By Sherry L. Howard

In September, the Dornsife School of Public Health proudly convened its second Urban Health Symposium. Some 300 researchers, practitioners, policymakers and students gathered at Nesbitt Hall on the Drexel University campus to share insights and perspectives on the health challenges facing cities, at a time of rapid urbanization locally and around the globe. They came away with a recognition that across vast differences, there is much to learn from each other, and — that when it comes to health — everything is connected: behavior, environment, equity and policy, in varied arenas such as housing, transportation, education and beyond.

For his age, the three-year-old boy was far from bashful. Dr. Abdul El-Sayed encountered the child about three weeks after being named director of the Detroit Health Department. El-Sayed had walked into a department with a staff so small that he could count them all on one hand. He said he found himself “drowning” in a mission so large that he could hardly wrap his own young mind around it. But the little boy helped him see the challenge clearly.

“He did something really peculiar for a three-year-old. This boy looked me right in the eye, walked right up to me, gave me a big hug and walked back to his mother,” El-Sayed said. “I thought about the confidence and the courage that it takes a three-year-old to go hug some random dude they’d never met before.

“And I thought about that in contrast to the set of challenges that boy is going to face because of the life in which he was situated, which has nothing to do with decisions he’s ever made. ... This boy taught me a lot about how ... we should be thinking about public health in the first place.”

Engaging individuals where and how they live - and taking into account their social environments and the elements that affect them - is the new focus of the public-health field. That was the overriding theme of presentations on “Health Issues Facing Cities Today” offered by four big-city health department officials at the biennial Urban Health Symposium sponsored by the Dornsife School of Public Health at Drexel University.

Public health professionals today are emphasizing the social, behavioral and environmental determinants of health, and how all have contributed to the inequities suffered by the people they serve. Their aim is to keep people healthy through prevention and access to quality care and to tackle the behaviors as well as external and systemic factors that lead to unhealthy lives, said Dr. Thomas Farley, commissioner of the Philadelphia Department of Public Health.

He cited smoking, unhealthy diet, physical inactivity, air pollution, alcohol and drug use as behavioral/environmental factors for disease. “We can now count how many people die from those risk factors,” he said, noting that smoking alone kills roughly 400,000 to 500,000 per year.

Among the social determinants of poor health, he cited racial and economic segregation, and inadequate education.

“If you go back say 40 years ago, public health was really about infectious diseases, said Farley. “We were immunizing children. We were responding to disease outbreaks. We still do that and that’s important, but those are now very low as relative causes of death. It’s caused something of an identity crisis in public health - who are we really and to what extent are we responsible for these social issues which have a big impact on health.”

This redefinition is nothing new. In the two centuries since public health emerged as a field in this country, its focus has changed depending on the nature of the health menace at the time. Early on, the federal government provided hospitals for sick sailors through the Marine Hospital Service, the forerunner of the Public Health Service.

When many people were dying of small pox, yellow fever and cholera a century later, public health officials reacted by quarantining and isolating the sick. When they realized that unsanitary living conditions led to disease outbreaks, they worked to clean up those communities.

“A lot of the early public health work was looking at the environment where people lived, which has a social justice context to it,” said Aletha Maybank, MD, MPH, one of the presenters on the panel, said in a later interview. She is deputy commissioner and professionals began to take an even bigger role in people’s health through educational campaigns and by stepping in to help stem major disease outbreaks. They responded to tuberculosis and polio epidemics, measles immunizations and the like.

Now, the field is evolving again. Panelist Julie Morita, commissioner of the Chicago Department of Public Health, attributed some of the shift to the Affordable Care Act (ACA), or Obamacare.

The act “freed public health up to think beyond what we traditionally focused on,” she said. “There was so much emphasis in the ACA related to prevention and public health and support for that within the health care delivery system that it freed us up to think more broadly. It was very liberating to now be able to think about determinants of health and root causes of health in general.”

Farley urged the participants to take an active role in figuring out how to prevent unnecessary deaths caused by social determinants of health, as well as behavioral and environmental factors.

The public health field, he said, must recognize that finding solutions to both social and behavioral/environmental health challenges is necessary - and requires stepping out of the traditional realm of health to grabble with issues such as poverty and income inequality.

“The social determinants of health and the behavioral determinants are ... in different dimensions but we probably ought to be working on both,” Farley said. “We’re not going to end poverty and income inequality with things like reducing air pollution, increasing access to healthy food, or parks and pedestrian infrastructure, or raising cigarette taxes. All those are wonderful and are going to save lots of lives, but they’re not going to do anything to poverty and income equality.”

He offered several policy recommendations that the public health field should push for to alleviate the impact of social determinants:

• increasing the minimum wage or work toward more union-negotiated wages
• creating a less regressive tax structure and providing an earned income tax credit
• providing “more opportunity to racial groups that are discriminated against right now” through affirmative action
• implementing affordable housing policies already on the books, along with zoning and planning regulations that promote integration
• increasing funding for public schools.

A Call-Out to Public Health Professionals

With the little boy in mind, El Sayed urged the symposium participants to become more attuned to the communities they help. “Pay attention to the individual,” he said. “Have empathy for the people we are actually serving as we think about trying to wrap our heads around some of these abstract concepts that sometimes feel so much bigger than anything we can do. A call-out to public-health professionals “I think it is a moment right now where we have to be thinking about public health in the grandest ways but then focus it on sometimes the smallest people.