What’s next for public health in a post-Bloomberg NYC?BMJ 2013; 347 doi: http://dx.doi.org/10.1136/bmj.f6272 (Published 18 October 2013) Cite this as: BMJ 2013;347:f6272
In the five years since the BMJ reported on the bold approach being adopted in New York City by its mayor, Michael Bloomberg, the city has continued to push ahead on public health. After the bans on smoking in public places and trans fats in restaurant foods, came 200 miles of cycle lanes, a bike share scheme and 500 “Green Cart” permits for mobile fruit and vegetable vendors. The health department has tried to reduce sugary drink intakes through a public information campaign and by proposing a limit on the portion size of sugary drinks. Not always universally popular, derided by libertarian commentators, and under constant attack from vested interests, these measures have earned Michael Bloomberg and the city’s health department admiration from the international public health community.
The city’s top health official, health commissioner Thomas Farley, is in no doubt about Bloomberg’s health legacy. “He is the first mayor of a major world level city who has really championed public health and demonstrated how public health approaches can be successful and improve health outcomes.” Bloomberg’s three terms—the City Council ruled to temporarily extend the mayoral two term limit, allowing him to be elected for a third term—have stretched from the months just after 9/11 to the era of Obamacare. During that time, average life expectancy in New York City has increased by three years to 80.9 years (on top of big gains in the 1990s), which makes it 2.2 years longer than for the United States as a whole.
Farley considers the mayor’s most important achievements have been in smoking prevention. This is a policy priority that Mr Bloomberg was explicit about on his election platform, and also reflects a key priority of his philanthropic foundation. The approach has involved raising taxes, banning smoking in public places, mass media campaigns and training for doctors to help smokers quit. Smoking rates dropped by more than a quarter to 15.5% in adults between 2002 and 2012.
The other important public health priority the administration has pursued—under both Farley and his predecessor Tom Frieden, now director of the US Centers for Disease Control and Prevention—has been tackling obesity.
Farley is clear that the administration’s approach has often set a precedent for other cities, states, and even countries. The city was one of the first places to introduce a ban on smoking in restaurants and bars in 2002. The prohibition on the use of trans fats in restaurants has also been widely copied across the US and elsewhere, and the requirement to put calorie counts on menus in chain restaurants has now been incorporated into national law. Elements of the city’s campaign to reduce sugary drink consumption are reported to have been replicated in eight states and in Australia. “So, really, throughout this entire time people in public health throughout the US have looked to New York City as leaders and as a model on public health and, to some extent, people around the world have too,” says Farley.
In the city itself, a more mixed view of Mayor Bloomberg’s legacy exists. Anthony Feliciano is director of an advocacy organisation, the Commission on the Public’s Health System, which hosted a mayoral candidate forum on public health back in January this year. Although he commends Bloomberg for supporting the public hospital system, he has concerns about the possible impact of some of the public health measures on health disparities and low income groups. He also criticises the administration for a lack of community engagement. Health disparities remain a problem in the city—life expectancy for the non-Hispanic black population is 3.7 years lower than the city average. Black New Yorkers are almost three times more likely than the white population to die from diabetes. The health department has acknowledged that more progress is needed, particularly in the poorest communities of South Bronx, East and Central Harlem, and North and Central Brooklyn.
The next mayor
The theme of inequalities—particularly income disparities—has loomed large in the mayoral election. One of the two main candidates, Democratic nominee Bill de Blasio, has made much of the situation where nearly 400 000 millionaires live in the city while nearly half of the population lives on, or near, the poverty line. His main rival, Republican nominee Joe Lhota, dismisses de Blasio’s “tale of two cities” approach as divisive.
Lhota, a previous deputy mayor under Rudolph Giuliani and former chair of the Metropolitan Transportation Authority, has said little about health during the campaign. His priorities are jobs, education, and making the city safer. It is hardly surprising that his campaign has largely avoided the issue of health—after all, attempts by some Republicans to defund the Affordable Care Act were at the heart of the unpopular federal government shut down. In response to questions from the New York Times, Lhota has made it clear that he does not see it as the government’s role to mandate on issues like the size of sugary drink servings. His manifesto published on 10 October does, however, draw attention to the double burden of obesity and food insecurity in the city. He pledges to advance nutrition education in schools and provide better school food.
Current front runner Bill de Blasio has gone on record as being “one of the most steadfast supporters of the Bloomberg Administration’s public health agenda” despite a campaign which, more generally, has been critical of the current mayor. He told the New York Times that he supported the attempt to limit the portion size of sugary drinks—the city is currently appealing a judge’s decision in March that ruled the proposed measure unlawful. De Blasio’s top three campaign priorities are funding for early years childcare, affordable housing, and income inequality. Currently the city’s public advocate, de Blasio has pledged to “pursue an ambitious public health agenda” and has set out a detailed plan for improving access to healthcare across the city. He has given few details of his public health vision but has pledged to introduce free school lunches for all public school children in most of the city’s schools, to revive after-school sports programmes and re-introduce physical education where needed, and to introduce mental health services in school settings.
Smoking is top priority
For Farley, the city’s number one health priority remains smoking. There is also much more to be done on obesity, as rates in adults continue to rise, and the related issue of diabetes. He also cites drugs and alcohol as a continuing major public health problem, highlighting overdose deaths due to prescription opioids. The health department has launched a campaign to try and change how opioid painkillers are used in the city.
Anthony Feliciano sees two key priorities for the next mayor. He will have to deal with any gaps that emerge in the arrangements under the Affordable Care Act, which is due to take full effect the day the next mayor takes office. The second is to address health disparities in a way that involves communities in trying to “create and ensure the health infrastructure, but also access to that infrastructure.”
Over and above what the city’s present or future mayors achieve for the health of New Yorkers, it is clear that we have witnessed an important shift in the politics of public health. In the US, responsibility for health issues is shared between cities, states, and the federal government. “In the past people looked to the national government at federal level for leadership on public health issues,” says Farley. “But the way that politics has changed in this country over the last generation, the federal government has been less and less able to take any action that would be valuable for public health and it is during that time that cities have become really the hotspots, where exciting things are happening in public health.”
Crucially for those involved in local government elsewhere, Farley stresses that local governments can often do more than they think. Where local government administrations are not in a position to take legal action, they can communicate with residents through mass media and they can pressure other levels of government to adopt policies. “We’ve been able to demonstrate here in New York that cities do have enough authority to make a big difference,” comments Farley. “If cities look for opportunities for public health action, they are there.”
Cite this as: BMJ 2013;347:f6272
Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.
Provenance and peer review: Commissioned; not externally peer reviewed.