeal across the political spectrum.
NPH: Where does the education start? Where does the training need to be?
Kim Isett: Well, I think that in order to have an effective approach, public health departments would have individuals, who understand not only the medical side of it but also to be able to take a step back and see population trends. And it’s not enough to know about health, but you have to know how the policy process works—and in particular, how to use regulations and the phenomenon of regulation and rule making. Having a coalition of leadership where those perspectives are respectful of each other and can understand the inner spaces where the overlaps are is. That certainly makes an effective public health department.
Miriam Laugesen: I think that part of it is also realizing that things are going on in local government—it’s not just state or federal policy that matters. We need to have a little bit more of a focus on what can be done in our backyards.
Kim Isett: There’s not a program in the country that is training people to do public health at the local level. If you want to have one to one direct impact, it’s at the local level.