Intended for healthcare professionals

Feature Public Health

New York’s road to health

BMJ 2008; 337 doi: (Published 08 July 2008) Cite this as: BMJ 2008;337:a673
  1. Karen McColl, freelance writer
  1. karen{at}

    From paying poor families to attend health checks to a law requiring the energy content of food to be shown on menus, New York City is taking a bold and pioneering approach to public health. Karen McColl reports

    The appropriateness of giving people cash incentives to look after their health is fiercely debated.1 2 But both critics and enthusiasts of this approach will be watching New York, as one of the world’s richest cities experiments with a programme of conditional cash transfers to break the poverty cycle.

    Opportunity NYC is a pilot project that gives cash rewards to poor families for investing in their own health, education, and welfare. Opportunity NYC draws heavily on experience in Mexico, where the first major conditional cash transfer programme, Progresa (now known as Oportunidades), was launched in 1997. The scheme is currently privately funded, but it has the backing of New York’s mayor, Michael Bloomberg, and may be rolled out if the results of the pilot study are positive.

    Opportunity NYC pays families for, among other things, ensuring that they have health insurance and for using prevention services. For example, families are paid $20 (£10; €13) a month for maintaining subsidised health insurance for each parent and $20 a month for maintaining it for all their children. Families who keep up their private or employer insurance for all the family receive $50 a month. Payments of $200 are made for each family member attending an annual medical check-up and, if the doctor recommends a follow-up visit, then $100 is paid for each family member attending within the recommended timeframe. Families also receive $100 for each family member who attends regular preventive dental check-ups. Six community organisations have recruited families from areas with high levels of deprivation. In total 4800 families are taking part in the pilot, half of which are randomly assigned to the control group. The first Opportunity NYC payments were made in September 2007, and they have the potential to increase household income by 25-30%.3

    British government ministers have visited the Opportunity NYC programme, and some of the ideas are now being translated into welfare policy in the United Kingdom. On 23 June, ministers announced a pilot scheme to give poor families a £200 ($400; €250) child development grant on condition that they take up local Sure Start services, such as early learning and childcare places.4 The pilots were announced as part of a broader package to tackle poverty and bring about Gordon Brown’s vision of “an upwardly mobile Britain.”5 They will run in 10 local authority areas for two years from early 2009 and at least £12.75m is available to fund the scheme. The aim of the pilot is to test whether financial incentives, combined with professional support, can encourage parents to take up services for their children.

    The Opportunity NYC initiative is indicative of the Bloomberg administration’s bold approach to public health. In recent years the city has introduced a broad mix of measures to improve public health. Many measures focused on reducing smoking and tackling coronary heart disease, obesity, and diabetes.

    Innovative legislation

    Although many countries have now legislated to prohibit smoking in public places, when New York City passed the Smoke Free Air Act in 2002 only the state of California had introduced similar legislation.6 Smoke-free legislation now covers more than half of the US population.7

    In 2006, New York City’s Board of Health introduced another controversial regulation.8 This time to phase out use of trans fatty acids (trans fats)—found in partially hydrogenated vegetable oil—in the city’s restaurants and catering outlets. This legislation drew on experience in Denmark, where trans fats legislation was introduced in 2004.

    Consumption of trans fats increases the risk of coronary heart disease by raising low density lipoprotein cholesterol and lowering high density lipoprotein cholesterol concentrations. A US study estimated that a reduction in trans fats could cut coronary heart disease events by 10-19%.9 New York’s health department estimates that trans fatty acid consumption kills at least 500 New Yorkers a year.10

    The legislation to phase out trans fat use in restaurants, with the exception of prepacked manufactured foods, was introduced after a voluntary approach had failed. New York City health commissioner, Tom Frieden, says that the implementation of the trans fat legislation has been surprisingly smooth. “The restaurants said that the sky would fall. They said that there would not be enough trans fat-free alternatives on the market. And that it would be expensive and wouldn’t taste the same,” said Dr Frieden.

    “In the first phase we mandated the elimination of trans fats from spreads and frying, and that ended up being extremely easy for restaurants. It was as easy as calling up their supplier and saying ‘please send me the trans-fat-free variety.’” He admits that the change was a challenge for the national restaurant chains, which use up to 400 million litres of oil a year. “But they all did it—and not only in New York City, but also throughout the country,” he said.

    By September 2007, within months of the first phase of the legislation coming into force, 94% of inspected restaurants were complying.11 The second phase was delayed for a year and came into force on 1 July. Dr Frieden says that this “doughnut hole” in the law was introduced because it is more difficult to produce doughnuts and baked goods without trans fats. New alternatives have now become available, however, and he predicts that the second phase of the ban will be implemented smoothly.

    As part of the city’s approach to tackling obesity, New York restaurant chains with more than 15 outlets nationwide are now required to display calorie information prominently on menus and menu boards.12 The legislation, which the food industry has been challenging in the courts, came into force at the end of March. New York consumers are currently suffering from what Dr Frieden calls “sticker shock” since the calorie contents have been revealed. It is too early to evaluate the impact, but the aim is to encourage restaurants to offer healthier choices and consumers to make healthier choices.

    Copycat measures

    “New York City’s actions have emboldened other cities and states to take action,” according to Michael Jacobson, executive director of the Center for Science in the Public Interest in Washington. Ten US cities or counties have passed trans fat legislation and more than 20 are now said to be considering putting calorie content on menus.13

    In addition, policy makers from much further away are watching developments. In reality, the New York City administration has more powers than many other city authorities. Under the US federal system of government, principal responsibility for public health lies at the state and local levels.

    “The New York mayor has much greater powers than the London mayor,” says Sue Atkinson, who has recently carried out a study comparing how social determinants of health are tackled in New York, London, and Glasgow. Professor Atkinson, who as London’s director of public health was health adviser to the mayor until 2006, adds that London’s mayor has a fairly limited remit for health. The legislation setting out the mayor’s responsibilities and establishing the Greater London Authority, however, does place a duty on the mayor to take Londoners’ health into account, and this has recently been extended to cover health inequalities. This is a useful lever to ensure that health issues are integrated into other strategic priorities such as transport and economic policy.

    National governments could also draw on New York’s experience. The UK’s Food Standards Agency, for example, is said to be interested in its law enforcing the inclusion of calories on menus. “We are exploring voluntary options as we know this approach works in the UK. However, we will watch with interest to see how the step taken in New York will impact on public health,” said a spokesperson.

    Strong political leadership

    What factors have come together to enable New York City to push the boundaries on public health in this way? One factor cited is that municipal leaders in the US have had to react to a lack of federal government action in recent years.14 “If federal government is not exercising its responsibility, then the city or state will step in,” says Dr Jacobson.

    It is also a question of political leadership on public health. “We have an unusual situation in New York City,” said Marion Nestle of New York University. “We have a health commissioner who is actually interested in public health—what a concept—and a fabulously wealthy and secure mayor who backs him up wholeheartedly.”

    The commissioner, Dr Frieden, cites the city health department’s long history of innovation and the independent health board as important factors. New York City is relatively unusual in having a health board that is appointed rather than elected. Dr Frieden argues that, as a result, the board is powerful and not easily influenced by vested interests.

    Dr Frieden is quite clear, however, that the “first, second, and third reasons” for the city’s boldness on public health are Mayor Bloomberg. “None of these things would have been possible without his leadership. It took a lot of political effort to get these things through, and it involved taking a lot of political heat to do the right thing. They are all now very popular, but getting them through meant standing up to vested interests and doing things that led to a fairly brutal critique in the tabloid newspapers. And Mayor Bloomberg was willing to do that because he knew that it would save lives,” Dr Frieden says.

    Although his official role is limited to civic leadership of New York City’s population of eight million people, his influence extends much wider because of his personal wealth. As a private philanthropist, Mr Bloomberg has committed $125m towards a global tobacco initiative15 and donated $100m to the school of public health at Johns Hopkins University.16

    Such strong political leadership on public health is rare. “It is very unusual to find a mainstream politician who is so committed to public health,” says Martin McKee, of the London School of Hygiene and Tropical Medicine. “And it is almost unique to find this combination of a politician who has his own independent resources and who is prepared to stand up against powerful vested interests.”

    City Hall says that the city’s approach to public health relies on evidence and cutting edge information technology. Receiving an award for public health at Harvard University last year, Mr Bloomberg said his approach was based on good solid health data and the city’s duty to “act on what we know.” Paraphrasing Mark Twain’s view that “thunder is impressive, but lightning does the work,” Bloomberg highlighted the importance of legislation for public health. “Public information campaigns are good, but it’s the law that really does the work.”17


    Cite this as: BMJ 2008;337:a673



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