Fighting Flu in Big Cities: Lots of Germs in that Big Petri Dish

By Chrissie Juliano, Director of the Big Cities Health Coalition

Chrissie Juliano

Chrissie Juliano

Fighting seasonal influenza (the flu) is serious business. It may sound rather pedestrian compared to headline-grabbing diseases like Ebola or Zika, but fighting flu, and other such “routine” outbreaks, is what local public health departments do every day to protect lives.

In a moderate to severe year, seasonal flu kills more Americans than car accidents. Over the past 30 years, it’s killed anywhere between 3,000 and 49,000 people in single a flu season. It also costs Americans $87 billion in direct costs and lost productivity. In short, there are many reasons to fight flu.

The U.S. Centers for Disease Control and Prevention (CDC) estimates that 5 to 20 percent of the U.S. population gets the flu each year, tens of thousands are hospitalized, and thousands die from flu-related illness. Families, businesses, communities, and our pocketbooks all suffer if we don’t work to prevent the spread of flu.

This issue is especially important to the members of our Coalition, who are the leaders of the biggest, most urban health departments in the country. Flu spreads when people cough, sneeze, or talk, causing droplets to land on people nearby.  People with flu can spread it to others who are up to 6 feet away. It can be spread more easily due frequent close contact. And people with the flu can infect others even before their symptoms start and while they are sick.  

The ease with which this infection spreads may be particularly disturbing news to urban dwellers, many of whom commute to work or school via crowded public transportation. No doubt, if you ride public transit to work like I do, you have been seatmates with a fellow passenger who is coughing and sneezing while being cramped like sardines in a train car.

The best defense against flu, as with many diseases, is preventing it from striking in the first place through vaccination. While there are other important public health practices like “covering your cough,” and frequent, thorough hand washing, getting vaccinated is the first step in preventing someone from falling ill.

Another secondary solution is staying home when sick – for those of us who can. Many of our Coalition members are pushing to pass paid sick leave, otherwise known as earned leave laws, in their communities, because these policies help everyone in a workplace stay healthy. For example, in San Francisco, every 30 hours worked earns workers one hour of earned leave. Nationwide, many workers do not enjoy these protections, so they are forced to report to work – even when they are sick with a highly contagious infection. We need to change this. Earned leave works because the infected individual is less likely to spread the infection to others when they are able to stay home.

When a critical mass of people is immunized against a disease, whether for flu or measles or mumps, most community members are protected because there is less of an opportunity for the disease to spread. This is called “herd immunity.” It means that when you get your flu shot, you aren’t just protecting yourself, but those in your “herd,” your friends, family, and all the people you encounter in your daily routine. Herd immunity also protects those among us, who for a variety of reasons are not able to get immunized – newborn babies or those undergoing certain cancer treatments, for example.

Getting your flu shot – and vaccinating your family – is important, no matter where you live. There’s a reason your local health official, your pharmacist, and your kids (like mine) harp on you to get your flu shot. So do your part!  Not just to protect yourself, but your community as well.

Beyond Thoughts and Prayers

Dr. Rex Archer

Dr. Rex Archer

By Dr. Rex Archer, Director of Health, Kansas City, Missouri Health Department

After the trauma of the events surrounding the Las Vegas mass shooting, stories of horror and heroism unfolded from that horrible act.  My compassion and prayers felt somewhat hollow.  I am in a position to move my compassion to actions that make a difference and to save many lives.  That is why I am in public health. Yet, the enormity of the challenge seems daunting.

Las Vegas gun violence blog.png

I do not know what all the answers are for a situation like the Las Vegas massacre. What I do know is that on a typical day in America, 93 people are killed by gun violence, and although there have been 277 mass shootings in our country so far this year, most Americans who die of gun violence actually die of suicide, not at the hands of a mass murderer. We know that women are too often killed by their abusers, and that domestic violence increases the chance that a women is killed by a gun by five times. This is especially important to remember now, because October is Domestic Violence Awareness Month.

What I can tell you is that the health department I lead in Kansas City has viewed violence and trauma as a public health issue for a long time, and that treating the problem that way has created results.  Our Aim4Peace program works to prevent retaliatory acts of violence.  I hope the story of this program can help those who want to reduce gun violence by providing some of the puzzle pieces we need to come to a solution.

A decade ago, a commission made up of city officials decided to address violence as a contagious disease. In public health, we know a lot about stopping epidemics of many kinds, and we recognized this problem as having many of the same characteristics. We observed the cyclical nature of the gun violence in our city, where a young person would get killed or injured by a gun and one of their allies would often seek revenge. The cycle would repeat itself in perpetuity if nothing was done to interrupt it.

When we started to look at the problem through a public health lens, we found that the sections of the city with the highest violence rates were also those with some of the highest health disparities and inequities. We saw an association with preventable related issues, including family instability, poverty, domestic abuse, educational failure and substance abuse.

When we were designing the solution, we looked at the evidence and considered 50 different anti-violence programs worldwide. We focused on programs that had the potential to be replicable and that focused on cultivating interpersonal relationships.

Based on those criteria, Kansas City created Aim4Peace, which:

  • Operates in the one-tenth of the city’s neighborhoods with the highest rates of killings and shootings.
  • Looks at violence as a learned behavior, and sets out to rewire some of the learned behaviors by those who are most prone to retaliate after a violent act. It seeks to engage people in the community who are at the highest risk of spreading the “epidemic” by interrupting that process.   
  • Sends “credible messengers,” respected individuals from the community, who can help to calm individuals after violence erupts and broker peace within high-risk neighborhoods.
  • Uses a core group of 25 outreach workers and violence interrupters to be called upon to intervene. Aim4Peace workers also are embedded in the Truman Medical Center’s trauma team.
  • Has a heavy focus on conflict resolution and mediation and does so via neighborhood outreach teams as well as the hospital prevention program.


  • In addition to reducing homicides by 75 percent in the target zone, the citywide homicide rate fell 28 percent between 2010 and 2014.       
  • Even though homicides have increased throughout the city in the last two years, homicides in the Aim4Peace target zone have continued to decline.
  • The program has broad support in the community, and is funded in part by a voter-approved “Health Levy.” A 2013 Office of Juvenile Justice and Delinquency Prevention (OJJDP) grant is enabling the city to expand the program beyond the target area.

This success story does not provide all of the answers we need to tackle every kind of gun violence in America, but it shows us that when we apply all of the tools in our public health tool box to address violence and trauma, it is possible to make serious progress. 

Public health professionals are known for tackling other tough issues too. We know from other big health challenges that we can save lives if we stick to evidence-based approaches to help change behaviors for the better. We didn’t respond to high rates of lung cancer by just treating lung cancer more effectively.  We also went to the root cause of the problem: cigarettes.

With cigarettes, we raised the prices, reduced their advertising, determined how and where they could be sold, where people could light up, provided cessation options and incentives, health insurance disincentives, and used legal challenges to go toe-to-toe with the cigarette manufacturers and the lobbyists.  We applied the best minds, research, policy and evaluation to make a difference.  We still have a long way to go, but we made incredible progress. The smoking rate in America has been more than halved

The tragic events in Las Vegas were met with statements about “thoughts and prayers” in Washington – and little else. It is a shame that our national leaders have abdicated their responsibility to be part of the solution, but we don’t need to wait on the Capitol or the White House to lead the way. Many of the answers can be found in our own communities. I know that the stories I’ve shared are not the only ones that can help us reach for effective solutions to our gun violence epidemic in America. Congress may be in a deadlock on this issue, but I call on local leaders in states and cities all over America to share their stories of successfully fighting gun violence – and then to implement what we learn.  



Acts of Nature are Public Health Emergencies

By Meredith Li-Vollmer, Public Health - Seattle-King County

The news from Hurricane Harvey has been heart wrenching. Among the memorable images that emerged was one of nursing home residents sitting in wheelchairs, waist-deep in flood water as they waited for help to arrive. As reported by the New York Times, among the thousands of posts to volunteer rescue groups were common pleas such as “East Houston, 9:53 p.m.: Needs evacuation, one elderly person in a wheel chair” and “Northeast Houston5:36 a.m.: He’s on bottled oxygen now, and running out. Nausea from lack of oxygen has already started.” As some of the most vulnerable in the community struggled, news also covered the toll that the hurricane has taken on the world-class hospitals in the Houston area who were well prepared with back-up generators but hampered by the extremity of the weather and flooded roadways to evacuate patients and bring in emergency vehicles, food, and supplies. Hurricanes and floods aren’t just acts of nature. They are also public health emergencies.

What would we do?

Like Houston, King County is known for its large and innovative healthcare hub. But any number of emergency events could put strain on hospitals that often function at near capacity during an average day. Our region has the potential for flooding rivers, wind and ice storms that knock out power, and of course, earthquakes. Even a severe flu season or a large traffic incident, like the Aurora Bridge bus collision, can put additional pressure on hospital resources. So what’s in place for our healthcare and public health systems in crisis circumstances?

We’re fortunate to have a robust coalition of private healthcare and public health organizations working together on emergency planning, led by the Northwest Healthcare Response Network (“the Network”). It has roots in our health department before the Network became an independent nonprofit that coordinates healthcare preparedness in King, Pierce, and Kitsap counties.

Before a disaster, the Network collaborates with the healthcare community, including nursing homes, hospitals and other facilities, to prepare and train. This includes creating plans to provide the right care for each patient when a facility must be evacuated. During a crisis, they coordinate with healthcare, public health and other emergency response agencies to share critical healthcare information (like ER capacity, bed availability and resource shortages). The Network also helps secure needed supplies, services and federal assistance for hospitals, blood centers, dialysis centers, and other healthcare facilities.

One important function that the Network provides in an emergency is tracking of patients. Imagine that the big earthquake finally hits and injured people are scattered into hospitals all over the region. Many might also have been at work, or at school, out running errands, or even from out-of-town, so it’s hard to know who’s hospitalized and where they might be. In a chaotic landscape, the Network’s tracking system will be critical in helping people find their family members within the healthcare system.

This kind of planning pays off. The University of Texas MD Anderson Cancer Center was able to continue the critical work of caring for cancer patients through Hurricane Harveybecause they had planned for staffing, transportation, and flood barriers. A thousand staff rode out the storm and kept their patients alive.

Public health and disasters

Every disaster also has significant public health impacts. Power outages increase the risk of carbon monoxide poisoning and food spoilage. Floods result in contaminated water systems, and after the water recedes, mold. Any time that roads are blocked, people have trouble getting dialysis, insulin, home-delivered oxygen tanks, and other essential medical services. That can result in more problems related to asthma, hypertension, and diabetes, in addition to other health problems and injuries caused by the disaster. And there are some crisis scenarios that are squarely within the public health arena, like influenza pandemics and other serious disease outbreaks.

That’s why the health department also has an emergency response function. Our Preparedness Section plans and trains with the Network and other emergency response agencies so that we all stay coordinated. We’ve created detailed plans for how to distribute life-saving medications or vaccines in emergencies. We’ve trained up response teams that can deploy to rapidly disseminate critical health information, conduct disease investigations, and inspect food and water sources to ensure safety. We’ve recruited and trained a Public Health Reserve Corps of over 700 volunteers who can augment the healthcare system in a time of need. Our experts are ready to provide guidance on infection control to schools, healthcare facilities, and businesses.

And there’s a role for you, too

Federal funding from previous administrations made it possible for our public health and healthcare systems to plan and train for disasters. But as ready as we are, a disaster on the scale of Hurricane Harvey will stretch resources thinly (like a major earthquake on the Cascadia or Seattle faults).  Like our highly capable colleagues in Texas, we cannot anticipate every aspect of a catastrophic event. So we count on you to be ready, too.

There are many great resources to help you make an emergency kit or household communication plan, such as or Here’s what you can do to plan for your health needs:

  • Include health-related items in your emergency kit, such as charged batteries for wheelchairs and hearing aids, and extra eyeglasses.
  • Plan with your doctor, pharmacist, or medical service provider about what to do if medical supplies can’t be delivered or if you can’t get to the pharmacy for prescription medications. Ask your doctor and/or pharmacist if you can have a 3-day emergency supply.
  • If you depend on dialysis, get information on other dialysis facilities if you cannot use your regular facility. Find out if they provide the type of treatment you need. Know what diet to follow if your dialysis must be delayed.
  • If you depend on medical equipment powered by electricity (beds, breathing equipment or infusion pumps): check with your medical supply company and get information regarding a back-up power source such as a battery or generator.

Finally, be ready to help your neighbors. There simply won’t be enough emergency responders to meet the demand, so people helping each other will be our most valuable resource.

Coverage of Hurricane Harvey shows how emergency professionals and everyday people have rallied under dire circumstances to protect their communities and each other. Our hats are off to the Texans who are showing such courage, resourcefulness, and compassion in the face of the most catastrophic disaster they’ve experienced in living memory.

Information from King County about donating to Hurricane Harvey relief.

“Back to School” Season: Backpacks, school supplies and cancer prevention

By Dr. Julie Morita, Commissioner of Health, Chicago Department of Public Health

Flipping my calendar from July to August, always yields a sense of melancholy as I can see the less structured, long, warm days of summer rapidly disappearing and the busy, regimented, new school year entering into sight. While many people overcome the sorrow of the summer ending with “Back to School” shopping for backpacks, new clothes and school supplies, since becoming a pediatrician almost 25 years ago, I have sought consolation in knowing that “Back to School” means that millions of school-aged children throughout the US will be receiving health examinations and vaccines, which prevent serious diseases including measles, mumps, whooping cough, and polio.

How the Senate's Obamacare repeal bill would wallop the urban poor, and especially those who rely on Medicaid and public hospitals

If there was any hope that Senate Republicans could bring some sanity into the national discussion around the future of our health care system, such hope completely vanished on Thursday. Like the House's health care bill, the Senate's proposal is nothing less than an all-out attack on public health and our public hospital system, and its consequences will be devastating for New York City and the country.

Showing up for LGBTQ communities

By Jesse Chipps, HIV Planning Council Administrator, Public Health - Seattle & King County

June is National Lesbian, Gay, Bisexual and Transgender (LGBT) Pride Month, and each year at this time hundreds of King County employees, department directors and public officials march together in Seattle’s Pride Parade. Rainbow tinsel laden vehicles, bubble machines, and matching t-shirts pull the group together as One King County.

The Zika Fight of 2017

By Chrissie Juliano, Director of the Big Cities Health Coalition

Last year’s high profile infectious disease outbreak of the Zika virus is still fresh in our minds. While official announcements last week told Americans that the outbreak is waning in the U.S., all of the same conditions that created a Zika emergency last year are still present today. And just like then, the consequences of inaction are very real for those at risk, especially pregnant women and their babies. Unlike last year, we are also dealing with an Administration proposing an absurdly large –$1.2 billion – cut to the U.S. Centers for Disease Control and Prevention’s (CDC) budget in a way that would severely hamper its ability to fight, not to mention prevent, disease.

Combining Disciplines, Reducing Stigma: How Long Beach Incorporates Mental Health into Public Health

By Kelly Colopy, MPP, Director, Long Beach Health Department

May is Mental Health Awareness Month, which brings a heightened awareness and opportunity to support the mental and emotional health of those in our communities experiencing a mental illness.  As individuals and families, as well as communities and organizations, we are learning that we all know someone, often close to us, who has experienced some level of mental illness in their lifetime.  Nearly 1 in 5 adults (43 million) in the United States experiences a mental illness each year.  The impacts of mental illness diagnosis vary widely; some have serious impacts on the ability to perform major life activities.  Access to treatment has improved with the passage of the Mental Health Parity and Addiction Equity Act of 2008 and under the Affordable Care Act in 2010, yet more capacity for treatment is needed.  The conversations are increasing at the systems level as we work to grow healthy supportive environments and increase access to mental health resources in our community.  Yet, at an individual and community level, the conversations continue to be difficult.  The stigma, while lessened, still remains.

Four Ways We Are Measuring Affordable Care Act Proposals

By Patty Hayes, Director, Public Health—Seattle & King County

This blog originally appeared in Public Health Insider

Any reform or replacement for the Affordable Care Act should help people lead healthier lives. We believe that’s the underlying purpose for health care reform (while acknowledging that there are economic and other reasons to reform, as well). We’re tracking four key areas that help us measure each proposal.

Health Equity and Minority Health in Bexar County and the City of San Antonio

By Vincent R. Nathan, PhD, MPH, San Antonio Metropolitan Health District

Bridging Health Equity Across Communities" is the theme of this April’s U.S. Department of Health and Human Services (HHS) Office of Minority Health (OMH) National Minority Health Month. Over the past month,  HHS OMH, with their partners, worked to raise awareness about efforts across health, education, justice, housing, transportation and employment sectors to address the factors known as the social determinants of health – environmental, social and economic conditions that impact health.  San Antonio, Texas joins DHHS in celebrating, and more importantly, recognizing the disparities in health among different groups.

Earth Day – A Celebration of Environmentalism and Environmental Justice for All

By Cynthia Harding, MPH, Robert Gilchick, MD, MPH and Angelo J. Bellomo, REHS, QEP, Los Angeles County Department of Public Health

Earth Day, celebrated each year on April 22, commemorates the birth of the modern environmental protection movement.  Started in 1970 during an era when pollution was rampant in our country, Earth Day is credited with bringing the concept of environmental protection into the national political agenda.  The first Earth Day was marked by massive rallies and demonstrations advocating for a healthy and sustainable environment.  In 2017, Earth Day will be marked by a national call to action around science, with a march in Washington DC and other communities throughout the nation.

The Chief Health Strategist Role in Tarrant County, Texas: Building Walkable Streets and Greener Food Carts

By Vinny Taneja, MBBS, MPH, Director of Tarrant County Public Health

Fort Worth and Arlington are both located in Tarrant County, a fast growing community of approximately 2 million individuals living within 902 square miles. Like many large urban communities, neighborhoods vary significantly by culture, race/ethnic background, income, education, green space, housing, crime and many of other social determinants of health.

More than the ACA: We Can’t Stop Fighting Now

By Dr. Oxiris Barbot, First Deputy Commissioner, NYC Health Department

This op-ed originally appeared on

Since the start of the new presidential administration, the onslaught of policies and executive orders have been met with outcries from communities, organizations and elected officials. In the medical community, there was an almost unprecedented bipartisan opposition to the White House’s proposed American Health Care Act. To some, the protection of the Affordable Care Act has given us a rare time to celebrate, rest and regroup.

Now is not that time.

Marking National Public Health Week, “Healthiest Nation 2030,” by Defending the CDC’s Support for Prevention in Local Communities

By Chrissie Juliano, MPP, Director of the Big Cities Health Coalition

This year’s American Public Health Association’s (APHA) National Public Health Week (NPHW) challenges us to think about what the “Healthiest Nation 2030” means. As we focus on this charge, we find ourselves again working to defend huge cuts in public health funding at the Centers for Disease Control and Prevention (CDC) and elsewhere.

Fighting TB in San Jose: New Urgency with Federal Funding at Risk

By Tara Perti, MD, MPH, Assistant Health Officer and Tuberculosis Controller at the Santa Clara County Public Health Department

Tuberculosis (TB) remains an enormous global problem and is one of the top ten causes of death in the world.  As we live in a global community, infectious diseases common in other countries also affect the United States.  In the United States, in 2015, 9,557 patients were diagnosed with TB disease

The ACA Replacement Would Devastate America’s Health

By Leana Wen, MD, MSc, FAAEM, Baltimore City Health Commissioner

This blog originally appeared on 

As a physician who has treated patients in the emergency department before and after the Affordable Care Act was instituted, I have seen firsthand how it has transformed the lives of many of my patients. And as the health commissioner for Baltimore city, I have seen how it has safeguarded the lives of more than 40,000 residents in my city, and millions more around the country, who would otherwise be uninsured.

ACA Repeal Would Mean Massive Cuts To Public Health, Leaving Cities And States At Risk

By Chrissie Juliano, MPP, Director of the Big Cities Health Coalition

This blog was originally posted in Health Affairs.

When the Affordable Care Act (ACA) was passed a little over six years ago, it brought with it the promise of health insurance for all Americans. It also sought to begin to shift the paradigm for health care in this country, emphasizing value over volume, and recognizing the importance of prevention coupled with appropriate access to care.

Repeal of ACA would imperil a little-known part with a huge impact

By Gretchen Musicant, MPH, BSN,Commissioner,  Minneapolis Health Department

The debate about the future of the Affordable Care Act (ACA) is in full swing, and many know that repealing the ACA would leave almost 20 million Americans without health care coverage. This is of great concern.

But the fact that repealing the law would also decimate the already-fragile public health system in America is not known to many policymakers or members of the public.

To End HIV/AIDS, Cities like Ours are Leading the Way by Setting Bold Goals

By Anthony Stamper, Denver Department of Environmental Health

This was originally published as an op-ed in The Hill newspaper.

On December 1st, communities across the nation will commemorate World AIDS Day. First memorialized in 1988, World AIDS Day offers the opportunity for people worldwide to unite in the fight against HIV, show support for people living with HIV, and remember those who have died. We know that in the U.S. the number of people living with HIV and AIDS is concentrated in cities, and that cities are also the most ambitious leaders in the fight against the disease. This World AIDS Day, Denver can report some major victories in fighting the disease that policy makers at every level should study carefully.