BCHC Head Urges the Surgeon General to Focus on Health Equity in Response Call to Action on Community Health Investment

November 2018

November 5, 2018

Martin J. Vincent
Office of the Associate Director for Policy
Centers for Disease Control and Preven on
1600 Clifton Road NE, Mail Stop D-28
Atlanta, Georgia 30329
via Federal eRulemaking Portal

Re: Surgeon General’s Call to Action: “Community Health and Prosperity” [CDC-2018-0082]
To Whom It May Concern:

On behalf of the Big Cities Health Coalition (BCHC), I am writing to provide comments on the Surgeon General’s Call to Action to Improve Community Health and Prosperity. As health leaders in the largest, most urban cities in the country, our members applaud the Surgeon General and the Centers for Disease Control and Prevention (CDC) for soliciting feedback on the business case for “Community Health and Prosperity.”

BCHC is a forum for the leaders of America’s largest metropolitan health departments to exchange strategies and jointly address issues to promote and protect the health and safety of their residents. Collectively, our 30 jurisdictions serve more than 55 million people, or one-in-six, Americans. BCHC members work to achieve healthier, more equitable communi es through big city innova on and leadership (our vision) to advance equity and health for present and future generations (our mission).

While BCHC signed onto comments submi ed by the Trust for America’s Health, we wanted to also share specific issues most relevant to our members. As you well know, big city health departments are the governmental agencies that work every day in their communi es to prevent disease and promote and protect health. They organize community partnerships, including with local businesses and the private sector, and facilitate important conversations with a number of stakeholders about how to create the conditions through which all people can get and stay healthy. Big city health departments have a number of touch points throughout their jurisdictions, and despite their size, are deeply rooted in their communities.

The following comments, though delineated by topic, should be read through the overall lens of the importance of addressing social determinants of health (SDoH) to make broad, impactful, long-lasting gains in community health. In recent years, we have made some progress in better understanding all of the factors impact health, including housing, income, education, and the environment, to name just a few. These societal elements account for approximately 80 percent of the modifiable factors that contribute to healthy outcomes for a community,i and jurisdictions with a higher ratio of social to healthcare spending have significantly better health outcomes. Thus, investing in community health, with an emphasis on prevention and policy, systems, and environmental change to address the SDoH and improve health equity, is necessary to improving both our overall health and prosperity.

Government Agencies Play a Key Role as Employers and Can Address Inequities in Communities Government agencies not only create policy and regulate economic activity across the country, but also employ a significant portion of the U.S. workforce. As such, the way agencies hire, promote, invest, and make policy are major drivers of a community’s health and economic prosperity. Poor health is driven by poverty and racism, and federal, state, and local governmental agencies have the responsibility to establish and enforce policies to address racism and income inequality.

In our collective work to advance racial equity, social justice, and community health and prosperity, it is important to first understand how racism operates within institutions and how structural racism shapes social, economic, and health inequities across our country. Secondly, there is a need to examine how structural racism impacts the work, including in priority setting and decision making. And, collaboration is needed to identify and implement strategies that counter racist systems and practices that exist within government institutions and across our country. The highly interconnected issues of health inequities and income and wealth inequality cannot be lost, which contribute to reduced life expectancy and income and class mobility. ii,iii,iv

As such, it is recommended that any framework put forward also draws attention to the private sector’s role in contributing to the goal of improving health equity. Health equity is when everyone has access to the conditions needed for optimal health and well-being. Cities and communities across the nation have unequal life expectancies, birth outcomes, access to health care, and other health outcomes and resources required to achieve optimal health. Inequities in health outcomes based upon race, language, income, sexual orientation, gender and biological sex, physical and mental abilities, and religion are factors that affect our health due to unfair policies and practices. Such inequities are unjust, unfair and avoidable, and affect the nation’s overall health and wellbeing, as well as the business workforce’s health and productivity. Resources and strategies must be put in place to make sure that everyone has what they need to be healthy. The private sector can participate in developing initiatives, strategic priorities, goals, and objectives to advance a health equity agenda to reduce the inequitable distribution of opportunities and resources necessary for health.

Governmental Public Health is Key Partner in This Work

Local health departments serve as the “Chief Health Strategist”v in the communities they serve, driving health transformation, and bringing together residents and partner organizations for collective impact on the social determinants of health. In this role as neutral conveners of stakeholders and facilitators of collective strategic action, departments and their leaders have an established history of engaging the business community to protect and improve community health. Additional opportunities to maximize these relationships would improve health.

Community health assessment and planning activitiesvi are also fundamental practices of local and state health departments, hospital systems, and federally qualified health centers to identify the health needs and priorities of the populations they serve and develop and implement effective strategies to protect and improve community health.

Having the business community included in these efforts is key to ensuring that the local public health system is responsive to the needs of employers and that they are included as an integral part of that system. This includes helping ensure that initiatives support a healthy and productive workforce and promote community vitality and prosperity, particularly by addressing the SDoH, including employment, education and job training, housing, and poverty.vii Having the private sector more actively engaged in community health assessment and planning efforts in their communities would be extremely beneficial.

Funding Considerations and Rationale

Funding is a common barrier in communities across the country and is both a challenge to, and rationale for, building the business case for healthy communities. While some companies recognize that if their workforce and clientele are healthy, they can be more productive, others do not. Private sector community health investments can often be good opportunities for good publicity. That said, additional, sustained, long term investments of government resources must also be considered. A common challenge is that when funding for community health initiatives is approved on a year-to-year basis, partners are unable to make long-term commitments to their stakeholders or plan how they would use funds more than one year ahead of time.

Below are examples about returns on investments in community health.
• CDC’s 2010-2012 Communities Putting Prevention to Work initiative invested $403 million across 28
communities with 55 million people targeting obesity, tobacco use, and secondhand smoke. An
evaluation found that, if these investments of approximately $2.50 per capita per year were
maintained through 2020, a return on investment of $6.90 would be realized over the 11 year
• Deaths from prescription painkiller use have more than quadrupled in the past 15 years and deaths
from heroin have tripled since 2010, contributing to higher death rates among middle-aged
whites. Investing $1 in substance use prevention can realize as much as $34 in return. Five of the
strongest school-based substance use prevention strategies have returns on investment ranging
from $3.8:1 to $34:1.ix, x, xi, xii
• One in three children will develop type 2 diabetes in their lifetime and one in four young adults are
not healthy enough to join the military. An investment of $10 per person in proven, evidence-based
community prevention programs to increase physical activity, improve nutrition, and reduce
tobacco use could save the country more than $16 billion annually – a $5.60:1 return.xiii
• More than half of U.S. children – across the economic spectrum – experience adverse experiences,
such as physical or sexual abuse, and more than 20 percent live below the poverty line, which
increases their risk for “toxic stress” – living under a constant state of stressful conditions – that can
contribute to a range of physical, mental, and behavioral health issues. Investments in early
childhood education can help mitigate against impact of these risks and increase resilience, while
also providing an annual return of 7 to 10 percent per year.
,xiv, xv Supportive nurse-family partnership
home visits for high-risk families show a return of $5.70:1.xvi
• Smoking costs the U.S. at least $289 billion each year, including at least $150 billion in lost
productivity and $130 billion in direct healthcare expenditures.
xviiAccording to a 2013 study of
California’s state-funded tobacco prevention program, for every $1 invested from 1989 to 2008 the
program saved over $55 in health care costs. This was driven in part by a 33 percent faster decline
in lung cancer deaths from 1986 to 2013, which took California from a slightly above national
average lung cancer death rate in 1985 to having 28 percent fewer lung cancer deaths than the rest
of the U.S. by 2013.xix
Public/Private, Multi-Sector Partnership Needed to Insure Healthy Communities
There are a number of examples of public/private, multi-sector collaborations across the country. Below
we highlight just a few that are central to our public health work in big cities.
• The BUILD Health Challengexx, supported by a coalition of national and regional philanthropies with
the founding partners being the de Beaumont, Kresge, and Robert Wood Johnson Foundations, this
national program strengthens partnerships between community-based organizations, hospitals and
health systems, and local health departments. The work coordinates resources and action to
support prevention and address the SDoH. BUILD has supported 37 projects from across the country
which have yielded promising approaches such as home remediation to address childhood asthma,
local code enforcement to reduce housing hazards, and improving access to healthy foods.
• Invest Healthxxi is an initiative of the Robert Wood Johnson Foundation and Reinvestment Fund that
supports multi-sector partnerships in 50 mid-sized U.S. cities, aiming to increase private and public
investments to improve health outcomes in low-income neighborhoods.
• The Build Healthy Places Networkxxii which is supported by the Federal Reserve Bank of San
Francisco, the Robert Wood Johnson Foundation, and the Public Health Institute, includes the
Healthy Communities Initiative, which deepens collaboration across the sectors of community
development, finance, population health, and public health.
Benefits of Strong Health System to Business as a Community member

The benefits of public health activities for the business sector have been noted in a number of areas, with efforts to reduce chronic diseases producing benefits from reduced worker illness and increased productivity (worker “presenteeism”).xxiii The costs of medical care, worker’s compensation, and lost productivity create a substantial economic burden for the private sector as well as the public sector. Gains in addressing underlying health risks that result in chronic diseases such as smoking, physical inactivity, nutrition, and obesity would thus result in significant savings. For example, tobacco use is directly linked with four leading causes of death: coronary heart disease, stroke, chronic obstructive pulmonary disease, and lung cancer.xxiv Private sector partners can also reap benefits from activities that address lack of physical activity and other contributors to the obesity epidemic. For example, businesses can support and promote opportunities for worksite wellness and health promotion programs that target not only individuals but also physical and social environments in workplace settings and their environments. These types of programs can lower health care expenditures and boost employee productivity.

Public health departments also typically provide a number of public health-supported health care services that benefit the business community’s bottom line by reducing employee illness and increase productivity.xxv These health care related services include treatment and prevention for infectious disease (tuberculosis, HIV, sexually transmitted infections, immunization services), injury and violence prevention efforts, communicable disease control, public health emergency preparedness, and substance abuse treatment. For example, public health actions to immunize and prevent the spread of influenza help reduce lost productivity from employee illness or from taking time off to care for sick family members.

Communities are Healthier When Engaged in Decision-Making

Jurisdictions across the country are using community-based participatory action research (CBPAR), which allows researchers to “center” and take the lead from those most impacted by the research or program. These principles can be applied to program planning, policy development, research design, data collection, and evaluation. The New York City Department of Health and Mental Hygiene, for example, has adapted the National Institute of Health’s Principles of Community Engagement (2011) framework and is using it as a guide to better and more meaningfully involve community partners in the work of public health.


xxvi They also use a Community Engagement Framework as a fundamental tool in developing public health policy, programming, and messaging. Finally, quantitative to evaluate the extent to which communities are engaged in research or program planning would be helpful to evaluate efforts to engage community members and improve practices among public health professionals and researchers doing projects in community health.

In closing, we cannot underdcore enough the importance of a strong health system. The 2003 Institute of Medicine (IOM) report, The Future of the Public’s Health in the 21st Century, described a framework for a “public health system,” which recognizes the role of multiple sectors and constituencies needing to work in partnership to create “the conditions in which people can be healthy.xxix Along with federal, state, tribal and local public health infrastructure, the business sector along with other sectors are seen as vital to contributing toward efforts that address social determinants of health to achieve broad gains in health and reduced morbidity and mortality.xxx

On behalf of the Big Cities Health Coalition, I so appreciate the opportunity to provide input to this work. BCHC members and I look forward to working with the office of the Surgeon General moving forward. Please do not hesitate to reach out to me for further information at either 202-783-3627 or cjuliano@naccho.org


Chrissie Juliano, MPP
Director, Big Cities Health Coalition

i Chokshi DA (April 2018). Income, Poverty, and Health Inequality. JAMA 319(13):1312–1313. Available at
ii Chetty R, Grusky D, Hell M, Hendren N, Manduca R, Narang J (April 2017). The fading American dream:
Trends in absolute income mobility since 1940. Science 356(6336):398-406. Available at
iiiBor J, Cohen GH, Galea S (April 2017). Population health in an era of rising income inequality: USA,
1980–2015. The Lancet 389(10077):1475-90. Available at
iv Chetty R, Stepner M, Abraham S, Lin S, Scuderi B, Turner N, Bergeron A, Cutler D (April 2016). The
association between income and life expectancy in the United States, 2001-2014. JAMA 315(16):1750-

  1. Available at https://jamanetwork.com/journals/jama/article-abstract/2513561.
    v https://www.naccho.org/uploads/downloadable-resources/NACCHO-PH-3.0-Issue-Brief-2016.pdf
    vi https://www.naccho.org/programs/public-health-infrastructure/performanceimprovement/community-health-assessment
    vii https://www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-of-health
    viii Soler R, Orenstein D, Honeycutt A, Bradley C, Trogdon J, Kent CK, Wile K, Haddix A, O’Neil D, Bunnell
    R, Communities Putting Prevention to Work Leadership Team. Community-based Interventions to
    Decrease Obesity and Tobacco Exposure and Reduce Health Care Costs: Outcome Estimates from
    Communities Putting Prevention to Work for 2010-2020. Preventing Chronic Disease Public Health
    Research Practice and Policy 2016; (13):E47.
    ix Miller T and Hendrie D (2008). Substance Abuse Prevention Dollars and Cents: A Cost-Benefit Analysis,
    DHHS Pub. No. (SMA) 07-4298. Rockville, MD: Center for Substance Abuse Prevention, Substance Abuse
    and Mental Health Services Administration. Available at:
    http://www.samhsa.gov/sites/default/files/cost-benefits-prevention.pdf. x National Institute on Drug Abuse (2014). DrugFacts: Lessons from Prevention Research. Available at:
    https://www.drugabuse.gov/publications/drugfacts/lessons-prevention-research. xi Communities that Care (2016). Research and Results. Available at:
    https://www.communitiesthatcare.net/prevention-science/. xii EPISCenter (2015). Evidence. Available at: https://epis.psu.edu/ . xiii Trust for America’s Health (2009). Prevention for a Healthier America: Investments in Disease
    Prevention Yield Significant Savings, Stronger Communities. Available at: https://www.tfah.org/report-details/prevention-for-a-healthier-america/.
    xiv Campbell F, Conti G, Heckman JJ, et al (2014). Early Childhood Investments Substantially Boost Adult
    Health. Science, 343(6178):1478-1485. xv Braverman P, Egerter S, Arena K, Aslam R (2014). Early Childhood Experiences Shape Health and WellBeing Throughout Life. Princeton, NJ: Robert Wood Johnson Foundation. Available at:
    http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2014/rwjf414926. xvi Robertson EB, Sims BE, and Reider EE (2016). Drug Abuse Prevention through Early Childhood
    Intervention. In H.H. Brownstein (Editor), The Handbook of Drugs and Society (pp. 525-554). West
    Sussex, United Kingdom: John Wiley & Sons, Inc.
    xvii U.S. Department of Health and Human Services (2014). The Health Consequences of Smoking – 50
    Years of Progress: A Report of the Surgeon General. Available at:
    https://www.hhs.gov/sites/default/files/consequences-smoking-exec-summary.pdf xviii Lightwood J, Glantz SA (2013) The Effect of the California Tobacco Control Program on Smoking
    Prevalence, Cigarette Consumption, and Healthcare Costs: 1989–2008. PLoS ONE 8(2): e47145.
    xix Pierce JP et al (2018). Trends in lung cancer and cigarette smoking: California compared to the rest of
    the United States. Cancer Prev Res (Phila). 2018 Oct 10. [Epub ahead of print] xxThe BUILD Health Challenge. About. Available at: https://buildhealthchallenge.org/about/. xxi Invest Health (2018). Invest Health Strategies for Healthier Cities: A Project of the Robert Wood
    Johnson Foundation and Reinvestment Fund. Available at: https://www.investhealth.org/. xxiiBuild Healthy Places Network. About us. Available at: https://www.buildhealthyplaces.org/about-us/ xxiii Simon, PA & Fielding, JE. Public Health And Business: A Partnership That Makes Cents. [Health Affairs
    25, no. 4 (2006): 1029–1039.
    xxiv Los Angeles County Department of Public Health, Office of Health Assessment and Epidemiology.
    (2016). Mortality in Los Angeles County 2013 Leading causes of death and premature death with trends
    for 2004-2013. Retrieved from
    http://publichealth.lacounty.gov/dca/data/documents/mortalityrpt13.pdf xxv Simon, PA & Fielding, JE. Public Health And Business: A Partnership That Makes Cents. [Health Affairs
    25, no. 4 (2006): 1029–1039.
    xxvi Centers for Disease Prevention and Control, Agency for Toxic Substances and Disease Registry.
    Principles of Community Engagement, Second Edition.
    https://www.atsdr.cdc.gov/communityengagement/pdf/PCE_Report_508_FINAL.pdf. Accessed October
    24, 2018.
    xxvii New York City Department of Health and Mental Hygiene. Race to Justice Community Engagement
    Accessed October 24, 2018.
    MEASURE DEVELOPMENT” Journal of community psychology vol. 45,1 (2016): 17-32.
    xxix 2003 Institute of Medicine (IOM) report, The Future of the Public’s Health in the 21st Century, xxx Simon, PA & Fielding, JE. Public Health And Business: A Partnership That Makes Cents. [Health Affairs
    25, no. 4 (2006): 1029–1039.