Population Health and the Legacy of Michael Bloomberg

Local leaders are going to be increasingly responsible for the health of the broader population. The former New York mayor's controversial approach will serve as a model.

The rapidly shifting health-care landscape, with its growing emphasis on the well-being of the broader population, will transform the role of local elected officials as it relates to public health, broadening their responsibilities and adding a new sense of urgency. The public-health legacy of former New York mayor Michael Bloomberg provides a model for the rest of the nation.

Historically, elected officials have been responsible for health infrastructure, from the operation of public hospitals and maintenance of vaccination and screening programs to the response to disease outbreaks and the stewardship of safe food and water, workplaces, and sanitation systems. To those obligations will now be added new dimensions of creating population health, which the federal government is making a priority for hospital reimbursements.

While daunting, this role offers leaders powerful ways to build not only a healthier population but also a more fiscally sound society. That's where Bloomberg's often controversial yet visionary legacy is so important. As a result of it, life expectancy has increased faster in New York City than in the United States as a whole over the past decade. In terms of public health, that legacy can be divided into three major areas:

First, Bloomberg and his health commissioners -- initially Thomas R. Frieden (now director of the U.S. Centers for Disease Control and Prevention) and then Thomas Farley -- crafted and implemented a 21st-century agenda for the public's health in New York City. The mayor and his team worked to ensure that all parts of city government understood that the conditions that supported good health were among their responsibilities. The city deployed an array of tools to prevent obesity, diabetes, heart disease, stroke and asthma. Strategic investments were made to reduce smoking, require that calorie counts be posted in many fast-food businesses, increase physical activity, grade restaurants for compliance with the city health code, increase screenings for people at risk and sponsor disease-prevention activities.

This aggressive agenda meant that disagreement was unavoidable. Yet even the city's controversial ban on smoking in all workplaces, including restaurants and bars, has been so effective that it has been replicated all over the United States and in other countries. It has accompanied significant growth in the number of restaurants, bars and related employment in the city -- the opposite outcome from that predicted by the ban's alarmist critics.

Second, Bloomberg and his administration created PlaNYC, bringing together more than two dozen city agencies to create a built environment that would work toward a greener, more healthful New York. PlaNYC combines support for building sustainably and reducing pollution with approaches to creating health for the whole population. Its initiatives take a broader approach to health, focusing on the water supply, transportation, energy, air quality, solid waste and climate change, as well as access to healthy food and to parks and playgrounds, pedestrian thoroughfares and bike lanes.

Third, Bloomberg engaged the public in a lively and informative discussion of some of the obstacles to good health, with the population as his patient. Even his unsuccessful proposal to ban large servings of sugary soft drinks is a case in point. While the ban was not enacted, the public is now more aware of the danger of consuming soft drinks in large quantities, vendors who sell those large servings have felt the pressure, and the resulting discussion and debate have influenced communities far from New York City.

Bloomberg's administration was unfairly called a "nanny state." But strong leadership and a clear public strategy are required to overcome linked epidemics that threaten to sink our health, our economy, our health-care systems and our communities. Driven largely by the rise in obesity, for example, one in 10 adults in America already has diabetes and as many as one in three could have the disease by 2050 if current trends continue, according to the Centers for Disease Control and Prevention. This is a health emergency requiring 21st-century approaches: science-based, proactive, prospective interventions to prevent this disease as well as new approaches to better treat it.

Cynics might reasonably ask whether Bloomberg was motivated to improve public health or to reduce governmental costs. As with many mandates for local leaders, the drive to enact this kind of intervention may indeed begin in the budget office. With the federal government increasingly tying health-care funding to population health, local leaders will have incentives to make longer-term investments in the prevention of chronic diseases and in promoting health at every age and stage of life.

When local leadership is held accountable for the health of their populations, the extent of the Bloomberg legacy will be fully apparent. Taxpayers who increasingly find themselves paying for the poor health of their neighbors -- and of themselves -- will demand that their elected officials do what they can to improve health for all.

VOICES is curated by the Governing Institute, which seeks out practitioners and observers whose perspective and insight add to the public conversation about state and local government. For more information or to submit an article to be considered for publication, please contact editor John Martin.

Dr. Linda P. Fried is dean of the Mailman School of Public Health at Columbia University, where she is the DeLamar Professor of Public Health.