Read The Whole BCHC Report

BIG CITIES HEALTH COALITION
BIG CITIES HEALTH INVENTORY
Acknowledgements
Funding for this project comes from the U.S. Centers for Disease Control and Prevention (CDC) through Cooperative Agreement
5U38OT000172-03. The mark CDC is owned by the US Department of Health and Human Services and is used with permission.
Use of this logo is not an endorsement by HHS or CDC of any particular product, service, or enterprise.
The Big Cities Health Coalition (BCHC) also thanks the de Beaumont Foundation and the Robert Wood Johnson Foundation for their
ongoing programmatic support of the BCHC.
Acknowledgements
Staff from the 26 1 local health departments profiled here provided the majority of the
data in this report. Each reported city or county level data, responded to questions
when clarification was needed, and reviewed the final data platform. We thank them
immensely for their role in this project.
John Mulcahey, a Johns Hopkins University (JHU) Masters of Public Health (MPH)
student, provided analysis of the US Census data, while Stephen Blazs, also an MPH
student at JHU, performed additional data cleaning. We thank both for their time and
contribution to the project. The Virginia Commonwealth University Center on Society
and Health (www.societyhealth.vcu.edu/maps), specifically Derek Chapman and his
team, provided life expectancy data when they were not otherwise available.
This report could not have been completed without the Advisory Committee, which
guided the project team on technical issues concerning data collection and reporting.
They included:

Charon Gwynn, PhD; Deputy Commissioner, Division of Epidemiology, New

York City Department of Health and Mental Hygiene;
Kinjia Hinterland, MPH; Director, Data Communications, New York City

Department of Health and Mental Hygiene;
Giridhar Mallaya, MD, MHSP; Director of Policy and Planning, Philadelphia

Department of Health; 2
Nik Prachand, MPH; Director of Epidemiology, Chicago Department of Public

Health;
Margarita Reina, MPH; Senior Epidemiologist, Chicago Department of Public

Health;
Marguerite Ro, DrPH; Chief, Assessment, Planning, Development and

Evaluation Unit, Seattle King County Public Health; and
Tim Van Wave, DrPH, Associate Director for Science, Office for State, Tribal,
Local, and Territorial Support (OSTLTS), CDC.
In addition, de Beaumont-supported research consultant, JP Leider, PhD, provided

guidance to the project. James Buehler, MD, Health Commissioner, Philadelphia
Department of Health, also provided input in the beginning stages to help shape the
project, as did Shelley Hearne, DrPH, former Director, and current Advisor, BCHC;
Laura Hanen, MA, Chief, Government Affairs, NACCHO; and Vicky Bass, MPH, BCHC
Specialist, NACCHO. Christopher J. Gearon, a free-lance writer, conducted interviews
and drafted the case studies included in this report using a critical health journalists
eye. Liz Richardson Voyles, consultant to BCHC, copy edited the document and assisted
in its final production and release. Our partner in the data website was Socrata; their
team provided much guidance early on in the process and was responsible for the
web design, as well as ensuring integrity and accessibility of the data. Tim Van Wave
provided ongoing guidance and support in his role as our CDC-based project advisor.
Finally, we thank the eight reviewers of the publication for giving their time and
expertise with a quick turnaround to review the document.
SUGGESTED CITATION: Big Cities Health Inventory, 2015, Big Cities Health Coalition
and National Association of County and City Health Officials, Juliano, C., editor.
Washington, D.C. 2015.
1 Data from Portland (Multnomah County), Oregon were not available for this project.
2 Dr. Mallaya left the Philadelphia Department of Heath in late September, 2015
About The Big Cities Health Coalition
27 MEMBER CITIES (COUNTIES)

ATLANTA (FULTON COUNTY), GA
LAS VEGAS (CLARK COUNTY), NV
SACRAMENTO, CA
BALTIMORE, MD
LOS ANGELES, CA
SAN ANTONIO, TX
BOSTON, MA
KANSAS CITY, MO
SAN DIEGO, CA
CHICAGO, IL
MIAMI, FL
SAN FRANCISCO, CA
CLEVELAND, OH
MINNEAPOLIS, MN
SAN JOSE (SANTA CLARA COUNTY), CA
DALLAS, TX
NEW YORK, NY
SEATTLE, WA
DENVER, CO
OAKLAND (ALAMEDA COUNTY), CA
WASHINGTON D.C.
DETROIT, MI
PHILADELPHIA, PA
FORT WORTH (TARRA NT COUNTY), TX
PHOENIX (MARICOPA COUNTY), AZ
HOUSTON, TX
PORTLAND (MULTNOMAH COUNTY), OR
ABOUT THE BIG CITIES HEALTH COALITION

The Big Cities He alth Co alitio n (B CHC) repre s en ts th e
health leaders of the 2 7 large s t citie s in th e n atio ns mo s t
urbanized areas. Me mber cities in th es e u rban areas h ave a
population of at leas t 3 5 0 ,0 0 0 . Th e B CHC s e r ve s as a fo ru m
where members exch an ge s trate g ie s an d j o in tly pro mo te
and protect the natio ns h ealth an d s afe ty fo r a h ealth ier
America. To gether, B CHC members s e r ve approx imate ly o n e
in s ix A merican s.
The
BCHC,
an
indepe n de n t
pro g ram
at
th e
N atio n al
Association of Coun ty an d City He alth Of f icials (NACCHO),

is made possible thro u g h th e ge n e ro u s s u ppo r t o f th e de
Beaumont and Ro be r t Wo o d Jo h n s o n Fo u n datio n s.
TABLE OF
CONTENTS
Table of Contents
Acknowledgments
About the Big Cities Health

Coalition
Executive Summary
Introduction
70
Wi nnable Bat t les

Cas e St udies
72
Digital Sleuthing, Engagement

To Battle Foodborne Illness in
Chicago
76
Los
Angeles
Restaurant
Grades Lower Illness, Boost
Awareness
and
Consumer
Engagement
80
Houston Hits Home with Youth

and HIV, STD Testing
84
San Francisco Determined to

Get to Zero When It Comes to
HIV
88
Innovative
Efforts
Have
Philadelphia Seeing Big Drops
in Obesity Among Youths of
Color
11 Background
12
Selection of Cities, Indicators,

And Report Organization
14
Key Themes
19
The Health of Our Cities
30
Disparities in Health Status
34
Healthy People 2020 Goals
92
38

Data
39
Overview and Data Limitations
42
City-by-City Tables
Getting Physically Active and

Cutting Calories via Mobile
Apps, Social Media and
Technology
96
A Collective Impact Gains

Traction in Atlanta (Fulton
County)
100
Preventing the Habit Anchors

the Big Apples Tobacco 21 and
Minimum Price Laws
104
Early E-Cigarette Ban Reignited

Seattle-King Countys Effort to
Snuff Out Tobacco Smoking
108
Three Cities Approaches to

Violence as a Public Health
Issue
116 Recommendat ions

120 Conclusion
122 Appendix
123
Sources of Data
126
Definitions
128 End Not es
EXECUTIVE
SUMMARY
Executive Summary
INTRODUCTION
A mer i ca' s he alt h lan dscape has ch an g e d dra ma t i ca lly
i n t h e l ast ce n t u ry. The n at io n ' s pu bli c he alt h syst e m,
o n c e f o cus e d p rim aril y o n san i tat io n an d i nfect ious
d i s e a s e , t o day f ace s a n e w s e t o f chal le n g e s d om i na t ed
by c h r o n i c dis e as e , wi t h i n n o vat ive so l u t io n s r out i nely
m i n ed f ro m a we al t h o f Bi g Data. i
Still, challenges remain great. Despite
spending far more on health care than
our international peers, Americans
die younger than people in almost all
other industrialized nations. Therefore,
preventing these illnesses is crucial to
both the physical and financial health of
our country and its people.
The nations urban local health
departments (LHDs) are critical to this
process. Metropolitan areas are now
home to almost 83% of Americans and
serve as key hubs for the greatest returns
on health investments.ii Because their
authority and focus is concentrated at
the local level, LHDs can be innovators
and advocates for health policy change.iii,iv
At their best, these urban LHDs have
the potential to impact large portions
of a population and contribute to an
environment in which the healthy
option is the default option.
Introduction
Policy innovations at the local level do

not just change the trajectory of health
for the population they serve. They also
can drive national change. For example,
LHDs were in the vanguard of drafting
and implementing ordinances to restrict
tobacco use in restaurants and bars in
the early 2000s across the United States.v
As a result, exposure to secondhand
smoke declined by 83 percent a m o n g
restaurant and bar employees.vi Today,
80 percent of all Americans live in
jurisdictions that prohibit smoking in
restaurants and bars, protecting them
from this unhealthy exposure. In the
last decade, the importance of LHDs
only has grown as Congressional action
has stagnated and state legislatures have
become increasingly politicized. vii,viii,ix
cities are winning key health battles by

executing cutting-edge programming
to address the CDCs Winnable Battles
public health practices with largescale impact and with known, effective
strategies to address them. The data
presented here and online (at http://
www.bigcitieshealth.org/data-andresearch-center) are meant to increase
knowledge and spur dialogue about the
health of our nations communities.
This publication also highlights some
real challenges these cities still face,
specifically with regard to the persistent
gaps in the public health systems ability
to collect basic, reliable health data at
the local level.
The purpose of this report is to provide a

snapshot of the health of people living in
dense, urban areas in the United States.
It also highlights some of the ways
Executive Summary
10
Executive Summary
BACKGROUND
The Big Cities Health Inventory 2015
(BCHI) fills a void previously there
was no single data source that allowed
big city (or their county counterparts)
health departments to compare key
health indicators with their similar
peer jurisdictions. In total, this report
considers the health of more than 52
million, or one in six, Americans who
live in BCHC member jurisdictions.
The ability to compare jurisdictions,
whenever or wherever possible, has
proven invaluable in addressing a
wide variety of health issues. The
BCHI allows LHDs to target needs and
justify efforts to oversight bodies and
potential (public and private) funders
by doing such comparisons.3 It is
also worth noting that the health of
the community is multifaceted and
complex, and socioeconomic factors
such as poverty and educational
attainment, play an outsized role in
the health outcomes of communities.
Therefore, city performance on any one
health indicator should not be entirely
attributed to the work of any one health
department.
3 See Data Limitations section; caution should be
used with some indicators regarding comparability
of data. These are flagged in the methodology
appendix and online.
4 Data from Portland (Multnomah County), Oregon
were not available for this project.
5 Big Cities Health Inventory, 2007: http://
health-equity.pitt.edu/933/1/Big_Cities_Health_
Inventory.pdf
Background
The 26 jurisdictions included in this

publication are BCHC members as of
March 2015.4 Where possible, data
presented are the city-level; where
necessary, county level data are
displayed and noted.
This BCHI is the sixth report in a series

of projects initially developed to present
epidemiologic data specific to large
cities. The last BCHI was published in
2007 largely by the Chicago Department
of Public Health with some support from
the National Association of County and
City Health Officials (NACCHO) thenmetro caucus.5 This version is unique
in that it is the first produced under the
auspices of the BCHC with funding for
the publication coming from the CDC to
NACCHO, the home of BCHC. The 2015
BCHI, because of its connection to the
BCHC, includes 26 jurisdictions, which
is a smaller group of cities than in
previous editions. Regardless, the BCHI
has always been, and continues to be, a
collaborative project among the cities
themselves.
New to this version of the BCHI
is a series of case studies on five
Winnable Battlesx: Food Safety; HIV/
AIDS; Injury and Violence; Tobacco;
and Obesity, Physical Activity, and
Nutrition. For the first time, all of the
data are available online. See http://
www.bigcitieshealth.org/data-andresearch-center for complete details
from each jurisdiction and additional
data visualizations. Brief snapshots of
up to 16 indicators from each city follow,
as available, along with overview tables.
11
Executive Summary
SELECTION OF CITIES,
INDICATORS & REPORT ORGANIZATION
Thi s r e po r t p r es en t s 34 h ea lt h an d 6 de m o g rap h i c
i ndi c t o r s fo r r es i d e n t s i n t h e la r g e st U .S. ci t ie s i n t h e
30 m os t u r ba n a r ea s i n t h e c o u n t ry, acco rdi n g t o t h e
U. S . Ce n s u s Bu r ea u . x i
(Though the number of indicators
varies depending on availability of data
in certain jurisdictions.) To be eligible
for membership in the BCHC (and this
report), the city must also possess
a population greater than 350,000.
The indicators encompass nine broad
categories of public health importance:
HIV/AIDS; Cancer; Food Safety;
Infectious Disease; Maternal and Child
Health; Tobacco; Nutrition, Physical
Activity, and Obesity; Injury and
Violence; and Behavioral Health and
Substance Abuse. The health indicators
were chosen based on their relationship
to the leading causes of morbidity and
mortality in the United States; their
inclusion in the U.S. Department of
Health and Human Services (HHS)
Healthy People 2020 objectivesxii or
CDC Winnable Battles; or BCHC
member interest.xiii There are also six
additional socio-demographic measures
that look at poverty, unemployment,
educational attainment, household
income, and country of origin, as well
as statistics relating to life expectancy
12
where available. (See Table 10: Selected

City Demographics.)
In addition to the information already
presented, this Executive Summary
includes key themes. Three additional
sections follow: the data section that
presents overview tables and a snapshot
of 16 indicators from each city, the
Winnable Battles case studies, and a
brief
recommendations/conclusion
section. Finally, the Appendix contains
more detailed descriptions of each
indicator, including data sources, along
with information regarding racial/ethnic
categories and related definitional
discussions.
Selection of Cities, Indicators & Report Organization
Executive Summary
I N D I C AT O R S
HIV /AIDS
HIV Diagnoses Rate (Per 100,000 People)
AIDS Diagnoses Rate (Per 100,000 People)
Persons Living with HIV/AIDS Rate (Per 100,000 People)
HIV-Related Mortality Rate (Age-adjusted; Per 100,000 People)
CANCER
All Cancer Mortality Rate (Age-adjusted; Per 100,000 People)
Lung Cancer Mortality Rate (Age-adjusted; Per 100,000 People)
Female Breast Cancer Mortality Rate (Age-adjusted; Per 100,000 People)
INFECTIOUS DISEASE
Percent of Adults Who Received Seasonal Flu Shot
Percent of Children Who Received Seasonal Flu Shot
Percent of Adults Over Age 65 Who Received Pneumonia Vaccine
Pneumonia and Influenza Mortality Rate (Age-adjusted; Per 100,000 People)
Tuberculosis Incidence Rate (Per 100,000 People)
MATERNAL AND CHILD
Infant Mortality Rate (Per 1,000 Live Births)
Percent Low Birthweight Babies Born
Percent of Mothers Under Age 20
TOBACCO
Percent of Adults Who Currently Smoke
Percent of High School Students Who Currently Smoke
NUTRITION, PHYSICAL ACTIVITY & OBESITY
Percent of Adults Who are Obese
Percent of High School Students Who are Obese
Percent of Adults Who Meet CDC-Recommended Physical Activity Levels
Percent of High School Students Who Meet CDC-Recommended Physical Activity Levels
Heart Disease Mortality Rate (Age-adjusted; Per 100,000 People)
Diabetes Mortality Rate (Age-adjusted; Per 100,000 People)
INJURY & VIOLENCE
Homicide Rate (Age-adjusted; Per 100,000 People)
Suicide Rate (Age-adjusted; Per 100,000 People)
Firearm Related Mortality Rate (Age-adjusted; Per 100,000 People)
Motor Vehicle Mortality Rate (Age-adjusted; Per 100,000 People)
FOOD SAFETY
Rate of Laboratory Confirmed Infections Caused by Salmonella (Per 100,000 People)
Rate of Laboratory Confirmed Infections Caused by Shiga Toxin-Producing E-Coli (Per 100,000 People)
BEHAVIORAL HEALTH/ SUBSTANCE ABUSE
Opioid-Related Mortality Rate (Age-adjusted and crude rates; Per 100,000 People)
Drug Abuse-Related Hospitalization Rate (Per 100,000 People)
Percent of Adults Who Binge Drank
Percent of High School Students Who Binge Drank
Selection of Cities, Indicators & Report Organization
13
Executive Summary
KEY THEMES
I n t h e e i gh t y ea r s s i n c e t h e la s t ve rsio n o f t h e Bi g
C i t i e s H e al t h In ve n t o r y , x iv key priorities and challenges
i n p u b li c h e a lt h h a ve s h i f t ed .
Traditional disease burdens are changing, with relatively fewer infectious disease
outbreaks, and a greater frequency of chronic diseases related to nutrition, physical
activity, and obesity. Thats not to say diseases like HIV or tuberculosis are not a
threat to the health of our communities particularly in big cities but, by and large,
best practices to prevent, control, and treat such diseases exist. To continue to tackle
these challenges, such interventions need to be scaled, which often necessitates
funds that are not readily available to LHDs.
14
Key Themes
Executive Summary
SELECTED FINDINGS
FIGURE 01
NUMBER OF CITIES EXPERIENCING AN INCREASE, DECREASE, OR
NUMBER OF CITIES EXPERIENCING AN INCREASE, DECREASE,

NUMBER OF CITIES EXPERIENCING AN INCREASE OR
NO CHANGE
IN SELECTED MORTALITY RATES 2005 TO 2012
OR NO CHANGE IN SELECTED MORTALITY RATES
DECREASE IN SELECTED MORTALITY RATES
( A G E - A D J U(AGE-ADJUSTED;
S T E D ; P E2005 TO 2012
R 1 0 0 PER
, 0 0 0100,000
P E O P L EPEOPLE)
) 2 0 0 5 T O 2 0 1 2
25
25
23
23
22
22
23
23
20
20
20
20
15
15
10
10
5
5
0
0
0
0
0
0
All
All CCause
ause
All
All CCancer
ancer
Diabetes
Increase
Increase
ARE CITIES HEALTHIER THAN

THEY WERE IN 2005?
Overall mortality rates have decreased

in cities since 2005. The graph at the
left illustrates this decrease in mortality
rates for all causes of death, as well as
for heart disease, diabetes, and cancer.
Heart Disease
Decrease
FIGURE 02
NUMBER OF CITIES AT, ABOVE, OR BELOW NATIONAL FIGURE
NUMBER OF CITIES AT, ABOVE, OR BELOW NATIONAL

FIGURE SELECTED MORTALITY RATES
SELECTED MORTALITY RATES 2005 TO 2012
(AGE-ADUSTED;
PER
100,000
PEOPLE)
2012
(AGE-ADJUSTED;
PER
100,000
PEOPLE)
23
25
21
20
15
11
12
10
5
0
All Cancer 2012
Diabetes 2012
Above
Key Themes
Below
Heart Disease 2012
HOW DOES THE HEALTH OF

CITY DWELLERS COMPARE WITH
THAT OF OTHER AMERICANS?
In 2007, the BCHI showed that city

dwellers were less healthy than other
Americans by almost every measure.
Now, where urban residents have far
lower diabetes mortality rates than other
Americans, they have similar cancer
mortality rates. However, urbanites still
struggle greatly to control rates of heart
disease mortality, when compared with
the United States as a whole.
15
Executive Summary
ARE CITIES ON TRACK TO MEET

THEIR
NATIONAL
DISEASE
PREVENTION GOALS?
Thirty years ago, HHS started creating

public health benchmarks for the
country to pursue each decade. Cities
are currently striving to meet the
Healthy People 2020 (HP2020) goals,
designed to address a wide variety of
health conditions. Big cities are largely
making progress on the path towards
meeting, and in some cases even
exceeding, them. The graphics at right
show that less than halfway through the
decade, the largest cities are ahead in
their pursuit of the 2020 benchmark for
diabetes, and half already met the goal
for cancer. Only a handful meet the 2020
heart disease goal by 2014.
For more information on how each city is progressing
on each goal, see the graphic on page 35.
WHAT IS THE STATE OF RACIAL AND

ETHNIC HEALTH DISPARITIES?
O f t he 2 2 ci t i es repo rt i n g m o rt ali t y dat a fo r a l l

t y pes o f can cer bet w een 2 0 1 0 an d 2 0 1 4 , h a lf ( 1 2 )
alread y hi t t he H ealt hy peo ple 2 0 2 0 t a r g e t o f
1 6 1 .4 deat hs /1 0 0 ,0 0 0 peo ple.
22 CITIES
Of
t he
23
ci t i es
repo rt i n g
heart
disease
m o rt ali t y dat a bet ween 2 0 1 0 an d 2 0 14 , o nl y 6

alread y hi t t he h ealt hy peo ple 2 0 2 0 t a r g e t o f
23 CITIES
1 29.2 deat h s /1 0 0 ,0 0 0 peo ple.
O f t h e 23 ci t i es repo rt i n g di abet es mo r t a li t y
dat a bet w een 2 0 1 0 an d 2 0 1 4 , all hav e a lr e a d y
hi t t h e h ealt hy peo ple 2 0 2 0 t arg et o f 6 6 . 6 d e a t h s
23 CITIES
RACE / ETHNICITY MORTALITY RATE

COMPARISON SELECT INDICATORS 2012
FIGURE 03
(AGE-ADJUSTED; PER 100,000 PEOPLE)
Health disparities continue to persist

to a troubling degree in Americas big
cities, but trends are evolving. While
health outcomes of black Americans
continue to lag significantly behind
those of whites, Hispanic mortality
rates have dropped markedly and are
often lower than the rate of the city as a
whole. Figure 03 shows how city dwellers
of different races and ethnicities fare,
depending on where they live, by
highlighting the lowest mortality rates
across all cities reporting.
4.5
5.0
DIABETES
26.1
36.6
57.6
ALL CANCER
111.5
31.8
63.5
HEART DISEASE
131.6
195.9
ALL CAUSE
224.7
566.3
100
LOWEST HISPANIC RATE
16
200
300
LOWEST WHITE RATE
400
500
LOWEST BLACK RATE
Key Themes
Executive Summary
SHIFTING LANDSCAPE
A mere eight years ago, indicators

such as nutrition, obesity, and physical
activity were not included in the BCHI,
likely because the data were not readily
available. The last decade, however, has
seen a significant culture shift towards
increasing awareness of the factors that
affect a healthy weight, such as access
to affordable fruits and vegetables, and
opportunities for safe physical activity.
Addressing these causes is a challenge
in many urban centers. This recognition
has caused the field to look more closely
at the social determinants of health, i.e.
the conditions that help create healthy
environments.xv
Health departments are also adjusting
their activities based on the passage of
the Patient Protection and Affordable
Care Act and the availability of health
insurance for many. A number of LHDs
are reassessing their role as providers
of clinical services, while others will
continue to provide such care, albeit
potentially through billing for services
and/or taking advantage of Medicaid
expansion, which tends to serve the
Key Themes
same populations that utilize LHD

services. The transforming health
system is creating different incentives
for LHDs and includes a focus on
population health, which is at the core
of what public health does. The shift in
fee for service to pay for performance
also presents a challenge to LHDs
in determining whether they should
continue to provide a number of clinical
services. For those LHDs that choose
to no longer provide such services,
this could free up resources to focus
on prevention and health disparities,
or it could lead to even fewer resources
throughout the department. The evershrinking budgets in governmental
public health cannot be overlooked
because at the same time many LHDs
are being expected to do more.
It is our intention that future BCHI work
capture a broader range of indicators in
addition to the traditional health burden
to illustrate this expanding definition of
health.
17
FIGURE 04
OVERALL DEATH RATE (AGE- ADJUSTED; PER 100,00 PEOPLE) 2004 & 2012
1800
1600
ALL 2012
1400
ALL 2005
1200
1000
800
All 2005
All 2012
600
400
200
Ch n
ica
g
Cl
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Fo
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an
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ar

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HOW IS EACH CITY PROGRESSING COMPARED WITH ITS PEERS?
As mentioned earlier, large cities mortality rates have generally dropped across the
board, but certain cities have made more progress than others since 2005. The graph
at right shows how mortality rates changed between 2005 and 2012 for each city.
Data provided by health departments as of 9/1/2015. *2005 data for Fort Worth (Tarrant County),
Las Vegas (Clark County), Miami (Miami-Dade County), and San Diego County are city only; 2012
data are county level.
18
Executive Summary
THE HEALTH OF OUR CITIES

T h e 2007 BCHI p u t f o rt h t hat ci t ie s we re gener a lly
le s s he al t h y t han t he re st o f t he co un t ry, w i t h a few
c a veat s. xvi
U R BA N M O RTA L I T Y
In 2015, based on data from 2010-2014,

the relationship of urban health to that
of the country as a whole is decidedly
more complicated. On a number of key
indicators, such as heart disease and
cancer, deaths are higher in cities than
they are in the rest of country (even
when adjusted for population figures
and age). Compared with eight years
ago, however, these numbers have
dropped, in some cases dramatically
(see discussion below). While health
challenges remain, the overall health of
urban America appears to be improving.
Note that the conditions and data
highlighted below are a selection of
indicators, not the entire set (more
can be found online at http://www.
bigcitieshealth.org/data-and-researchcenter).
100,000 people) and Detroit (1,032.5 per

100,000 people) had the highest and Los
Angeles the lowest at 341.3 per 100,000
people. The remaining 21 cities figures
are close to each other, ranging from a
rate of 880.0 to 520.0, as illustrated on
page 18.
Of the 22 cities reporting 2012 all-cause

mortality (death rate), nine of them
had higher overall death rates than the
national average, and 12 had lower rates.
The all-cause (age-adjusted) mortality
rate for the United States in 2012
was 732.8 per 100,000 people. Of the
cities included, Cleveland (1,049.8 per
When looking at the leading causes of

death, many cities appear less healthy than
the nation at large, particularly relating
to heart disease and all cancer mortality
rates. However, in both cases the city with
the highest mortality rate in this data set is
still lower than the city with the highest in
2005 (data from 2007 BCHI).
Similarly, of the 19 cities that reported

life expectancy data over the course of
the last 10 years, more than half (11)
had higher than the national age of 78.8
(2012). Life expectancy in Los Angeles,
San Diego County, San Francisco,
Seattle, and Oakland (Alameda County)
was highest at 82 years, while Cleveland
and Baltimore had the lowest at the
ages of 73.6 (2010) and 73.9 (2011-2013)
respectively. (See Table 10, Selected City
Demographics.)
R AT E S I M P ROV I N G
Th e h i g he st ur b a n m or t a l i t y ra t es
fo r
he a r t
d i se a s e
and
cancer
in 20 1 3 a re st i l l l ow er t h a n t h e
hi g he st ra t es i n 2 0 0 5 .
The Health of our Cities
19
Executive Summary
In the case of heart disease, Clevelands

top rate of 339.2 in 2012 is lower than
the seven cities with the highest rates in
2004 and, Cleveland saw a decrease in
its heart disease mortality rate as well.xvii No
cities saw an increase in heart disease
mortality between 2004 and 2012, but
most lag behind the countrys overall
heart disease death rate.
TA B L E 0 1
H E A RT DISE ASE M ORTAL IT Y
( AG E - ADJ U ST E D, P E R 100,000) CIT Y COM PAR ISONS - 2004/ 2012*
2004 Value
2004 Rank
2012 Value
2012 Rank
Cleveland
362.8
339.2
Detroit
370.0
334.6
Sacramento
383.4
282.5
Baltimore
287.2
241.6
Washington, D.C.
273.7
10
218.0
Chicago
258.3
13
210.5
Philadelphia
265.9
11
202.8
Atlanta (Fulton County)+
230.2
15
197.7
New York City
300.6
188.2
Las Vegas (Clark County)+
465.0
183.9
10
356.0
178.9
11
Houston
356.2
171.9
12
Kansas City
224.8
16
167.0
13
388.2
162.4
14
Denver
175.4
19
158.1
15
San Antonio
265.8
12
143.2
16
San Diego County
210.5
17
140.6
17
184.0
18
136.5
18
Boston
175.4
19
131.1
19
Seattle
171.7
21
117.0
20
Minneapolis
140.7
22
114.6
21
U.S. TOTAL
217.5
Fort Worth (Tarrant County)
Miami (Miami-Dade County)
San Jose (Santa Clara County)
I N T H E C A S E O F H E A RT
D I S E A S E , C L E V E L A N D S TO P
R AT E O F 3 3 9 . 2 I N 2 0 1 2 I S
LOW E R T H A N T H E S E V E N
CITIES WITH THE HIGHEST
R AT E S I N 2 0 0 4 .
Phoenix^
Los Angeles
105.4
N/A
N/A
103.7
22
250.8
14
92.8
23
*Note that the 2007 BCHI ranked a total of 54 cities and this version only includes 26. +Use caution when
comparing data as 2004 data are city only, 2012 are countywide figures. ^Phoenixs 2004 data are not
comparable and thus were not included in the rankings.
20
Heart Disease Mortality
TA B L E 0 2
A L L C AN CER MO RTA LI T Y RAT E
( AGE-AD J US TED P E R 1 0 0 , 0 0 0 ) C I T Y C O M PAR ISONS - 2004/2012*
2004 Value
2004 Rank
2012 Value
2012 Rank
Sacramento
324.2
302.2
Detroit
230.4
217.6
Baltimore
231.0
213.9
Philadelphia
232.2
206.8
Kansas City
212.0
187.0
Boston
193.8
15
186.3
Chicago
204.8
13
186.1
Washington, D.C.
205.6
12
179.5
185.8
16
177.6
222.0
174.3
10
Minneapolis
198.6
14
168.1
11
U.S. TOTAL
184.6
Denver
Houston
166.5
217.3
160.3
12
Las Vegas (Clark County)
354.6
160.2
13
San Diego County
178.3
19
158.3
14
New York City
170.2
21
155.1
15
180.6
18
152.9
16
211.3
10
152.8
17
San Jose (Santa Clara County)+
174.5
20
150.6
18
258.5
139.6
19
San Antonio
207.5
11
137.5
20
N/A
N/A
109.1
21
182.3
17
83.1
22
Seattle
Atlanta (Fulton County)
Phoenix^
Los Angeles
Eleven cities had higher cancer mortality

rates in 2012 than the U.S. total. While
cancer deaths remain high, for all of the
cities where comparisons can be made,
their rates are lower than in 2004.
* Note that the 2007 BCHI ranked a total of 54 cities and this version only includes 26. For those cities
included in both, 2005 figures have been re-ranked. +Use caution when comparing data as 2004 data
are city only, 2012 are countywide figures. ^Phoenixs 2004 data are not comparable and thus were not
included in the rankings.
Cancer Mortality
21
Executive Summary
All of the cities have lower diabetes

mortality rates in 2012 than the
national figure of 69.1. All but three
(Cleveland, Minneapolis, and San Jose/
Santa Clara County) have lower rates
now compared with 2004, bucking the
national trend. Clearly, many cities are
addressing diabetes with a number of
community-based programs that seek
to improve awareness of the problem,
both to better prevent, and better treat,
diabetes. The case study A Collective
Impact Gains Traction in Atlanta
(Fulton County), on page 97, highlights
the work that city is doing to address
diabetes in elementary schools with a
cross-sector collaboration.
A L L C I T I E S H AV E LOW E R
D I A B E T E S M O R TA L I T Y R AT E S
T H A N T H E U. S . A S A W H O L E ,
A N D A L L BU T T H R E E H AV E
LO W E R R AT E S T H A N I N 2 0 0 4 .
TA B L E 0 3
D I A B E T E S M ORTAL IT Y R AT E
( AG E - A DJ U ST E D, P E R 100,00) CIT Y COM PAR ISON 2004/ 2012*
2004 Value
2004 Rank
2012 Value
2012 Rank
US TOTAL
30.5
69.1
Sacramento
42.5
40.4
Cleveland
31.4
38.6
28.0
12
30.8
Baltimore
38.5
28.9
Detroit
32.4
28.4
Minneapolis
23.0
17
28.3
Chicago
28.4
11
25.6
Washington, D.C.
39.8
24.2
Fort Worth (Tarrant County)+
35.0
22.9
San Antonio
49.8
22.6
10
Philadelphia
26.6
13
22.1
11
Phoenix^
N/A
N/A
22.1
12
Houston
31.9
21.9
13
Miami (Miami-Dade County)+
39.8
21.7
14
Kansas City
25.9
14
21.6
15
Denver
21.5
20
21.1
16
New York City
22.8
18
20.8
17
Seattle
24.6
15
20.8
18
San Diego County
21.7
19
20.4
19
Boston
20.0
22
19.6
20
20.4
21
15.8
21
Los Angeles
30.4
10
14.9
22
24.1
16
13.4
23
included in both, 2005 figures have been re-ranked. +Use caution when comparing data as 2004 data
are city only, 2012 are countywide figures. ^Phoenixs 2004 data are not comparable and thus were not
included in the rankings.
22
Diabetes Mortality
TA B L E 0 4
OB ESITY AN D P H YS I C A L AC T I V I T Y A M O N G ADU LT S (2011 2013)*
Percent of Obese Adults

(2012)
Percent of Adults Meeting

CDC-Recommended Phys
Act Levels (2011)
19.9
23.8
Baltimore
30.7
68.4
Boston
21.7 (2013)
24.2 (2013)
Chicago
24.6 (2011)
50.7
Denver
19.1
84.4
Detroit
39.7
19.1
29.4
47.9
27.5
44.0
Los Angeles
21.6 (2011)
29.0
Minneapolis
21.7
57.7
New York
24.2
67.3 (2013)
Oakland
21.0 (2011)
32.0
Philadelphia
31.9
44.6
Phoenix
25.4
52.6
34.7 (2013)
47.0 (2012)
22.3
N/A
22.0 (2013)
53.0 (2013)
Seattle
22.0
63.0
Washington, D.C.
21.9
80.2
U.S. TOTAL
34.9
48.8
San Antonio
San Diego County
*Cities were not ranked due to differing years of data
6 For comparability purposes, BRFSS data was

requested. Approximately five other cities reported
obesity data that were not BRFSS and were not
included in the analysis or data platform.
7 At least 2 hours, 30 mins of moderate-intensity
aerobic activity every week; or 1 hour, 15 mins of
vigorous-intensity aerobic activity; or an equivalent
mix of moderate and vigorous.
Obesity and Physical Activity
While the challenges related to obesity

and physical activity have become the
subject of national concern in recent
years, accurate, comparable data at the
local level remain hard to find. In any
given year between 2010 and 2014, only
a third of the cities included in this
publication were able to report obesity
numbers in a manner comparable to
their peer cities.6
Of the 18 cities reporting adult obesity
rates between 2011 and 2013, the
percent of obese adults ranged from
highs of 39.7 in Detroit (2012) and 34.7
in San Antonio (2013) to a low of 19.9
percent in Atlanta (Fulton County)
(2012). In the same time period, about a
third (34.9 percent) of adults nationwide
were obese.xviii Thus, these cities are
outpacing national obesity estimates
among adults.
Similarly between 2011
and 2013,
about half of all U.S. adults (48.8
percent) met the CDCs physical activity
recommendation.7 Of the 18 cities
that could provide data for the BCHI
between 2010 and 2013, adults in half of
the cities - Baltimore, Chicago, Denver,
Minneapolis, New York, Phoenix, San
Jose (Santa Clara County), Seattle,
and Washington, D.C. - exceeded the
U.S. estimate of those meeting the
recommended levels. See the Getting
Physically Active and Cutting Calories
via Mobile Apps case study on page 93
to learn more about how some cities are
using technology to encourage residents
to increase their physical activity.
23
Executive Summary
Trends regarding obese high school students

are more mixed than among adults. In
2013, 13.7 percent of high school students
nationwide were obese.xix Between 2011
and 2013, among the 13 cities reporting
Youth Risk Behavior Surveillance
System (YRBSS) or Youth Risk Behavior
Survey (YRBS)8 data for obese high
school students, six cities had estimates
higher than the nation as a whole, while
Denver, LA, New York City, and San
Francisco had lower obesity estimates.
Three cities Boston, Las Vegas (Clark
County), and Los Angeles had similar
rates to the national estimate (see
table).9 The Innovative Efforts Have
Philadelphia Seeing Big Drops in Obesity
Among Youths of Color case study
outlines the many activities that city
has undertaken to address disparities in
obesity rates among youth.
High school students in cities are less
likely than their peers nationally to meet
CDC-recommended physical activity
levels, with only three cities, Miami
(Miami-Dade County) (40.5 percent),
San Antonio (31.6 percent) and San Jose
(Santa Clara County) (29.0 percent),
outpacing the national estimate.10
TA B L E 0 5
OBESITY AND PHYSICAL ACTIVITY AMONG HIGH SCHOOL STUDENTS (2013)*
Percent of Obese HS
Students
Percent of HS Students
Meeting CDC-Recs
Boston
13.8
15.4
Chicago
14.5
19.6
Denver
10.7
20.2
Detroit
22.9
13.3
13.8
23.6
Los Angeles
13.6
22.5
9.4
40.5
New York City
11.8
18.7
Philadelphia
14.6
26.9
San Antonio
14.4
31.6
7.7
16.4
20.0
29.0
Seattle
N/A
23.0 (2012)
Washington, D.C.
14.8
16.4
U.S. TOTAL
13.7
27.1
San Francisco
*Cities were not ranked due to differing years of data. +Not total high school students, includes grade 8,
10, and 12.
8 The Youth Risk Behavior Surveillance System

is a national, school-based survey that monitors
health risk behaviors among youth. It is sometimes
referred to as the Youth Risk Behavior Survey as
well. More information is available at: http://www.
cdc.gov/healthyyouth/data/yrbs/index.htm.
9 Note that some of these estimates are county
level and some based on school district lines.
YRBS/YRBSS collections areas and data availability
vary. See: http://www.cdc.gov/healthyyouth/data/
yrbs/participation.htm
10 Physically active for a total of at least 60
minutes per day.
24
Obesity and Physical Activity
TA B L E 0 6
HIV D IAG N O S ES (N E W C A S E S ) RAT E
( PE R 1 0 0 ,0 0 0 ) C I T Y C O M PA RI S O N S - 2 0 05/2012*
Cities continue to experience new cases

of HIV and HIV-related deaths in higher
numbers compared with the rest of the
country. But among these cities, great
strides have also been made since the
last BCHI. In Baltimore, for example,
which had the second highest diagnoses
rate in 2012 (among cities in the BCHI),
the rate has been cut nearly in half since
2005. Sixteen of the 25 cities reporting
data for the 2015 BCHI also had data
in the 2007 version, and among those
cities, only four had higher diagnoses
rates in 2012 (Chicago, Los Angeles,
Minneapolis, and New York City).
San Francisco, which has decreased
its diagnoses rate considerably, is
highlighted in the Getting to Zero
case study on page 85.
2005 Value
2005 Rank
2012 Value
2012 Rank
N/A
N/A
112.0
164.0
89.9
N/A
N/A
73.8
San Francisco
76.0
54.9
339.6
43.9
Chicago
38.5
39.8
Detroit
N/A
N/A
38.1
New York City
34.7
10
35.8
Dallas
61.7
32.9
Philadelphia
N/A
N/A
31.7
10
Houston
36.7
31.6
11
Seattle
31.8
11
30.6
12
Los Angeles
26.1
13
30.0
13
Boston
42.4
28.8
14
Minneapolis
24.6
14
26.4
15
Denver
42.0
24.0
16
G R E AT S T R I D E S M A D E
Sacramento
N/A
N/A
22.5
17
Was hing to n, D.C., Baltimore, and
San Antonio
21.5
15
19.9
18
A tlanta have the highest rates
Oakland
20.0
16
19.7
19
o f new HI V cas e s, yet pro g ress
N/A
N/A
16.9
20
has be e n made in th e past seven
Washington, D.C.
Baltimore
U.S. TOTAL
H I V D I AG N O S I S S T I L L
H I G H E R I N C I T I E S , BU T
to e ig ht ye ars.
15.3
For instance,
Phoenix^
N/A
N/A
15.3
21
Baltimo re co ntinue s to have the
Kansas City
29.7
12
14.6
22
s e co nd hig he s t dia g nosis rate in
37.2
10.4
23
the natio n, but has cut it nearly
San Diego County
N/A
N/A
10.3
24
in half.
N/A
N/A
8.8
25
* Note that the 2007 BCHI ranked a total of 54 cities and this version includes only 26. For those cities
included in both, 2005 figures have been re-ranked. Also, this indicator was called HIV Incidence in 2007,
but it is the same calculation. +Use caution when comparing data as 2004 data are city only, 2012 are
countywide figures. ^Phoenixs 2004 data are not comparable and thus were not included in the rankings.
HIV / AIDS
25
Executive Summary
Similarly, while higher rates of HIVRelated Mortality persist in cities

when compared with the rest of the
country, trends are moving in the right
direction. With the exception of Detroit,
the remaining 20 cities with data to
compare all have lower rates than in
2004, and some dramatically so.
TA B L E 0 7
H I V RE L AT E D M ORTAL IT Y R AT E
( PE R 100,000) CIT Y COM PAR ISONS 2004/2012*
2004 Value
2004 Rank
2012 Value
2012 Rank
Baltimore
50.5
20.0
Washington, D.C.
41.1
15.4
Detroit
12.0
12.7
San Francisco
21.7
10.6
42.1
9.8
58.4
7.9
New York City
18.2
6.8
Phoenix#
N/A
N/A
6.4
Philadelphia
16.1
5.9
9.9
11
5.6
10
14.1
4.7
11
Chicago
9.7
12
4.4
12
Kansas City
9.4
15
3.2
13
8.2
17
3.2
13
Boston
9.5
13
3.1
15
San Antonio
6.8
20
3.0
16
Denver
10.0
10
2.9
17
Seattle
7.8
18
2.5
18
9.6
14
2.3
19
U.S. TOTAL
4.4
Los Angeles
8.9
16
2.2
20
Minneapolis
N/A
N/A
1.9
21
San Diego County
7.6
19
1.7
22
Oakland
Houston^
H I V M O R TA L I T Y R AT E S H AV E
D R O P P E D I N E V E RY C I T Y BU T
O N E : D E T RO I T.
2.2
included in both, 2005 figures have been re-ranked. ^These data are for Harris County, the county where
Houston is located. +Use caution when comparing data as 2004 data are city only, 2012 are countywide
figures. #Phoenixs 2004 data are not comparable and thus were not included in the rankings.
26
HIV / AIDS
Executive Summary
O P I O I DR ELAT ED
D EAT H S I N
A M ER I CA'S
B I G C I T I ES
Drug
mis us e
and
abus e
ch a l l e n ge s have be co me a large r
par t
of
the
he alth
co ns ide ratio ns due to a larger

fo cus o n s tate a ge ncies.
dis cus s io n
rec en t ly. N atio nally, de aths f ro m
Fo r this repo r t, city-level data
op i oi d
on
pre s criptio n
paink ille rs
o pio id-mo r tality
rates
were
were three times higher in 2013
re que s te d. While s everal cities
than they were in 2001. xx Fe de ral
repo r te d
of fi c i a ls re ce ntly to o k actio n to
co mparable
to
a d d re s s this g row ing pro ble m,
de f initio ns
of
w i t h H HS s how ing le ade rs hip o n
de aths var y acro s s j urisdictions.
t h e i s s u e and calling fo r multileve l
While
gove r n m e ntal co llabo ratio n.
be caus e o f the impo r tance of the
the
data,
they
e ach
are
not
other,
as
o pioid-related
data
a re
inc luded
epide mic, they are not unifor m

Big
c i tie s
have
battling
and s ho uld no t be interpreted as
h er oi n and pre s criptio n o pio id
s uch. I t is the inte nt of B C HC to
abu s e fo r de cade s and have be e n
w o rk o n a co ns e ns us definition in
a t t h e fo re f ro nt o f
o rde r to g athe r co mparable data
p r o g ra m matic
Th ey
h ave
alarm
be e n
inte r ve ntio ns. 11
be e n
and
po licy and
s o unding
re s po nding
to
mov ing fo rw ard.
the
this
The
fo llow ing
table
inc ludes
g r ow i n g public he alth pro ble m
citie s that prov ide d data from
for
s eve ral
2012 and 2013 and is meant as
for
i n cre as e d
n a l oxon e,
d r u g,
an
and
ch a n ge s. xxi
p a r t n ers,
l e ft
ye ars,
ou t
m a ki n g
advo cating
acce s s ibility
of
a s naps ho t o f whats going on in
ove rdo s e -reve rs al
tho s e indiv idual citi es re g arding
o the r
key
po licy
The s e inte g ral lo cal

how eve r,
of
and
fe de ral
o f te n
are
de cis io n-
data-co lle ctio n
o pio id-re late d
de aths.
As
with
o the r indicato rs, additional data

can be fo und o nline at:
h t t p : / / w w w. b i g c i t i e s h e a l t h . o rg /
data-and-research-center/.
11 This is not to say that rural areas are not seeing

severe opioid problems in their communities as
well, though until recently this has generally been
prescription opioid misuse and abuse. Heroin use
has largely been a city problem.
Opioids
27
Executive Summary
TA B L E 0 8
OP IO ID - R EL ATED M O RTA LI T Y RAT E S S E L E CT E D CIT IE S 2012/2013
( AGE- AD J US TED PE R 1 0 0 , 0 0 0 PE O PLE , E XCE P T W HE R E NOT E D)
CITY
2012
2013
NOTES
Boston
13.0
N/A
Age-adjusted rates using a 2000 US standard population of residents 12+. For

unintentional/undetermined intent opioid overdose mortality. Case definition
was based on the following ICD-10 codes: D52.1, D59.0, D59.2, D61.1,
D64.2, E06.4, E16.0, E23.1, E24.2, E27.3, E66.1, F11.0-F11.5, F11.7-F11.9,
F12.0-F12.5, F12.7-F12.9, F13.0- F13.5, F13.7-F13.9, F14.0-F14.5,
F14.7-F14.9, F15.0- F15.5, F15.7-F15.9, F16.0-F16.5, F16.7-F16.9,
F17.0, F17.3-F17.5, F17.7-F17.9, F18.0-F18.5, F18.7-F18.9, F19.0-F19.5,
F19.7-F19.9, G21.1, G24.0, G25.1, G25.4, G25.6, G44.4, G62.0, G72.0,
I95.2, J70.2, J70.3, J70.5, K85.3, L10.5, L27.0, L27.1, M10.2, M32.0, M80.4,
M81.4, M83.5, M87.1, R50.2, R78.1, R78.2, R78.3, R78.4, R78.5, X40-X44,
and Y10-Y14 ) and one or more of the applicable T-codes (t400, t401, t402,
t403, t404, t406) among the additional cause/condition fields.
Cleveland
22.7
29.7
Crude Rates. Opioid death data was obtained from the Cuyahoga County Medical Examiners Office. ICD-10 codes were not udesAn opioid death was defined
as any intentional or accidental overdose with an opioid that resulted in death.
Denver
11.7
8.2
Age-adjusted rates. Cases were detected by a manual review of Medical

Examiner records based on chemical evidence that an opioid was a
contributing factor in the death.
7.00
Crude rates. ICD-10 codes included T40.0 or T40.2 with underlying causes of
X42 or X62. The T codes specify that Opium or other opioids were mentioned
on the death certificate. X42 is accidental poisoning and X62 is intentional
self-poisoning.
12.4
Age-adjusted rates. The Nevada State Health Division Vital Records Mortality
Files (eg., state death records) data were utilized to identify opiate overdoses
and calculate age-adjusted rates. This included the entire population of Clark
County in 2012. A case was considered poisoning if External Cause of Death
was X40-X49, X60-X69, X85-X90, U01.6-.7, Y10-Y19, or Y35.2. A case was
considered opiate poisoning if it included a T-code of T40.1, T40.1, T40.0,
T40.2, T40.3, T40.4, T40.3 or T40.6 as a Contributing Cause of Death.
6.0
Age-adjusted rates using a 2000 US standard population. Acute drug

poisonings associated with the effects of opioid analgesics are defined by
the Safe States Injury Surveillance Workgroup (ISW7). The ICD-10 definition
of these deaths includes those with an underlying cause of death code
of X40-X44, X60-X64, X85, or Y10-Y14 and one or more of the following
contributing cause of death codes: T40.2, T40.3, T40.4.
Detroit
Las Vegas
(Clark County)
Minneapolis
28
8.00
15.6
4.0
Opioids
Executive Summary
TA B L E 0 8
OP IO ID - R EL ATED M O RTA LI T Y RAT E S S E L E CT E D CIT IE S 2012/2013
( AGE-AD J US TED P E R 1 0 0 , 0 0 0 PE O PLE , E XCE P T W HE R E NOT E D)
CITY
2012
2013
NOTES
3.2
Age-adjusted rates using a 2000 US standard population. Unintentional drug

poisoning deaths involving opioid analgesics include ICD-10 codes X42 and
F11 (excluding .2 and .6). Methadone is reported separately and not included
in opioid analgesic analyses. Rates are age-adjusted to Census 2000.
25.2
21.1
Crude rates. Data collected by the Philadelphia Medical Examiners Office

based on diagnoses from death certificates and toxicology screens. This
includes deaths of all intents (accidents, suicides, homicides, undetermined).
Opioids include heroin, morphine, methadone, and all prescriptions opioids
such as codeine, hydrocodone, and oxycodone. These are deaths that were
determined by the medical examiner to be caused by drug/medication
overdose and for which a toxicology test was positive for an opioid.
Phoenix
5.0
5.1
Age-adjusted rates. AZ Death Certificates; T401, T402, T403, T404
San Antonio
8.9
8.8
Crude rates. San Antonio Metro Health Death Certificates supplied by Texas
DSHS. Opioid Deaths ICD-10 Codes: X40-X49 for Bexar County (not just San
Antonio.)
9.3
Age-adjusted rates using a 2000 US standard population. County of San

Diego, Health and Human Services, Emergency Medical Services, Medical
Examiner Database; includes deaths of all intents (accidents and suicides).
Opioids include heroin, morphine, methadone, and all prescriptions opioids
such as codeine, hydrocodone, and oxycodone. These are deaths that were
determined by the medical examiner to be caused by drug/medication
overdose and for which a toxicology test was positive for an opioid.
New York City
Philadelphia
3.0
San Diego County
8.6
Seattle
9.2
8.5
Age-adjusted rates; F11.0-F11.9 or T40.0-T40.6 as the primary cause of

death or X42 or X44 as a contributing cause of death.WA State Department of
Health, Center for Health Statistics, Death Certificate Data, 1990-2013, August
2014.
U.S. TOTAL
7.1
7.2
Data come from Census & CDC Wonder
TOTAL
Opioids
WHITE
BLACK
HISPANIC ASIAN/PACIFIC ISLANDER

29
Executive Summary
DISPARITIES IN HEALTH STATUS

While there have been some improvements on health disparities in recent years, the
data show that differences in health outcomes continue to persist for Americans of
different races and ethnicities in large cities. The stubborn trend that populations of
color have worse health outcomes than whites remains troubling, but has also started
to show some signs of change. While blacks generally still suffer higher mortality
rates than whites for cancer, heart disease, diabetes, and HIV/AIDS, the picture is
more complicated for Hispanics, depending on the condition. With the exception of
Boston and Phoenix, inequalities are clear in the overall death rate between white
residents and their black counterparts.
FIGURE 05
CITY MORTALITY RATES 2012 BY RACE/ETHNICITY
(AGE-ADJUSTED, PER 100,000 PEOPLE)
1200.0
1000.0
800.0
600.0
400.0
200.0

De
n
rt
ve
W
r
or
th
D
(T
e
tro
ar
ra
it
nt
C
ou
nt
y)
*
Ho
us
to
La
n
s V
Ka
ns
eg
a
as
s C
(C
ity
la

rk
C
ou
M
nt
ia
y)
m
*
Lo
i(M
s A
ia
ng
m
i-D
el
es
ad

e
Co
un
ty
)*
M

in
ne
ap
ol
is
Ne
w
Y
or
k
Oa
kla
nd
Ph

ila
de
lp
hi
a
Ph
oe
ni
x
Sa
n
An
Sa
t
n
on
Di
io
eg

o
Co
un
ty
Sa
*
n
Fr
an
cis
co

Se
W
aS
as
le
hi

ng
to
n
D.
C.

nd
el
a
go
Fo
At
la
nt
a (
Fu
Cl
ev
ica
on

Ch
st
ty
un
Co
lto
n
Bo
0.0
ALL
WHITE
All
White
Black
BLACK
Hispanic
HISPANIC
Data provided by health departments as of 9/1/2015. *2005 data for Fort Worth (Tarrant County), Las
Vegas (Clark County), and Miami (Miami-Dade County) are city only; 2012 data are county level.
30
DETROIT
Disparities in Health Status
Executive Summary
Age-adjusted; Per 100,000 People
PLACE
ALL
BLACK
H I SPANI C
WHITE
Chicago
186.1
240.1
131.1
173.9
Denver
177.6
247.3
196.5
166.4
Kansas City
187.0
232.6
111.1
180.0
Philadelphia
206.8
235.7
160.6
189.5
Sacramento
302.2
492.0
108.2
492.0
Washington, D.C.
179.5
217.5
158.8
128.4
U.S. TOTAL
166.5
193.8
166.9
166.6
PLACE
HEART DISEASE MORTALITY RATE 2012
ALL CANCER MORTALITY RATE 2012
Interestingly, however, in almost all

cities, the Hispanic all-cause mortality
rate is lower than the overall citys rate
and in many cases, by large margins.
ALL
BLACK
H I SPANI C
WHITE
Cleveland
339.2
325.5
N/A
432.6
Denver
158.1
205.0
150.0
153.4
Las Vegas
(Clark County)
183.9
292.2
157.2
183.3
Sacramento
282.5
275.0
82.2
506.1
San Jose (Santa

Clara County)
136.5
163.6
140.9
159
Washington, D.C.
218.0
288.5
159.4
118.2
U.S. TOTAL
105.4
121.3
81.1
105.6
Disparities in Health Status Cancer and Heart Disease
Not only are black residents more

likely to die of cancer than their white
counterparts are, in these urban areas,
their cancer mortality rate is much
higher than for all blacks nationwide.
Exceptions to this include Sacramento
and New York, where rates are
comparable. Among Hispanics, those
who live in urban areas are less likely
to die of cancer than their non-urban
counterparts are. In almost all the cities
included here, the cancer death rate was
much higher for whites than Hispanics.
Similarly, except in a few cases,
whites, blacks, and Hispanics in cities
have higher heart disease mortality
rates compared with the rest of the
country, and the disparities are more
complicated. In Sacramento, San Jose
(Santa Clara County), and Phoenix, for
example, white residents have higher
heart disease-related death rates than
both blacks and Hispanics. Further, in all
but Washington, D.C and Los Angeles,
Hispanic mortality rates are lower than
those of whites.
31
32

Per 100,000 People
Looking at HIV/AIDS diagnoses and

deaths, disparities exist between
blacks, whites and Hispanics in these
urban areas. Nine cities have higher
HIV diagnoses rates than the U.S. total
among blacks, and large disparities
exist between black and white residents.
HIV DIAGNOSES RATE 2012
At the same time, blacks, whites, and

Hispanics residing in urban areas had
lower diabetes-related mortality rates
than their non-urban counterparts.
Similar disparities exist when comparing
blacks, whites and Hispanics, except
when comparing Hispanics and whites
in Miami (Miami-Dade County), and Las
Vegas (Clark County), where diabetesrelated mortality rates are comparable.
In Sacramento and Minneapolis,
however, whites have far higher rates
than Hispanics.
DIABETES MORTALITY RATE 2012
Executive Summary
PLACE
ALL
B L ACK
HISPANIC
WHI TE
Denver
21.1
37.0
49.8
12.4
Las Vegas
(Clark County)
13.4
33.4
14.9
11.3
Miami
(Miami-Dade County)
21.7
43.9
18.7
17.0
Minneapolis
28.3
74.5
7.2
19.6
Sacramento
40.4
67.1
10.6
56.5
San Jose
(Santa Clara County)
30.8
71.3
40.5
24.9
Washington, D.C.
24.2
36.1
4.5
5.0
U.S. TOTAL
69.1
109.1
79.9
65.2
PLACE
ALL
B L ACK
H I S PA NI C
WHI TE
Baltimore
89.9
125.1
71.3
25.6
Detroit
38.1
42.8
10.3
21.6
Kansas City
14.6
30.9
4.4
7.9
Miami
(Miami-Dade County)
43.9
100.1
31.5
37.3
San Francisco
54.9
91.4
87.0
67.0
Washington, D.C.
112.0
161.7
105.7
47.7
U.S. TOTAL
15.3
58.3
18.5
6.7
Disparities in Health Status Diabetes and HIV Diagnoses
Executive Summary
WHITE
Baltimore
72.3
101.1
28.5
89.9
Philadelphia
28.2
45.5
34.6
8.3
Phoenix
7.8
25.5
5.9
7.0
Sacramento
9.1
23.9
8.6
12.2
San Francisco
29.8
85.5
41.1
36.2
Seattle
19.6
75.9
26.4
14.0
U.S. TOTAL
8.3
32.9
10.0
3.3
PLACE
ALL
BLACK
H I SPANI C
WHITE
Detroit
81.0
87.1
45.2
45.0
7.9
34.3
2.80
3.8
San Francisco
10.6
29.9
11.5
13.6
Washington, D.C.
15.4
26.9
8.7
3.7
U.S. TOTAL
2.20
9.8
2.2
1.0
Miami
(Miami-Dade County)
Disparities in Health Status AIDS Diagnoses and HIV-Related Mortality
HIV-RELATED MORTALITY RATE 2012
H I SPANI C
AIDS DIAGNOSES RATE 2012
BLACK
ALL
Per 100,000 People
PLACE
With regard to the AIDS diagnoses rate,

10 cities have higher rates for blacks
than the U.S. total. Again, disparities
sometimes large ones exist in the
rates for blacks and whites. Among
Hispanics, 13 cities have higher rates
than the U.S. total. Disparities still exist
between Hispanics and whites, but not
to the same degree as between whites
and blacks. The exceptions to this are
Baltimore, Phoenix and Sacramento,
where the Hispanic AIDS diagnoses
rates are lower than among white
residents.
In about half of the cities, HIV-related

mortality rates for blacks are higher than
the U.S. total, with disparities between
the races persisting everywhere but
Denver. Of the 13 cities reporting HIV
rates for Hispanics, all but Houston and
Los Angeles have higher rates than the
U.S. total for Hispanics. However, seven
of the 13 have comparable or lower rates
than for whites in those cities. These
numbers suggest that, with regard to
HIV/AIDS, disparities are related to
being in an urban setting, not just due
to race or ethnicity.
33
Executive Summary
HEALTHY PEOPLE 2020 GOALS

The H e a l t h y Pe o p le g o a ls w e r e cre at e d 30 ye ars ag o
by H H S t o p r o vi d e 1 0-y e a r o bj e c t ive s t o im p ro ve t he
healt h of a ll A mer i c a n s . x x ii T h e curre n t targ e t s s e e k
t o i mp r ov e k e y h e a lt h mea s u r e s by t h e ye ar 2020. xx i i I In
s ho r t , i t is a fr a mew o r k a r o u n d w h i ch co m m u n i t ie s can
judge h e a lt h i n a me a s u r a ble , a c co un tabl e way.
While several years remain for cities to
meet these key benchmarks, most are
already well on their way to doing so.
Due to lags in data collection, the figures
included in this report range from 2010
to 2014. It is a positive sign that less than
halfway through the decade, the largest
cities are ahead in their pursuit of the
2020 benchmark for diabetes, and half
already met the goal for cancer. When it
comes to heart disease, however, cities
have work to do, as only four had met
the 2020 heart disease goal by 2014.
Following are the relevant Healthy
People goals for the data categories
34
included in this report. Where possible,

the cities that currently meet the 2020
goals (or in some cases 2015 Winnable
Battles goals) are highlighted. Note that
a city is considered having met the
target if it did so in at least one of the
years for which it reported data (ranging
from 2010 to 2014).
Healthy People 2020
Executive Summary
TABLE 09: CITIES ON TRACK TO MEET HEALTHY PEOPLE 2020 OBJECTIVES AND 2015 WINNABLE BATTLES TARGETS
I N D I C ATO R C AT E G O R Y
BE HAVI ORAL HEALTH

S U BSTANCE ABUSE
Reduce the proportion of adolescents
2015
WINNABLE
BAT T L E
TA R G E T ^
2 0 2 0 H E A LT H Y
PEOPLE
OBJECTIVES
N/A
30.5%
C I T I E S M E E T I N G 2 0 1 5 / 2 0 2 0 TA R G E T
1 3 C I T I E S R E P O R T I N G T W O H I T TA R G E T
Los Angeles; San Diego County
engaging in binge drinking in last month**
BE HAVI ORAL HEALTH

S U BSTANCE ABUSE
Reduce the proportion of Adult binge drinking
1 9 C I T I E S R E P O R T I N G 1 4 H I T TA R G E T
Atlanta (Fulton County); Baltimore; Fort Worth (Tarrant County);
N/A
24.4%
Houston; Las Vegas (Clark County); Los Angeles;

Miami (Miami-Dade County); Minneapolis; New York; Philadelphia;
in last 30 days***
Phoenix; San Antonio; Seattle; Washington, D.C.
C AN C ER
Reduce overall cancer death rate**
N/A
161.4 deaths/
100,000
Atlanta; Houston; Las Vegas (Clark County); Los Angeles;

Miami (Miami-Dade County); New York; Oakland; Phoenix;
San Antonio; San Diego County; San Jose (Santa Clara County);
Seattle
Atlanta; Boston; Chicago; Denver; Houston;
C AN C ER
Reduce lung cancer death rate**
N/A
45.5 deaths/
100,000
Las Vegas (Clark County); Los Angeles;

Miami (Miami-Dade County); New York; Oakland; Phoenix;
Seattle; Washington, D.C.
CANCER
Reduce the female breast cancer death rate**
N/A
20.7 deaths/
100,000 females
Boston; Fort Worth (Tarrant County); Houston;

Miami (Miami-Dade County); Minneapolis; Philadelphia; Phoenix;
San Antonio; San Jose (Santa Clara County); Seattle
1 8 C I T I E S R E P O R T I N G 8 H I T TA R G E T
FOOD SAFETY
Reduce infections caused by Shiga-Toxin
producing E-Coli*
0.85 cases/
100,000
0.6 cases/
100,000
Five hit 2020 target: Cleveland; Houston;

Miami (Miami-Dade County); Philadelphia; San Antonio
Three additional hit 2015: Chicago; Las Vegas (Clark County);
Washington, D.C.
FOOD SAFETY
Reduce infections caused by Salmonella*
13.0 cases/
100,000
11.4 cases/
100,000
Nine hit 2020 target: Cleveland; Denver; Houston;

Las Vegas (Clark County); Los Angeles; Phoenix; Sacramento;
Two additional hit 2015: Chicago; San Diego County
Notes: Cities are listed as meeting the target if they did so in one or more years of the data they reported, ranging from 2010 to 2014. For the most part, data were
2012 or 2013. *Winnable Battles Progress Report 2010-2015 (http://www.cdc.gov/winnablebattles/targets/pdf/winnablebattlesprogressreport.pdf) **http://www.
healthypeople.gov/2020/topicsobjectives2020/default ***Healthy People 2020 Leading Health Indicators: Progress Update (http://www.healthypeople.gov/sites/
default/files/LHI-ProgressReport-ExecSum_0.pdf) ^Some winnable battle-related indicators have 2015 goals in addition to the 2020 goal. Where applicable, both
are shown.
Healthy People 2020
35
Executive Summary
summary
2015
WINNABLE
BAT T L E
TA R G E T ^
2 0 2 0 H E A LT H Y
PEOPLE
OBJECTIVES
HIV/AI DS
Reduce deaths from HIV Infection*
N/A
3.3 deaths/
100,000
Boston; Denver; Fort Worth (Tarrant County); Kansas City;

Las Vegas (Clark County); Los Angeles; Minneapolis; San Antonio;
San Diego County; Seattle
One additional hits 2020 target: Houston
IN J U RY & VI OLENCE
Reduce rate of motor vehicle crash-related
deaths*
Twenty one hit 2015 target: Atlanta (Fulton County); Boston;
9.5 deaths/
100,000
12.4 deaths/
100,000
Chicago; Cleveland; Denver; Detroit; Fort Worth (Tarrant

County); Kansas City; Las Vegas (Clark County); Los Angeles;
Miami (Miami-Dade County); Minneapolis; New York; Oakland;
Philadelphia; Phoenix; San Antonio; San Diego County;
San Jose (Santa Clara County); Seattle; Washington, D.C.
Atlanta (Fulton County); Boston; Chicago; Cleveland; Detroit;
Reduce the Suicide Rate***
N/A
10.2
Houston; Los Angeles; Miami (Miami-Dade County); New York;

Oakland; Philadelphia; San Antonio;
San Jose (Santa Clara County); Washington, D.C.
2 2 CI T I E S R E P O RT I N G 9 H I T TA R G E T
Reduce the Homicide Rate***
Denver; Fort Worth (Tarrant County); Las Vegas (Clark County);
N/A
5.5/100,000
Minneapolis; New York; San Antonio; San Diego County; San Jose
(Santa Clara County); Seattle
2 2 CI T I E S R E P O RT I N G 1 7 H I T TA R G E T
Atlanta (Fulton County); Boston; Denver; Houston; Kansas City;
M AT ERNAL AND CH ILD H EA LTH

Reduce Infant Mortality Rate**
N/A
6.0
Las Vegas (Clark County); Los Angeles; Miami (Miami-Dade

County); Minneapolis; New York; Oakland; Phoenix; Sacramento;
Seattle
M AT ERNAL AND CH ILD H EA LTH
Reduce low birth weight births**
N/A
7.8
Houston; Los Angeles; Minneapolis; Oakland; Philadelphia;

Phoenix; Sacramento; San Diego; San Jose (Santa Clara County);
Seattle
N U T R I TI ON, PHYSI C A L AC TIV ITY,
& OBESI TY
Reduce the proportion of adults who are
obese**
Atlanta (Fulton County); Baltimore; Boston; Chicago; Denver;
N/A
30.5%
Fort Worth (Tarrant County); Las Vegas (Clark County);

Los Angeles; Miami (Miami-Dade County); Minneapolis; New
York; Oakland; Phoenix; San Diego;
See p. 37 for notes.
36
Healthy People 2020
Executive
Executive Summary
summary
N U T RI TI ON, PHYSI C A L AC TIV ITY,

& OBESI TY
Reduce the proportion of adolescents who are
2015
WINNABLE
BAT T L E
TA R G E T ^
2 0 2 0 H E A LT H Y
PEOPLE
OBJECTIVES
16.1%
Boston; Denver; Los Angeles; Las Vegas (Clark County);

Miami (Miami-Dade County); New York; Philadelphia; San Antonio;
San Francisco; Washington, D.C.
N/A
obese**

& OBESI TY
Increase the proportion of adolescents
N/A
31.6%
San Antonio
who meet current Federal physical activity

guidelines**

& OBESI TY
Increase the proportion of adults who engage
in aerobic physical activity of at least moderate
N/A
47.9%
intensity for at least 150minutes/week, or more
Baltimore; Chicago; Denver; Fort Worth (Tarrant County);

Minneapolis; New York; Phoenix, San Jose (Santa Clara County);
than 75 mins/week of vigorous intensity, or an

equivalent combination**
Atlanta (Fulton County); Boston; Chicago; Cleveland; Denver;

& OBESI TY
Detroit; Fort Worth (Tarrant County); Houston; Kansas City;
N/A
66.6/ 100,000

Miami (Miami-Dade County); Minneapolis; New York; Oakland;
Reduce the Diabetes death rate**
Philadelphia; Phoenix; Sacramento; San Antonio; San Diego;


& OBESI TY
N/A
129.2/ 100,000
Reduce coronary heart disease deaths**
Boston; Los Angeles; Minneapolis; Phoenix;

San Jose (Santa Clara County); Seattle
Five hit 2020 Target: Miami (Miami-Dade County); Oakland;
TOBACCO
Decrease percentage of adults who smoke*
Las Vegas (Clark County); San Jose (Santa Clara County); Seattle
17.0%
12.0%
Nine hit 2015 target: Atlanta (Fulton County); Fort Worth

(Tarrant County); Los Angeles; Minneapolis; New York; Phoenix;
San Antonio; San Diego County; San Francisco;
1 4 C I T I E S R E P O R T I N G 1 4 H I T B OT H TA R G E T S
TOBACCO
Decrease percentage of adolescents who smoke
Baltimore; Boston; Chicago; Denver; Detroit; Houston;
17.0%
16.0%
Las Vegas (Clark County); Los Angeles; Miami (Miami-Dade

County); New York; Philadelphia; San Antonio; Seattle;
Washington, D.C.
Notes: Cities are listed as meeting the target if they did so in one or more years of the data they reported, ranging from 2010 to 2014. For the most part,
data were 2012 or 2013. *Winnable Battles Progress Report 2010-2015 (http://www.cdc.gov/winnablebattles/targets/pdf/winnablebattlesprogressreport.pdf)
**http://www.healthypeople.gov/2020/topicsobjectives2020/default ***Healthy People 2020 Leading Health Indicators: Progress Update (http://www.healthypeople.gov/sites/default/files/LHI-ProgressReport-ExecSum_0.pdf) ^Some winnable battle-related indicators have 2015 goals in addition to the 2020 goal.
Where applicable, both are shown.
Healthy People 2020
37
DATA
38
Data
T h e f ol lo wi n g p ag e s o f f e r a sn apsh o t o f p ubli c hea lt h

i n d i c a t o rs f o r e ach ci t y. Th e s e ct io n start s wi t h a n
o ve r vie w o f e ach are as de m o g raphi cs as we ll.
DATA LIMITATIONS
Much work was done to ensure that

the data in this publication and the
online platform are comparable. The
advisory committee, BCHC staff, and
staff in the 26 cities iteratively revised
definitions and changed sources of data
in an effort to ensure that numbers were
as accurate, up to date, and equivalent
as possible. That said, these data give
a brief overview of the public health
conditions in each city, and while many
are comparable, there are jurisdictional
differences at play.
Further, not all cities were able to
provide data for all indicators. The
lack of an indicator for a particular
city could mean (1) that those data are
not collected or (2) that the data are
collected in a way that does not allow
for comparison with peer jurisdictions,
Data Overview
and were therefore, not included in this

publication. If there was a discrepancy
between a localitys data collection
and our method, we erred on the side
of caution by not including that data,
rather than have erroneous conclusions
be made. For example, some California
jurisdictions
use
a
state-based
instrument that is similar to the YRBS.
Consequently, their obesity data is
different enough that their numbers
are not comparable, and thus were not
included in this report. Methodological
variety such as this made the task of
collecting data from 26 of the largest
metropolitan health departments let
alone making them comparable a
daunting one and illustrates the need
for uniformity of data standards across
the governmental public health field.
39
Data
s ele c t e d ci t y de m o g rap h i cs
TABLE 10
CITY
U.S. Total
Foreign Born
2013
Median Household
Income 2013
High School
Graduates
(over 18) 2013
Below 200% of Children Living

in Poverty
Poverty Line
2013
2013
Unemployment
Rate (over 16)
2013
Life Expectancy
Year Varies
12.9%^
$53, 046^
86.0%^
34%#
19.9%
7.4%**
78.8 (2013)
Atlanta
(Fulton County)
7.8%
$46,485
89.3%
41.5%
40.0%
11.3%
78.0 (2003-2013)
Baltimore
7.1%
$42,266
82.2%
43.4%
36.1%
11.1%
73.9 (2011-2013)
Boston
27.7%
$53,583
87.0%
37.5%
30.4%
8.1%
80.1
(2008-2012)
Chicago
21.1%
$47,099
82.4%
43.9%
33.9%
12.7%
78.0
(2003-2012)
4.4%
$26,096
78.0%
60.7%
58.5%
18.1%
73.6 (2010)
Dallas
24.4%
$41,978
75.6%
50.8%
39.4%
7.9%
Denver
15.2%
$51,089
86.2%
38.6%
31.1%
5.9%
Detroit
5.0%
$24,820
78.2%
64.0%
60.6%
25.3%
Fort Worth
(Tarrant County)*
15.6
$56,853
84.5%
40.9%++
22.1%
7.5%++
28.3%
$45,353
77.6%
46.4%
35.8%
7.9%
8.4%
$45,551
88.6%
40.2%
28.0%
7.2%
77.6 (2013)
Las Vegas
(Clark County)*
21.8%
$52,873
83.9%
39.3%++
22%
12.9%++
79.0 (2012)
Los Angeles
38.3%
$48,466
75.9%
46.8%
34.0%
10.7%
81.8* (2011)
Miami*
(Miami-Dade
County)
51.3%
$43,100
78.8%
56.1%++
26.6%
9.9%++
81.7* (2013)
Cleveland
Houston
Kansas City
40
78.6
(2007-2012)
76.9* (2013)
Selected City Demographics
Data
s e le c t e d ci t y de m o g rap hi cs
TABLE 10 CONTINUED
CITY
Foreign Born
2013
Median Household
Income 2013
High School
Graduates
(over 18) 2013
Below 200% of Children Living Unemployment

in Poverty
Poverty Line
Rate (over 16)
2013
2013
2013
Life Expectancy
Year Varies
U.S. Total
12.9%^
$53, 046^
86.0%^
34.0%
19.9%
7.4%
78.8 (2013)
Minneapolis
16.1%
$50,563
89.8%
40.9%
28.1%
8.0%
New York
37.0%
$52,223
80.9%
40.5%
29.2%
9.8%
Oakland
25.9%
$54,394
81.3%
41.5%
24.6%
12.5%
Philadelphia
12.7%
$36,836
82.6%
49.3%
37.1%
13.8%
Male: 72.3 (2012)

Female: 79.3 (2012)
Phoenix
19.8%
$46,601
80.6%
46.5%
35.7%
9.1%
80.0* (2004-2013)
Sacramento
22.5%
$48,546
84.7%
45.3%
33.6%
12.5%
San Antonio
14.2%
$45,399
82.5%
44.3%
30.0%
7.8%
79.4* (2013)
San Diego
County*
23.4%
$67,753
85.8%
32.7%
18.7%
9.5%
82.3 (2013)
San Francisco
34.9%
$77,485
87.5%
28.4%
18.6%
7.3%
82.0 (2013)
San Jose
(Santa Clara
County)
39.3%
$80,977
82.8%
28.8%
17.5%
9.4%
Seattle
17.7%
$70,172
93.6%
25.5%
15.7%
5.9%
82.2 (2013)
Washington,D.C.
14.4%
$67,572
89.9%
33.6%
25.4%
10.4%
77.5 (2010)
81.1 (2012)
Most data come from various U.S. Census files, details of which can be found in the data appendix. Cities for Census data were defined using micropolitan code
based statistical areas defined by the Office of Management and Budget (OMB) February 2013 Delineation Files, which may be different from other jurisdictional
lines. An exception to this is Fort Worth (Tarrant County), Las Vegas (Clark County), and San Diego County, where numbers reflect county level statistics. Some
county and national level numbers were pulled from other sources other than the U.S. Census Bureau and are noted accordingly below. Life expectancy data came
from individual health departments or other sources as noted in the appendix. *Denotes county level data. -- denotes data not available. ^U.S. Census data from
2009-2013 (http://quickfacts.census.gov/qfd/states/00000.html). #Kaiser Family Foundation State Health Facts (http://kff.org/other/state-indicator/populationup-to-200-fpl/). **Bureau of Labor Statistics. ++County level data were not secured prior to publication.
Selected City Demographics
41
Data
C I T Y - BY - C I T Y TA B L E S
THE
F O L LOWIN G
TA B LES
S HOW
C OMPAR ABL E
P UBLI C H E A LTH S TATIS TICS FOR THE 26 L AR GE

AM E RI C A N C ITIES IN CLUD ED IN THIS P UBL IC ATION
AND DATA S ET. WHILE S OME J U R ISDICTIONS HAVE
M O R E R EC E N T DATA AVA ILA B LE, THOSE DISP L AYED
HE R E
ARE
FOR
THE
YEA R
THAT
WAS
MOST
CO M MO N LY AVA ILA B LE FOR EACH INDIC ATOR .

Some cities did not report data for a given year, and therefore, those data are not
included below. Blank cells can also mean (1) data were simply not available; (2) data
were not reported in time for publication; or (3) there were too few cases for a rate
to be calculated and included. For simplicity of display, the Asian/Pacific Islander
racial/ethnic group category was combined. It should be noted, however, that many
of the Californian cities, as well as Seattle, reported numbers that only represent
Asians, not Pacific Islanders. These are noted in the following tables. In a few other
cases, certain populations with small numbers were collapsed into other as well.
Additional indicators and years for all cities can be found via the online data platform
at http://www.bigcitieshealth.org/data-and-research-center.
Notes refer to the Entire United States table on

p. 43: * for Asian only; Native Hawaiian or other
Pacific Islander for % of High School Students
Who Meet CDC-Recommended Physical Acitivity
Levels is equal to 23.6. ** is for Asian only; Native
Hawaiian or other Pacific Islander HIV Diagnoses
Rate is 15.1.*** For Asian only; Native Hawaiian
or other Pacific Islander rate for persons living
with HIV/AIDS is 166.4. **** is for Asian only;
Tuberculosis Incidence Rate for Native Hawaiian
or other Pacific Islanders is 11.3.
42
City-by-City Tables
Data
e n t ire u n i t e d stat e s
I N D I C ATO R
HIV DIAGNOSES RATE, 2012
(Per 100,000 people)
Based on number of persons with newly diagnosed HIV
AIDS DIAGNOSES RATE, 2012
Based on number of persons with newly diagnosed AIDS
PERSONS LIVING WITH HIV/AIDS RATE, 2012
Based on number of persons living with diagnosed HIV/AIDS
HIV-RELATED MORTALITY RATE, 2012
(Age-adjusted; Per 100,000 people)
Based on number of HIV-related deaths
ALL TYPES OF CANCER MORTALITY RATE, 2012
Based on number of cancer deaths
PNEUMONIA & INFLUENZA MORTALITY RATE, 2012
Based on number of pneumonia and influenza deaths
ALL
PERSONS
WHITE
B L AC K
H I S PA N I C
ASIAN/ PI
N AT I V E
AMERICAN
15.3
6.7
58.3
18.5
6.1**
9.9
8.3
3.3
32.9
10.0
291.5
149.2
1011.0
347.8
70.5***
124.1
2.2
1.0
9.8
2.2
0.4
1.0
166.5
166.6
193.8
166.9
104.2
111.4
14.4
14.3
15.7
12.0
14.0
13.1
5.8
5.3
19.0
TB INCIDENCE RATE, 2012

Based on number of diagnosed TB cases
3.4
INFANT MORTALITY RATE, 2011

(Per 1,000 live births)
Based on the number of infant deaths (<1 year old)
6.1
5.1
11.5
5.2
4.4
8.2
% LOW BIRTHWEIGHT BABIES BORN, 2012

Percentage of babies born weighing less 5 lbs, 8 oz
8.1
7.1
13.3
7.0
8.4
7.6
% ADULTS WHO ARE OBESE, 2011

Percentage of adults who are obese
35.3
33.4
48.6
40.5
% OF HIGH SCHOOL STUDENTS WHO ARE OBESE, 2013

Percentage of high school students who are obese
19.4
17.8
22.9
22.9
% OF ADULTS WHO MEET RECOMMENDED PHYSICAL ACTIVITY

LEVELS, 2011
Percentage of adults meeting CDCs physical activity
recommendations
48.8
50.2
41.0
40.0
45.1
42.9
% OF HIGH SCHOOL STUDENTS WHO MEET RECOMMENDED

PHYSICAL ACTIVITY LEVELS, 2013
Percentage of high school students meeting CDC physical activity
recommendations
27.1
28.2
26.3
25.5
21.3*
30.8
105.4
105.6
121.3
81.1
60.5
79.2
DIABETES MORTALITY RATE, 2012

Based on number of deaths attributed to diabetes
69.1
65.2
109.1
79.9
51.0
96.2
HOMICIDE RATE, 2012

Based on number of deaths attributed to homicide
5.4
2.6
19.4
4.9
1.9
5.8
10.5
10.0
19.0
5.7
2.5
7.6
HEART DISEASE MORTALITY RATE, 2012

Based on number of deaths attributed to heart disease
FIREARM RELATED MORTALITY RATE, 2012

Based on number of firearm-related deaths
Notes for Entire United States table on p. 42.
Data Entire United States
43
Data
AT L A N TA ( F ULTON COUN TY) ME ETS THE HEALTHY

PE O PLE 2 0 2 0 TA RGETS FOR CANC ER & DIABETES
D E ATH S . I T D OES NOT MEET THE TAR GET F OR
H E A RT D I S EA S E D EATHS .
I N D I C ATO R
ALL
PERSONS
WHITE
B L AC K
H I S PA N I C
1581.7
702.4
2444.0
731.7
9.8
2.8
19.2
152.8
128.1
196.3
10.5
10.1
11.3
7.3
4.6

10.6


73.8

39.6

ASIAN/ PI
60.1
64.6
9.9
3.2
6.5
6.7
13.6
7.8
10.2
22.8
9.7
37.9
23.8
29.9
21.7
197.7
149.0
275.1
84.7
95.3

15.8
7.3
27.6
HOMICIDE RATE, 2012

9.5
1.0
19.5

INFANT MORTALITY RATE, 2011 (Per 1,000 live births)

% OF ADULTS WHO MEET RECOMMENDED PHYSICAL ACTIVITY LEVELS,
2011
Percentage of adults meeting CDCs physical activity recommendations
% OF HIGH SCHOOL STUDENTS WHO MEET RECOMMENDED PHYSICAL
ACTIVITY LEVELS, 2013
recommendations

44
Data
BA LT IMOR E MEETS THE HEALTHY P EOP L E TAR G E T

FOR DIABETES DEATHS. IT DOES NOT M E E T T H E
TA RGETS F OR C ANCER OR HEART DISEASE D E AT H S .
ALL
PERSONS
WHITE
B L AC K
H I S PA N I C
ASIAN/ PI

89.9
25.6
125.1
71.3
14.4

72.3
18.5
101.1
28.5
14.4
2541.1
967.0
3395.0
1631.3
216.5
I N D I C ATO R

20.0
213.9

3.5
2.7

10.5
4.0
14.6

11.6
6.7
14.1

37.3
25.3
46.4
68.4
77.5
63.9
8.2

LEVELS, 2011
recommendations
recommendations
241.6

HOMICIDE RATE, 2012
Baltimore
45
Data
BOSTON MEETS THE
HEALTHY PEOPLE 2020 TARGET
FOR DIABETES DEATHS. IT IS ONE OF ONLY SIX CITIES TO

MEET THE TARGET FOR HEART DISEASE DEATHS. BOSTON
DOES NOT MEET THE TARGET FOR CANCER DEATHS.
I N D I C ATO R
ALL
PERSONS
WHITE
B L AC K
H I S PA N I C
28.8
21.7
37.2
49.1
885.5
756.9
1581.4
898.8
159.4
132.6
131.9
ASIAN/ PI

3.1
6.1
186.3
200.0
209.5
15.7
18.8
15.1
10.9

6.6
2.1
15.3
17.7

5.3
5.0
7.8
2.6

9.2
7.1
12.0
9.1
13.8
8.7
14.8
18.0
131.1
144.9
155.9
80.2

19.6
14.3
39.5
HOMICIDE RATE, 2012

6.6
2.0
19.9
7.7

4.4
2.0
13.7
7.9

10.5

2011
recommendations
46
44.6
Boston
Data
CHIC AGO
MEETS
THE
HEALTHY
P EOP L E
2020
TA RGET F OR DIABETES DEATHS. IT DOES NOT M E E T

THE TAR GETS F OR CANC ER OR HEART D IS E AS E
D EATHS.
I N D I C ATO R
ALL
PERSONS
39.8
21.7
WHITE
B L AC K
H I S PA N I C
25.7
64.8
28.6
10.6
38.5
14.5
ASIAN/ PI

826.5
643.5
1296.4
526.9
150.6

4.4
2.2
8.7
2.8
2.0

186.1
173.9
240.1
131.1
101.5

20.2
19.7
22.9
16.9
13.9

5.4
1.8
4.9
5.8
29.6

8.2
4.2
14.3
6.2
2.8

9.7
6.8
14.8
7.4

24.6
17.1
35.4
24.2

14.5
5.7
15.7
15.9
50.7
55.8
45.7
49.8
19.6
19.7
19.9
18.7

210.5
202.6
270.0
124.3
114.2

25.6
20.1
32.8
27.2
24.8
HOMICIDE RATE, 2012

15.7
2.8
40.5
8.6
2.0

15.4
3.9
39.0
7.9
1.2

LEVELS, 2011
recommendations
recommendations
Chicago
47
Data
C L E V E LA N D M EETS THE HEA LT HY P EOP L E 2020

TA RG E T F O R D IA BETES D EATH S. IT DOES NOT
ME E T T H E TA RGET FOR HEA RT DISEASE.
I N D I C ATO R
ALL PERSONS
WHITE
B L AC K
H I S PA N I C
0.7
0.9
18.3
11.8

9.2
15.2
5.1

9.9
15.8
10.9
339.2
432.6
325.5

38.6
41.6
39.3
HOMICIDE RATE, 2012

24.9

13.9


2011
recommendations

48
Cleveland
Data
DA LLA S
DATA W E R E N OT AVA I L A B L E AT T H E T I M E O F P U B L I C AT I O N TO D E T E R M I N E H P
2 0 2 0 TA R G E T S F O R D I A B E T E S , C A N C E R , O R H E A RT D I E A S E D E AT H S I N DA L L A S .
I N D I C ATO R
ALL
PERSONS
WHITE
B L AC K
H I S PA N I C
32.9
23.4
71.4
21.4
625.0
622.6
1156.4
354.7
7.5
3.3
12.7
6.0
ASIAN/ PI

25.2

LEVELS, 2011
recommendations
recommendations
HOMICIDE RATE, 2012
Dallas
49
Data
D E N V ER
MEETS THE HEA LTHY P EOP L E
2020
TA RG E T F O R DIA B ETES D EATHS . IT DOES NOT MEET

T HE TA RG E TS FOR CA N CER OR HEART DISEASE
D E ATH S .
ALL
PERSONS
WHITE
B L AC K
H I S PA N I C
ASIAN/ PI
N AT I V E
AMERICAN

24.0
22.0
32.5
26.7
4.9
85.1

15.5
12.8
27.4
16.2
4.9
56.7
515.0
524.3
825.5
460.8
166.5
851.1
2.9
3.1
1.6
3.9
177.6
166.4
247.3
196.5
146.4
184.5
13.9
14.2
8.1
17.6
23.1

1.7
0.3
1.7
3.1
9.8

4.6
3.2
7.8
6.1

21.1
13.5
40.1
28.1

10.7
3.9
11.1
13.3
84.4
86.7
79.2
81.6
20.2
22.4
24.6
18.7
6.8
158.1
153.4
205.0
150.0
145.1
192.7

21.1
12.4
37.0
49.8
13.3
139.1
HOMICIDE RATE, 2012

6.6
3.3
20.1
8.0
7.7
10.9
9.3
23.8
10.6
I N D I C ATO R



LEVELS, 2011
recommendations
recommendations

50
8.1
Denver
Data
D ETROIT
MEETS
THE
HEALTHY
P EOPL E
2020

THE TAR GETS F OR C ANCER OR HEART D IS E AS E
D EATHS.
ALL
PERSONS
WHITE
B L AC K
H I S PA N I C
38.1
21.6
42.8
10.3
8.5
1.8
10.1
2.1
744.2
562.9
802.8
339.0
12.7
7.2
12.4
4.1
217.6
181.6
222.5
136.7
17.3
18.3
17.4
5.2
10.0
4.2

12.6
10.1
14.8

13.0
8.3
14.1
6.6

39.7
33.9
39.3
47.2

22.9
22.6
29.2

2011
19.1
14.9
19.3
25.6

recommendations
49.0
54.0
34.0
46.0
334.6
265.6
348.0

28.4
28.5
28.5
HOMICIDE RATE, 2012

47.9
18.4
52.7

47.2
23.3
51.4
I N D I C ATO R

Detroit
6.2
51
Data
FORT
WO RTH
( TA RRA N T
COUNTY)
MEETS
THE
HE A LT H Y P EOPLE 2020 TA RGET F OR DIABETES

DE ATH S . I T D OES NOT MEET T HE TAR GETS F OR
CA N C E R O R HEA RT D IS EA S E D EATHS.
I N D I C ATO R
ALL PERSONS
WHITE
B L AC K
H I S PA N I C
10.4
5.1
39.6
7.2
174.3
178.5
210.7
138.3
16.9
16.1
20.9
22.7
2.1

2.3

4.0

7.7
5.4
14.3
7.9

8.2
7.2
13.5
6.8
178.9
179.3
240.3
130.7

22.9
19.1
46.6
34.1
HOMICIDE RATE, 2012

4.3
9.5
4.8
12.7
4.5

4.3
29.2

2011
47.9

recommendations

52
10.0
10.7
Fort Worth: Tarrant County
Data
HOUSTON
MEETS
THE
HEALTHY
P EOPL E
2020
TA RGETS F OR C ANCER & DIABETES DE AT H S . IT

D OES NOT MEET THE TAR GET F OR HEART D IS E AS E
D EATHS.
I N D I C ATO R
ALL PERSONS
WHITE
B L AC K
H I S PA N I C

31.6
13.2
81.4
27.2

19.1
8.1
52.0
15.2
521.4
338.5
1394.1
328.8
4.7
2.4
16.1
2.2
160.3
169.9
217.7
107.8
13.4
13.7
17.0
11.2

9.2
3.2
12.6
9.4

5.6

1.6
1.2
2.9
1.4
171.9
181.3
229.1
117.5
21.9
16.0
38.6
26.1


2011
recommendations
HOMICIDE RATE, 2012
Houston
5.8
53
Data
KANS A S C I T Y MEETS THE HEA LTHY P EOP L E 2020

TAR G E T F O R DIA B ETES D EATHS . IT DOES NOT MEET
T H E TA RG E TS FOR CA NCER O R HEART DISEASE
DE AT H S .
ALL
PERSONS
WHITE
B L AC K
H I S PA N I C

14.6
7.9
30.9
4.4

17.4
10.3
32.4
15.2
26.6
241.4
206.1
373.0
145.8
115.3
3.2
2.3
4.8
187.0
180.0
232.6
111.1
180.2
10.8
11.5
9.2

5.8
3.5
9.9
6.1

8.9
6.3
13.4
6.8
167.0
157.0
202.1
92.5

21.6
16.1
38.2
HOMICIDE RATE, 2012

20.6
6.5
51.6

24.2
11.4
53.7
I N D I C ATO R

ASIAN/ PI

8.3

2011
recommendations
54
Kansas City
Data
LA S VEGAS (CL AR K C OUNTY) MEETS THE H E ALT H Y

PEOP L E 2020 TAR GETS F OR CANC ER & DIABE T E S
D EAT HS. IT DOES NOT MEET THE TAR G E T F O R
HEA RT DISEASE DEATHS.
ALL
PERSONS
WHITE
B L AC K
H I S PA N I C
ASIAN/ PI
HIV D IAGNOSES RATE, 2012

16.9
10.0
35.7
18.5
13.0

10.0
6.1
28.9
10.0
3.0
415.1
308.1
1067.1
321.1
165.3
3.2
2.6
9.5
2.5
160.2
160.6
203.9
142.1
20.0
18.8
34.2
20.0

3.6
1.5
3.1
3.7

5.3
4.8
7.1
6.1

8.2
7.6
12.6
7.0

13.8
11.6
11.7
17.6

2011
44.0
48.8
44.0
37.1

recommendations
23.6
28.6
27.5
20.5
183.9
183.3
292.2
157.2

13.4
11.3
33.4
14.9
HOMICIDE RATE, 2012

4.8
3.1
15.5
4.1
12.6
14.3
21.1
5.8
I N D I C ATO R
PERSONS LIVING WI TH HIV/AIDS RATE, 2012

ALL TYPES OF CANC ER MORTALITY RATE, 2012
16.3
9.6



55
Data
LOS A N G ELES MEETS THE HEA LTHY P EOP L E 2020

TA RG E TS F O R CA N CER & D IA BETES DEATHS. IT IS
O N E O F O N LY S IX CITIES TO MEET THE TAR GET
FO R H E A RT DIS EA S E D EATHS .
ALL
PERSONS
WHITE
B L AC K
H I S PA N I C
ASIAN

30.0
26.0
68.0
29.0
12.0

16.0
13.0
42.0
16.0
5.0
724.0
827.0
1601.0
615.0
180.0
2.2
1.9
7.5
1.8

83.1
57.6
206.4
75.8
75.7

13.1
7.4
31.4
12.9
17.1

7.5
1.0
8.5
8.0
20.9

4.8
3.7
10.2
4.6
3.4

7.1
6.7
11.8
6.5
7.3

21.6
14.8
29.2
29.0
6.8

13.6
6.6
13.7
15.2
5.5

2011
29.0
33.0
30.0
27.0
26.0

recommendations
22.5
15.8
22.1
23.2
19.4

92.8
63.5
266.7
85.3
66.8

14.9
5.4
37.2
23.4
11.7
HOMICIDE RATE, 2012

5.7
29.5
4.9

5.0
22.3
3.6
I N D I C ATO R

56
2.1
Los Angeles
Data
MIA MI (MIAMI-DADE COUNTY) MEETS THE H E ALT H Y

PEOP L E 2020 TAR GETS F OR C ANCER & D IABE T E S
D EAT HS. IT DOES NOT MEET THE TARG E T F O R
HEA RT DISEASE DEATHS.
I N D I C ATO R
ALL PERSONS
WHITE
B L AC K
H I S PA N I C

43.9
37.3
100.1
31.5

23.7
11.6
63.3
16.3
980.9
799.8
2608.0
613.4
7.9
3.8
34.3
2.8
139.6
151.8
165.8
130.8

8.4
9.0
10.0
7.7

4.9
1.8
8.1
4.6

4.7
4.2
8.8
3.2

8.7
7.2
13.1
7.3
9.4
6.1
11.4
9.4
40.5
45.2
33.7
42.2
162.4
175.5
205.8
147.0

21.7
17.0
43.9
18.7
HOMICIDE RATE, 2012

9.2
1.7
32.4
4.5
11.0
7.0
31.7
6.0


2011
recommendations

57
Data
MI NN EA P O L I S MEETS THE HEA LTHY P EOP L E 2020

TA RG E T F O R D IA B ETES D EATHS. IT IS ONE OF
O N LY S I X C I T IES TO MEET THE TAR GET F OR HEART
D I S E A S E D EATHS . HOWEVER, IT DOES NOT MEET
T HE TA RG E T FOR CA NCER D EAT HS.
ALL
PERSONS
WHITE
B L AC K
H I S PA N I C

26.4
19.1
44.3
39.9

18.0
13.0
37.2
20.0
769.3
673.3
1419.2
618.9
1.9
1.6
4.8
168.1
157.7
246.1
72.8

13.9
14.8
10.9
24.9

10.7
50.0
12.5
I N D I C ATO R

ASIAN/ PI
N AT I V E
AMERICAN
153.0
1039.2

5.9
3.5
10.2
7.1
1.6
2.0

7.2
5.4
11.2
5.3
7.9
8.6
114.6
111.0
133.4
39.9

28.3
19.6
74.5
7.2
HOMICIDE RATE, 2012

5.6
1.4
24.5
1.4

6.1
4.3
14.7
1.4

20.9

LEVELS, 2011
recommendations
recommendations
58
57.7
Minneapolis
Data
N EW YOR K CITY MEETS THE HEALTHY P EOP L E 2 0 2 0

TA RGETS F OR C ANCER & DIABETES DE AT H S . IT
D OES NOT MEET THE TAR GET F OR HEART D IS E AS E
D EAT HS.
ALL
PERSONS
WHITE
B L AC K
H I S PA N I C
ASIAN/ PI
HIV D IAGNOSES RATE, 2012

35.8
20.7
69.3
41.0
9.2

24.4
10.5
56.0
26.0
4.6
1391.0
867.9
2097.5
1564.4
184.3
6.8
2.5
17.5
6.7
155.1
175.3
178.6
119.4
108.3
25.2
25.2
28.6
24.2
17.6

7.8
1.6
7.2
7.4
24.0

4.7
3.1
8.1
4.9
2.9

8.6
7.0
12.6
7.7
8.2

23.7
18.7
33.3
29.5
9.1

11.8
7.4
14.0
14.6
5.3
18.7
22.4
21.4
17.7
14.1
188.2
206.0
221.7
145.1
98.2

20.8
13.7
37.6
21.7
14.4
HOMICIDE RATE, 2012

5.3
1.8
14.2
4.4
1.2

3.7
1.7
10.2
2.3
I N D I C ATO R
PERSONS LIVING WI TH HIV/AIDS RATE, 2012

ALL TYPES OF CANC ER MORTALITY RATE, 2012

2011
recommendations
New York City
59
Data
OA K L A N D
MEETS
THE
HEA LT HY
P EOP L E
2020
TA RG E TS F O R CA N CER & D IA BETES DEATHS. IT

D O ES N OT MEET THE TA RGET FOR HEART DISEASE
D E ATH S .
ALL
PERSONS
WHITE
B L AC K
H I S PA N I C
ASIAN

19.7
10.9
42.2
15.1
6.0

11.5
4.9
22.5
11.1
4.5
818.2
823.3
1629.8
450.2
183.0
5.6
5.6
11.3

4.2
3.1
10.4
4.1
3.0

6.6
5.4
11.2
8.5
4.0
21.0
21.6
43.1
26.6
32.0
34.4
I N D I C ATO R


2011
44.2
25.8

recommendations
HOMICIDE RATE, 2012
60
Notes: * for Asian only, Native Hawaiian/Pacific Islander All Cancer Mortality Rate is 221.8.
Oakland
Data
PHILADEL P HIA
2020
MEETS
THE
HEALTHY
PEOPLE
TAR GET F OR DIABETES DEATHS. IT D O E S
NOT MEET THE TAR GETS F OR CANC ER O R H E ART

D IS EASE DEATHS.
ALL
PERSONS
WHITE
B L AC K
H I S PA N I C

31.7
10.9
50.2
38.9

28.2
8.3
45.5
34.6
7.3
160.6
101.4
I N D I C ATO R
ASIAN/ PI

5.9
8.6
206.8
189.5
235.7
13.1
14.6
11.7

5.6
1.6
5.6
2.5
35.1

9.3
5.4
14.1
5.2
1.5
14.6
13.6
15.3
13.9
6.2
26.9
21.9
21.0
21.6
19.0
202.8
187.1
228.8
145.2
64.7

22.1
16.6
29.7
24.6
HOMICIDE RATE, 2012

19.7
3.2
37.8
18.4

21.4


2011
recommendations
Philadelphia
61
Data
PHO EN I X
M EETS
THE
HEA LTHY
P EOP L E
2020
TA RG E TS F O R CA N CER & D IA BETES DEATHS. IT IS

O N E O F O N LY S IX CITIES TO MEET THE TAR GET
FO R H E A RT DIS EA S E D EATHS .
ALL
PERSONS
WHITE
B L AC K
H I S PA N I C
ASIAN/ PI
N AT I V E
AMERICAN
15.3
11.4
42.6
14.9
8.6
345.9
7.8
7.0
25.5
5.9
8.6
103.8
6.4
8.0
19.2
3.0
4.3
109.1
158.6
111.5
36.6
60.1
39.5
24.8
34.0
24.8
9.9
6.0
25.4

7.5
0.9
16.0
4.9
28.5
9.3

7.1
6.2
7.5
7.5
6.1
3.0

7.5
7.2
14.0
6.7
9.5
5.8
25.2
21.5
35.4
52.6
57.2
41.4
103.7
150.9
131.6
31.8
42.9
33.4

22.1
21.5
44.5
12.9
15.2
15.3
HOMICIDE RATE, 2012

8.4
4.5
25.0
10.1
6.2
10.0
14.1
14.7
22.7
12.9
4.6
10.0
I N D I C ATO R

LEVELS, 2011
recommendations
recommendations

62
Phoenix
Data
S ACRAMENTO MEETS THE HEALTHY P EOPL E 2 0 2 0

THE TAR GETS F OR C ANCER & HEART D IS E AS E
D EATHS.
ALL
PERSONS
WHITE
B L AC K
H I S PA N I C
ASIAN/ PI
22.5
25.7
44.7
19.5
6.6
12.2
23.9
8.6
357.3
413.1
141.2
51.4
6.1
14.4
302.2
492.0
492.0
108.2
223.9

26.5
45.4
24.0
10.6
20.3

41.0
4.3

5.2
3.8
11.8
5.2
3.3

6.9
5.3
10.9
6.3
7.1
282.5
506.1
275.0
82.2
167.4

40.4
56.5
67.1
10.6
20.3
HOMICIDE RATE, 2012

13.1
11.1
32.0
8.9
12.8

17.6
20.9
25.2
9.8
11.7
I N D I C ATO R
235.5

27.7

2011
recommendations
Sacramento
63
Data
SAN ANTONIO MEETS THE HEA LTHY P EOP L E 2020

TARGETS FOR CANCER & DIABETES DEATHS. IT
DOES NOT MEET THE TARGET FOR HEART DISEASE
DEATHS.
I N D I C ATO R
ALL PERSONS
WHITE
B L AC K
H I S PA N I C
19.9
12.3
37.2
21.2
9.1
5.8
17.8
9.1
258.5
175.3
449.2
276.8
3.0
1.8
5.0
3.7
137.5
146.2
171.0
126.9

9.1
9.1
10.7
8.9

4.1
1.3
8.5
4.5

4.9
4.7

9.0
8.0
14.4
6.9
16.0
31.6
27.0
28.3
143.2
144.9
152.4
143.3

22.6
12.1
27.0
32.4
HOMICIDE RATE, 2012

5.6
3.5
9.9
6.5

9.4
13.5
9.5
7.0

4.8
14.0
9.0

2011
recommendations
64
San Antonio
Data
S A N DIEGO COUNTY MEETS THE HEALTHY P E O P L E

2020 TAR GETS F OR C ANCER & DIABETES D E AT H S .
IT
DOES
NOT
MEET
THE
TAR GET
F OR
H E ART
D IS EASE DEATHS.
I N D I C ATO R
ALL
PERSONS
WHITE
B L AC K
H I S PA N I C
ASIAN
225.5
123.4
120.9
9.2
8.8
10.3
7.7
393.1
1.7
1.4
158.3
169.4

8.9
8.9

7.3
1.1
8.6
12.4
21.9

4.3
3.7
6.1
4.5
3.0

6.5
5.6
10.3
6.0
8.6
24.1
20.1
27.7
28.4
140.6
147.1
219.6
115.5
106.2

20.4
16.7
38.3
32.4
19.6
HOMICIDE RATE, 2012

3.5
2.0
15.8
4.4

6.3
8.3
15.1
4.3


LEVELS, 2011
recommendations
recommendations
San Diego
1.4
65
Data
SAN FRA N C I S C O
DATA W E R E N OT AVA I L A B L E AT T H E T I M E O F P U B L I C AT I O N TO
D E T E R M I N E H P 2 0 2 0 TA R G E T S F O R D I A B E T E S , C A N C E R , O R H E A R T
D I E A S E D E AT H S I N S A N F R A N C I S C O.
ALL
PERSONS
WHITE
B L AC K
H I S PA N I C

54.9
67.0
94.1
87.0

29.8
36.2
85.5
41.1
1881.8
2765.4
4104.2
2206.5
10.6
13.6
29.9
11.5
14.1
3.5
32.5
4.7
15.6
14.6
23.1
15.8
I N D I C ATO R

ASIAN/ PI

29.4

7.7

2011
recommendations
16.4
27.1

HOMICIDE RATE, 2012
66
San Francisco
Data
S A N JOSE (SANTA C L AR A C OUNTY) ME E T S T H E

HEA LTHY P EOP L E 2020 TAR GETS F OR CA N C E R &
D IA BETES DEATHS. IT IS ONE OF ONLY SI X C IT IE S
TO ME ET THE TAR GET F OR HEART DISEASE D E AT H S .
ALL
PERSONS
WHITE
B L AC K
H I S PA N I C
ASIAN/ PI

8.8
8.5
25.4
11.8
4.9

6.0
5.2
32.7
8.3
2.6
231.5
303.3
897.7
284.4
65.2
150.6
177.6
213.8
131.8
122.6

14.5
16.6

10.8
1.5
7.3
5.1
26.4

3.5
3.0
8.6
3.7
3.0

7.0
7.0
8.0
6.0
8.0
I N D I C ATO R

14.6

20.0

2011
recommendations
29.0
51.0
136.5
159.0
163.6
140.9
95.8

30.8
24.9
71.3
40.5
32.8
HOMICIDE RATE, 2012

4.9

5.5

19.0
7.5
67
Data
S E AT TLE
M EETS
THE
HEA LTHY
P EOP L E
2020
TA RGETS F O R CA NCER & D IA B E TES DEATHS. IT IS

O N E O F O N LY S IX CITIES TO M EET THE TAR GET
FO R H EA RT DIS EA S E D EATHS .
ALL
PERSONS
WHITE
B L AC K
H I S PA N I C
ASIAN

30.6
33.0
56.3
29.3
10.0

19.6
14.0
75.9
26.4
8.6
1065.2
1082.3
2319.0
1533.8
1016.1
2.5
2.7
152.9
156.4
207.2
81.7
123.9

8.1
7.8

8.3
1.1

3.6
2.5

5.9
4.9
63.0
65.0
117.0
121.5
159.6

20.8
15.3
70.6
HOMICIDE RATE, 2012

3.1
2.1
16.9

7.6
7.9
17.8
I N D I C ATO R

9.7
3.1
3.6
8.3
8.5
4.1
7.7

2011
58.0

recommendations
68
72.4
183.4
24.5
Seattle
Data
WA S HINGTON D.C. MEETS THE HEALTHY P E O P L E

2020 TAR GET F OR DIABETES DEATHS. IT D O E S
N OT MEET THE TAR GETS F OR CANC ER O R H E ART
D IS EASE DEATHS.
I N D I C ATO R
ALL PERSONS
WHITE
B L AC K
H I S PA N I C
112.0
47.7
161.7
105.7
2651.4
1272.0
3961.8
1784.1
15.4
3.7
26.9
8.7
179.5
128.4
217.5
158.8
12.6
7.6
17.0
3.1
10.2
7.3
64.9

5.9

7.4
1.8
11.6
5.2

10.5
6.3
13.7
8.2

23.8
10.7
36.7
13.3

14.8

2011
80.2
91.5
71.8
76.2

recommendations
16.4
218.0
118.2
288.5
159.4

24.2
5.0
36.1
4.5
HOMICIDE RATE, 2012

11.6
26.1
2.0


Washington D.C.
9.3
1.5
19.8
69
WINNABLEBATTLES
BATTLES
WINNABLE
CASESTUDIES
STUDIES
CASE
Winnable Battles Case Studies
U p o n arrivi n g at CDC as t h e Ag e n cy' s n e w Dir ect o r , D R.

T h o ma s F rie de n i n t ro duce d t h e co n ce p t o f "Wi nna ble
Ba t t l e s" o n whi ch CDC an d i t s p art n e rs sh ould focus
"b a s e d o n t h e m ag n i t u de o f h e al t h p ro ble ms a nd t he
a bi li t y o f CDC an d i t s p ubli c he alt h p art n e r s t o ma ke
s i g n if i can t p ro g re ss t o im p ro ve o u t co m e s." xx iv
TH E S E I N CLU D E : XXV

R E D U CI N G TO BACCO U S E
I M P ROV I N G N U T R I T I O N , P H YS I CA L ACT I V I T Y, A N D OB ESI TY
ENSURING FOOD SAFETY
P R E V E N T I N G H E A LT H CA R E - A S S O CI AT E D I N F E CT I ONS
I M P ROV I N G M OTO R V E H I CL E S A F E T Y
R E D U CI N G T E E N P R E G NA N CY
R E D U CI N G N E W H I V I N F E CT I O N S
Urban LHDs have proven to be critical

innovators in the process of creating
solutions for these important Winnable
Battles. Indeed, cities are often ideal
laboratories for policy because their
leaders authority and focus are so
concentrated. To illustrate these
advances that have developed to address
some of the nations most pressing
health problems, following are case
studies detailing innovative programs
and notable achievements made by
BCHC LHDs regarding food safety;
Winnable Battles Case Studies
HIV/AIDS; injury and violence; obesity/

physical activity/nutrition; and tobacco.
Additional data for each of these topics
are included in the online platform.
While these examples focuses on very
different health problems in cities
of different sizes, populations, and
geographic locations, each story shows
the potential of innovative LHDs to
create an environment where the
healthy option is the default option.
71
4
percentag e po i nt i n cr ease
US IN G
HIGH-TECH
TO O LS ,
CHICAGO
IN C R EAS E D I T S D I S C OV E RY O F CR IT ICAL
H EALTH V I O LAT I O N S I N RE S TAU R ANT S BY
4 P ER C E N TAG E PO I N T S ( F RO M 16% TO
2 0 %) IN JU S T 1 0 M O N T H S .
72
Source: Chicago Department of Public Health
Winnable Battles Case Studies Chicago
D I G I TA L S L E U T H I N G , E N G A G E M E N T T O
B AT T L E F O O D B O R N E I L L N E S S I N C H I C A G O
F O O D BOR NE CHICAGO
In
1876, Chicagos first health
commissioner, Oscar Coleman De
Wolf, made history when he called for
sanitary inspectors to inspect the citys
slaughterhouses and confiscate tainted
meat. Today, the Windy City, like most
jurisdictions, battles foodborne illness
largely through a gaggle of inspectors
randomly checking its 16,000 food
establishments. Sometimes inspectors
get leads from the public some hot,
some not which occasionally can
prevent or halt a foodborne illness
outbreak.
Considering that one in six Americans
experience a food-related illness
each year, this traditional method to
combat foodborne illnesses has room
for improvement. In fact, according to
the CDC, foodborne illness costs the
nation as much as $4 billion annually,
hospitalizing 128,000 people; 3,000 of
whom die from their illness.xxxiii
To reduce these numbers, Chicagos
Department of Public Health has
embraced innovation and turned to 21st
century technologies in an effort to gain
an upper hand on one of public healths
most incessant problems. By turning to
social media, information technology,
Food Safety
and smart computing, the department is

able to more quickly identify foodborne
illness and can better squelch potential
food-poisoning outbreaks. Such tools,
for instance, led to the discovery of
more critical health violations than
traditional means could identify 20
percent vs. 16 percent in the first 10
months alone.
This new approach causes the
department to identify and respond
to potential outbreaks that might
otherwise go unreported. In 2012
Chicago launched a system whereby
residents can call 311 to file a suspected
food-poisoning report, which is then
immediately investigated by the health
departments Food Protection Services
unit.
However, residents may not be aware
that they can file a complaint, much
less how to do so. The CDC estimates
that about 45 percent of foodborne
illnesses go unreported. With the help
of community partners, Chicagos health
department made it easier for those
potentially afflicted with food poisoning
to lodge a complaint with the launch of
a new program in 2013 called, Foodborne
Chicago.
73
Foodborne Chicago would not have been possible had department leadership
not embraced innovation. Luckily, innovative ideas were brimming at the
department in 2011, the department unveiled an open data portal,
publishing food inspection results, and officials were attending Tuesday
Hack Nights that drew the citys brightest minds in technology to improve
civic engagement. That led to a partnership among the department, Code for
America, and the Smart Chicago Collaborative to launch 311. The department
made all its coding on Foodborne Chicago public. Publicly publishing codes
also allows other civic techs, universities, and health departments to apply
[the code] locally, customizing it as they see fit, thus spreading the tech
knowledge and spurring further innovation in the field, notes Raed Mansour,
who serves as the projects lead at Chicagos Department of Public Health.
CHALLENGE
Fo odbor ne illn ess c ost s t he na t i on $ 2 b i l l i o n t o $ 4 b i l l i o n an nu al l y.
S TA N DA R D I N T E R V E N T I O N
Sending health insp ec t o r s t o foo d est abl i shme n t s.
IN N OVAT I O N
Fo odbor ne Ch ic a go, a w eb si t e t ha t i d en t i f i e s an d re s p o n d s t o
re sidents food p oi so ni ng c o m p l a i nt s on Tw it t e r, w as aw ard e d a 2 0 1 5
Top 25 Innovatio ns i n Am er i c a n Gover nm en t by H ar vard U n ive r s i t y s
A SH Cen ter for Dem o c ra t i c Gover na nc e a nd I n n ovat i o n at t h e Ke n n e dy
Sch ool of Gover n m ent .
R E S U LT S
Leading to more complaints that result in critical violations,
capturing additional real-time complaints, and helping residents
better engage with city public health officials.
74
Food Safety
The Foodborne Chicago website

aims to improve food safety in the
city by identifying and responding to
complaints on Twitter about possible
foodborne illnesses. The website tracks
Twitter messages around Chicagoland,
using an algorithm that fixates on local
mentions of food poisoning. Project
staff use Twitter to reply to the food
poisoning tweets, encouraging those
individuals to file a complaint and
providing them a direct link to the 311
complaint page.
There are conversations going on
around us, says Mansour. We could
ignore those conversations, or engage.
Thanks to Foodborne Chicago, we are
getting complaints that we previously
hadnt beenand getting them in real
time and were getting more critical
violations overall, said Mansour.
270 TWEETS
wit h sp e c i f i c c om p l a i n t s of
fo o d b o r ne i l l n e s s
193 OFFICIAL COMPLAINTS
for food poisoning submitted
1 3 3 E S TA B L I S H M E N T S
received health inspections
N E A R LY 9 2 P E R C E N T
o f t h o s e i m m e d i a t e l y t a rge t e d
fo r i n s p e c t i o n re c e ive d a t
least one violation
Food Safety
For example, in the first 10 months

after launching Foodborne Chicago,
project staff identified 270 tweets
with specific complaints of foodborne
illness, leading to 193 complaints of
food poisoning submitted to Foodborne
Chicago. Ten percent of those who
filed complaints sought medical care,
and as a result of their complaints, 133
food establishments received health
inspections. Nearly 92 percent of those
immediately targeted for inspection
received at least one violation. More
importantly - 20 percent - compared to
16 percent of inspections not prompted
by Foodborne Chicago, revealed at least
one critical violation, or an immediate
health hazard. Critical violations are
more likely to result in foodborne illness

and must be fixed immediately or else
the establishment gets shuttered.
But heres the thing: Machine learning
explores the construction and study
of algorithms and learns from data. In
other words, it becomes smarter and
more precise over time with regard to
prediction making. Were working on
a 2.0 version, said Mansour, adding
that officials are looking to use this
technology for other applications,
such as tracking influenza or
other communicable diseases. The
department also is working with Yelp
to integrate Foodborne Chicago into
its ratings platform, and with New York
City, St. Louis, Baltimore, and Boston to
help these jurisdictions launch similar
efforts.
City officials say Foodborne Chicago is
a big win, as it helps to keep residents
healthy; improves the health conditions
of restaurants; leads to collaborations
across the city, with more organizations
tackling foodborne illness; and allows
the public health department to better
engage with residents. We find people
thanking us on Twitter, says Mansour.
75
20%
d ecr ease
TH E N UMB E R O F F O O D B O RN E I LL NE SS
H O S P ITALI Z AT I O N S
ABO UT
20%
WAS
WHEN
RE D U C E D
PU B LI C
BY
H E ALT H
L ETTER G RA D E S W E RE PLAC E D I N LOS

AN G EL ES RE S TAU RA N T S W I N D OWS.
76
Source: Los Angeles Department of Public Health
Winnable Battles Case Studies Los Angeles
L O S A N G E L E S R E S TA U R A N T G R A D E S
L O W E R I L L N E S S , B O O S T AWA R E N E S S
AND CONSUMER ENGAGEMENT
After getting food poisoning from a
Newport Beach restaurant, Southern
California restaurant critic Brad A.
Johnson declared in the Orange County
Register that had Orange County
adopted the same restaurant letter
grading system that nearby Los Angeles
County put in place in 1998, he would
not have gotten sick. Wrote Johnson:
If this restaurant had opened in Los
Angeles instead of Newport Beach, it
would have to display a letter grade of C,
or possibly B, in the front window and
I never would have dined there.
Almost two decades ago, the nations
most populous county, Los Angeles,
instituted an innovative school-like
letter rating system for what today totals
more than 25,000 restaurants. The effort
to publicly grade food establishments
and require restaurants to post
their most recent health department
inspection results in the form of a
letter grade in their front window
has contributed to safer food facilities
in the county, reduced foodborne
illness hospitalizations by about
20 percent, xxvi and, according to
Los Angeles Department of Public
Health officials, improved consumer
information and created a cultural
awareness of food safety. The
Food Safety
department conducts nearly 50,000

restaurant inspections each year.
There isnt anyone in LA County
who doesnt know what an A, B, or C
is, says Terri S. Williams, assistant
director of environmental health at
the LA County Department of Public
Health. Restaurant letter grades
have become part of the culture in
LA County. Patrons regularly check
restaurant letter grades before dining,
and in late 2013 the user-reviewer
website Yelp made that easier when
it incorporated LA County restaurant
letter grades into its reviews. Letter
grades increase the awareness of
food safety everywhere, and thats a
big plus, notes Williams.
LA County initially turned to letter
grades in a further step to reduce
foodborne illness, which each year
sickens roughly 1 in 6 Americans
(or 48 million people), hospitalizes
128,000, and kills 3,000, according
to the CDC. xxxiv About half of the
foodborne
disease
outbreaks
nationally occur at restaurants and
commercial eating establishments.
In the six years prior to LA Countys
letter grade system, foodborne
disease hospitalizations increased in
77
LA County can point to data to show the effectiveness of the restaurant letter
grade system, but public health officials admit they want more robust data.
While LA Countys move to apply Hazard Analysis and Critical Control Point
(HACCP) Principles to risk-based retail and food service inspections should
help, its a reminder of how much we need evidence in public health and
better data, notes Betty Bekemeier, associate professor of psychosocial
and community health at the University of Washington. Thats beginning to
change with public health practice-based research networks (PBRNs) and
other efforts, says Bekemeier, who recently authored a study in the American
Journal of Public Health showing that higher spending on food safety
measures correlates to lower rates of foodborne illness. A goal of the study: to
show policymakers that public health investments yield good returns.
the county, and ran 20 percent higher

than the rest of California. Onethird of Californias restaurants are
located in LA County according to the
California Restaurant Association.
Letter grades have had an impact. A
2005 Journal of Environmental Health
study found that foodborne illness
hospitalizations dropped by nearly 19
percent in the first year letter grades were
implemented. Researchers attribute
more than two-thirds of the decrease
specifically to the grades. The decrease
was sustained in subsequent years.
Stanford University and University of
Maryland researchers also found that
letter grades reduced hospitalizations
by 20 percent, and further found that
while only about 25 percent of LA
County restaurants would have earned
78
an A prior to 1998, more than 50 percent

did in the first year letter grades were
implemented.
For restaurants, the letter grades can
be a badge of honor or a scarlet letter.
With the grades, consumers vote with
their feet. Research shows that shortly
after letter grades started, LAs A-rated
restaurants earned an average of 5.7
percent more revenue than before
1998, while revenue among B-rated
restaurants remained flat, and for
C-rated establishments, dropped 1
percent.
Letter grades have opened a whole
other element in our efforts to make
food safety more effective, says
Williams. In essence, letter grades give
officials another arrow in the quiver
Food Safety
to battle foodborne illness. LA County

continues to build on its letter grade
success. In the past few years, the
County aligned its inspections with the
state inspection report, which provides
several benefits, mainly uniformity,
not only for regulators but for industry
entities with operations up and down
At least six other BCHC jurisdictions

have established and implemented
a restaurant letter grading system,
including: Atlanta (Fulton County)xxvii,
Chicagoxxviii, New Yorkxxix, Phoenix
(Maricopa County)xxx, San Franciscoxxxi,
and San Jose (Santa Clara County)xxii.
California.
FOODBORNE
SICKENS
ILLNESS
R O U G H LY
IN
AMERICANS
48
MILLION
(OR
PEOPLE),
Going forward, the health department

wants to work with industry to get ahead
of potential problems by supporting
chain restaurants in employee training,
working with corporate offices to identify
outliers among their restaurants, or
helping food establishments improve
certain food-preparation practices.
H O S P I TA L I Z E S 1 2 8 , 0 0 0
A N D K I L L S 3 , 0 0 0 E AC H
YEAR.
Food Safety
79
57,000
h iv tests
TH E
TOTA L
NUMBER
OF
TESTS
T HAT
H AV E BEEN A D M I N I S T E RE D A S A R E SU LT
O F H O US TO N I N I T I AT I V E S S I N C E 2 007.
80
Source: Houston Health Department
Winnable Battles Case Studies Houston
H O U S T O N H I T S W I T H YO U T H
AND HIV, STD TESTING
The Houston Health Department truly
understands that if you want to affect
behavior you must reach out to those
whose behavior you want to change, not
wait for them to come to you. Otherwise,
you may never reach them. Thats the
motivation behind Houston Hits Home,
a public health initiative targeting some
of the highest-risk groups for HIV, the
human immunodeficiency virus, which
can lead to acquired immunodeficiency
syndrome, or AIDS. One of these
vulnerable groups is youth of color, and
its Houstons goal to get members of
this demographic tested so they know
their status.
How do you do that? Put on hip-hop
concerts and invite the citys youth to
sporting events, where the only price
of admission is getting tested for HIV
and other sexually transmitted diseases
(STDs). Listen to some basic education
about the diseases, and enjoy yourself.
2X
HIGHER
WHICH
THE
R AT E
AT
H O U S TO N I A N S
AG E D 2 0 TO 2 4 C O N T R AC T
H I V, C O M PA R E D TO T H O S E
IN THEIR 30S AND 40S.
HIV
The innovative approach seems to be

working. Since 2007, 57,000 HIV tests
have been administered at the annual
events, with most of those concertgoers
also getting screened for gonorrhea,
chlamydia, Hepatitis C and other STDs.
Age-appropriate immunizations are
also provided. Each concertgoer receives
about one hour of education on HIV
and other STDs and information on

seeking care should they need to do so
while their tests are processed onsite.
Thirty percent of concertgoers report
its the first time theyve been tested.
HIV is getting to be a younger
epidemic, says Marlene McNeese, chief
of the departments Bureau of HIV/
STD and Viral Hepatitis Prevention.
In Houston, rates of HIV among those
aged 20 to 24 are about double that of
Houstonians in their 30s and 40s, while
rates for those in their late 20s run
about 1.5 times higher than their older
peers. Further, nearly 80 percent of the
transmission risk for males is among
men who have sex with men, and the
epidemic is largely concentrated among
those with low incomes.
Moreover, the epidemic has become
one that disproportionately impacts
communities of color. There are 1
million Americans living with AIDS,
and nearly half are black, says McNeese.
In Houston, 60 percent of new HIV
cases annually are concentrated among
blacks. Meanwhile, 1 in 5 people living
with HIV in the metro area dont know
they have it. Of the nearly 23,000
Houstonians diagnosed with HIV, 73
percent are receiving medical care.
81
One of our initial goals, or aims,

was to destigmatize HIV in these
communities, says McNeese. Several
years of events seem to have made an
impact. In recent years, each annual
event has attracted about 15,000
people. We have young people who
look forward to this each year, she
adds. Several cities have since rolled
out similar events, including Chicago,
Dallas, New York (the Bronx), Oakland,
and Philadelphia.
Houstons event got its start in 2007
with a local radio station initially
developing the Hip Hop for HIV
intervention, offering a free concert
to attract black youth in exchange for
a free screening test. The event drew
7,500 people, but organizers quickly
realized they needed more capability,
says McNeese. They didnt know how
to provide care. After the department
got involved, it took the lessons
learned from the first summer concert
and applied them to the second years
event. We needed the ability to offer
more types of testing and we needed
more staff, says McNeese.
In 2008 the department applied those
lessons and added a 60minute HIV/
STD education class, while staff
processed test results. The event was
also smaller so that the department
and its multiple sponsors (see
following page) could successfully
apply the first years lessons. When
participants register, they consent to
testing and get a confidential code,
and volunteer staff from state and
local health departments, hospitals,
phlebotomy schools, and elsewhere
collect and process specimens. Skilled

youth facilitators conduct an hourlong education class while tests are
processed. On site treatment also is
available.
Of the 57,000 tests, administered since
2007, one in 193 people have tested
positive for HIV, one in 48 have tested
positive for gonorrhea, while one in
nine have tested positive for chlamydia.
Pre- and post-assessments have
found significant positive changes in
knowledge level and beliefs about the
diseases. We havent reached the point
of saturation to see a decline in new
incidence, says McNeese, [but] Im
hoping were at a tipping point.
New challenges have arisen recently,
its become harder to draw artists to do
free stand-alone shows, and there has
been a rise in HIV rates in Houstons
Latino community. Weve had to be
more creative, notes McNeese. In 2014,
the citys health department rebranded
the effort, calling it Houston Hits Home
in recognition of a new partner, the
Houston Astros baseball team, and
the departments attempt to reach
a broader population, especially the
Latino community. Baseball is pretty
incentivizing, McNeese says.
On July 26, 2014, thousands of Houstons
youth were provided free admission to
the ballpark to see the Astros play the
Miami Marlins. The game was followed
immediately by a Jason Derulo concert.
We had a pretty good success, says
McNeese, who is busy planning the next
event.
60%
annual pe rce nta ge of new
HI V cas e s in Ho uston that
are
co nce ntrate d
among
black s
1 IN 5
numbe r
of
pe o ple
living
w ith HI V in the m etro area

do n t k now they have it
73%
pe rce nta ge o f
23,000
dia g no s e d
th e nearly
Ho ustonians
w ith
HIV
are re ce iv ing me dical care

Source: Houston Health Department
82
who
HOUSTON
USES
PARTNERSHIPS,
EMERGENCY
RESPONSE
MODEL TO INCREASE HIV TESTING , AWARENESS

Houston Hits Home, the Houston Health Department-led effort to increase
the testing for and knowledge of HIV and other STDs, is rooted in a vibrant
collaboration of partners. The health department, the Houston Astros, KRBE104.1, Planned Parenthood Gulf Coast, Memorial Hermann, and Harris
County Public Health & Environmental Services are just a few of the entities
that have rallied to implement a personalized HIV/STD prevention and
intervention strategy and to standardize service delivery. Its only because
of our partners that we are able to reach the numbers of people we do each
year, says Marlene McNeese, chief of the departments Bureau of HIV/
STD and Viral Hepatitis Prevention. The partnership approach grew out of
the departments efforts at teaming up with public schools and other entities
during the emergency preparedness efforts in the face of Hurricanes Ike and
Katrina a decade ago. We took that experience in developing our Houston
Hits Home model, says McNeese.
HIV
83
359
n ew h iv d iag n oses
TH E N UMB E R O F H I V D I AG N O S E S IN SAN
F R AN C IS C O I N 2 0 1 3 , W H I C H I S FE W E R
TH AN
H A LF
OF
THOSE
RE C O RDE D
2002.
84
Source: San Francisco Department of Public Health
IN
Winnable Battles Case Studies San Francisco
SA N FRA N CISCO D ETER M I N ED TO G ET

TO ZERO WHEN IT COMES TO HIV
San Francisco is on a mission to be the
first city in the nation to reduce HIV
infection and HIV/AIDS deaths to zero.
Yes, zero. To achieve that lofty goal, the
San Francisco Department of Public
Health and a broad-based coalition of
more than 35 organizations launched
the San Francisco Getting to Zero
Consortium in 2014. The consortium
set a short-term goal of reducing HIV
infections and HIV/AIDS deaths by 90
percent by 2020.
65%
OF
ALL
HIV
PATIENTS
IN
FRANCISCO
ACHIEVED
VIRAL
INFECTED
SAN
HAVE
UNDETECTABLE
LOADS
WITH
ANTIRETROVIRAL THERAPY.
From the very beginning of the HIV

epidemic, San Francisco has been a
leader in its response and in setting
standards for prevention, care, and
treatment. The city has a strong HIV
surveillance system, plentiful testing
services, syringe access programs,
comprehensive care in the public and
private sectors, and robust linkages
between community organizations and
scientists. To see where San Francisco is
headed, its valuable to understand how
far the city has come in combatting the
epidemic.
We would not be where we are
without the leadership of the
department of health, says Jeff Sheehy,
communications director of the AIDS
Research Institute at the University of

California, San Francisco (UCSF). The
San Francisco Department of Public
Health is the only health department
with its own clinical trials unit, Bridge
HIV, which has been working since the
start of the epidemic to find innovative
ways to fight HIV/AIDS. In 2011 the
department refocused HIV prevention
on increasing testing resulting in
more than doubling the number of HIV
tests performed annually. About five
years ago, the widely respected, health
department-run San Francisco General
Hospital (SFGH) was the nations first
to recommend treatment for all persons
living with HIV, and the department
was the first in the nation to make the
recommendation citywide, a policy that
has since been adopted nationally.
Such efforts have helped to reduce the
number of new HIV diagnoses in the city;
for example, in 2013 there were 359 new
diagnoses, fewer than half the number
in 2002. HIV death rates have dropped
by nearly half. The percentage of those
with HIV who dont know they have it
has plunged by two thirdsfrom 18
percent to 6 percent. Nine of 10 patients
are linked to medical care within 90
days of their diagnosis, while about 65
Source: San Francisco Department of

Public Health
HIV
85
An FDA-approved medication that reduces the risk of HIV by more than 90

percent is a new tool San Franciscos Department of Public Health is using
to help get the citys HIV infections and HIV deaths to zero. Taken once
daily, a new pre-exposure prophylaxis (PrEP), Truvada, does not come
without controversy. Some suggest Truvada can diminish the public health
message of protected sex and could potentially lead to an increase in sexually
transmitted diseases. We think the community has embraced PrEP and we
have demonstrated evidence of its effectiveness, says Susan Buchbinder,
director of the departments Bridge HIV, Population Health Division. The city
is expanding its PrEP studies and access to the medication. In doing so, it
is training primary care providers to offer PrEP to at-risk patients, creating
systems to link at-risk persons to prevention services, helping patients obtain
PrEP cost coverage, providing information about PrEP, and monitoring the
its impact.
percent of all HIV-infected residents

have achieved undetectable viral loads
with antiretroviral therapy, according
to the health department. Patients who
have undetectable virus levels are 96
percent less likely to transmit HIV to
their uninfected partners.
represents a renewed effort to battle

HIV/AIDS in the city. This really is a
collective effort; there is no one entity
in charge or owning it, says Buchbinder,
adding
that a steering committee
representing multiple institutions helps
guide the work.
Still, to achieve the UNAIDS vision of

Zero new HIV infections, Zero HIV
deaths and Zero HIV Stigma, more
needed to be done. That message came
during a citywide gathering on World
AIDS Day 2013, where a variety of
stakeholders said even more could be
done if efforts were better integrated
with community partners. The city
listened. The community has changed
this epidemic from the start, says
Susan Buchbinder, director of the
departments Bridge HIV, Population
Health Division, and Getting to Zero
Stigma still is a really important

issue, says Buchbinder. Nationally, HIV
diagnoses are increasing among those
aged 25 to 29, and the highest rate of new
infections is among African Americans
and Latinos. Its an important reason
why people dont get tested, why they
dont get or stay in treatment, says
Buchbinder, adding, its difficult to get
the care you need when care is lower
on your list of priorities than getting
housing or food.
THE
P E R C E N TAG E
OF
SAN FRANCISCANS WITH

H I V W H O D I D N T K N OW
THEY HAD THE DISEASE
P LU N G E D F RO M 1 8 % I N
2 0 0 2 TO 6 % I N 2 0 1 3 A
DECREASE OF
T WO - T H I R D S .
Source: San Francisco

Department of Public Health
86
HIV
NINE
OUT
OF
10
H I V- I N F E C T E D
SAN
FRANCISCANS
ARE
LINKED
TO
MEDICAL
C A R E W I T H I N 9 0 DAY S O F
THEIR DIAGNOSIS.
Source: San Francisco Department of
Public Health
In order to get to zero, the effort has

taken on three elements. Focusing just
on prevention or just on treatment will
never be enough, notes Buchbinder.
The three-pronged Getting to Zero
effort aims to reduce the number of new
HIV infections, cut HIV transmission,
and preserve health via early treatment
and care retention. The initiative
includes:
Preexposure prophylaxis (PrEP) has

been shown to reduce the risk of
HIV infection by more than 90
percent among individuals who are
considered high risk. The use of antiHIV medications by HIV-negative
individuals to prevent infection is
a fairly new, promising prevention
method, and the department is
expanding its ongoing studies of
and access to a medication called
Truvada, which is U.S. Food and
Drug Administration approved and
recommended by the CDC.
PREP
RAP ID
E XPANSION:
R E T E NT ION IN HIV CA RE:
Consistent, reliable medical care

is critical in Getting to Zero.
People with lower incomes,
individuals with mental health
or substance abuse, and other
vulnerable populations face more
acute challenges in receiving
consistent care. The consortium
is convening HIV providers,
service organizations, community
advocates, and government to
identify gaps and coordinate new
outreach and retention strategies
to keep people in HIV care.
With one of the highest prevalence
levels, San Francisco is dramatically
reducing community viral load, and
thus incidence, says Jeff Levi, executive
director of the Trust for Americas
Health, a non partisan public health
nonprofit. The city has fully embraced
PrEP. They are the model for making
HIV a winnable battle.
ART: Early diagnosis
and treatment of HIV prevents

further transmission during the
highest-risk period: when a newly
infected person is most contagious
but unaware of their infection. So
the Getting to Zero Consortium is
expanding the SFGH/UCSF-based
Rapid ART Program Initiative
for HIV Diagnosis, which aims to
facilitate the start of antiretroviral
therapy (ART) and counseling the
same day someone is diagnosed
with HIV, as well as help transition
clients to sustainable long-term
HIV care.
HIV
87
6.3%
d ecr ease
TH E
P E RC E N T
P H IL AD ELPH I A
R ATES
RE D U C T I O N
C H I LD H O O D
BE T W E E N
THE
IN
O BE SIT Y
2006/07
AND
2 0 1 2 / 1 3 SC H O O L Y E A RS .
88
Source: Th e Phi l a d el p hi a D ep a r t m ent of P u bl i c H e al t h
Winnable Battles Case Studies Philadelphia
I N N O VAT I V E E F F O R T S H AV E
PHILADELPHIA SEEING BIG DROPS IN
O B E S I T Y A M O N G YO U T H S O F C O L O R
2 4 % D RO P
i n Philadelphia ki d s i nt a ke
of soda betw een t he 2 0 0 6 / 0 7
an d 2012/13 scho o l yea r s .
1 8 . 8 % D RO P
i n obesity rates a m ong Asi a n
boys in Ph iladel p hi a b et w een
the
2006/07
a nd
2012/13
school yea r s .
1 1 . 3 % D RO P
i n obesity rates i n Afr i c a nA merican boys i n t he sa m e
perio d .
0 % D RO P
i n obesity rates by Afr i c a nA merican an d As i a n- Am er i c a n
boys in America a s a whol e a t
th e same t i m e.
The Philadelphia Department of Public

Healths persistent, multi-pronged
population health approach to get
residents of one of Americas poorest
big cities to live healthier is getting
some eye-catching results, particularly
among the citys youth. A 24 percent
drop in kids intake of soda, along with
healthier eating and increased physical
activity, has helped drive a 6.3 percent
reduction in childhood obesity rates.
What really sets Philadelphia apart from
other cities: the larger reductions in
obesity among kids of color, which have
been tougher for other jurisdictions to
achieve. The City of Brotherly Love (and
Sisterly Affection), for example, saw the
largest drops among Asian and African
American boys 18.8 percent and 11.3
percent, respectively between the
2006/07 and 2012/13 school years. This
is even more compelling when compared
with national numbers, where there
was no change in obesity prevalence
between 2007 and 2012 (according to
the NHANES).
The achievements have come as part of the
health department-led Get Healthy Philly
initiative, an innovative and collaborative
public health approach that brings together
government agencies, community-based
organizations, academic institutions

and the private sector to lower obesity
and smoking rates in the Philadelphia
area. (Smoking rates have dropped 18%
among adults and 30% among youth
since 2007).
With the 2010 Get Healthy Philly
launch, officials wanted to revitalize
environments to make it easier to
engage in healthy habits. The poorest of
Americas 10 largest cities, Philadelphia
for too long provided many residents
with an overabundance of unhealthy
choices: children could buy almost
350 calories of candy, chips or soda for
about one dollar at more than 1,500
corner stores in the city; city schools
had minimal physical education
requirements; and safe recreation
places were a rarity. As a result, some
1,600 Philadelphians died each year
as a result of poor diet and physical
inactivity, with obesity adding $750
million annually to health care costs in
the city.
Key activities that primed the pump for
Get Healthy Philly included a universal
feeding initiative in the 1990s that
provided greater access to free and
low-cost school meals to students in
schools with high levels of poverty;
Source: The Philadelphia Department of

Public Health and NHANES
Obesity, Physical Activity & Nutrition
89
THE BENEFITS OF COLLABORATION

The Food Trust works across the nation to ensure that everyone has access
to affordable, nutritious food and information to make healthy decisions.
But Philly is special, notes Food Trust Executive Director Yael Lehmann.
There are some special things happening there, especially around food and
food access. Of the 100+ organizations working with Get Healthy Philly,
The Food Trust is a particularly special partner. It has led efforts to get more
than one-third of the citys corner stores to offer healthier food options, even
offering cooking demonstrations in neighborhood bodegas; worked to bring
18 supermarkets and grocers to the citys food deserts; and helped to make
Philadelphia a vibrant city for farmers markets. There are very smart and
innovative people in Philadelphias Department of Public Health.
a large-scale, school-based nutrition

education program begun in 1999; and
a comprehensive school wellness policy
in 2006 that removed soda from vending
machines and set nutrition standards
for all foods served in cafeterias. These
were supplemented by city-wide policy
changes, such as the 2007 trans-fat ban
and 2008 menu labeling law. These were
important successes, but we needed to
do more, ssays Giridhar Mallya, MD,
MSHP, the departments former director
of policy and planning. We wanted to
give Philadelphians the opportunity to
be healthy where they live, learn, work,
and play.
Through Get Healthy Philly, city health
officials fostered health-promoting
environments for all city residents. By
building on earlier achievements, the

initiative has:
SE E N
NU T R IT IONAL -
RE LAT E D SU CCE SSE S: 13 new
farmers markets opened in lowincome communities, which helped

increase an innovative SNAP (food
stamp) redemption at farmers
markets by 335 percent; 650 corner
stores today sell healthy items such
as produce, water, and low-fat dairy;
200 Chinese take-out restaurants
are reducing the sodium content of
popular dishes by 20 to 30 percent;
and school officials removed junk
food from classrooms and school
stores.
13
NEW FARMERS MARKETS
OPENED IN PHILADELPHIAS
LOW-INCOME COMMUNITIES,
WHICH
SNAP
HELPED
INCREASE
(FOOD
STAMP)
REDEMPTION AT FARMERS
MARKETS BY 335 PERCENT.
Source: The Philadelphia Department of
Public Health antiretroviral therapy.
90
ADOP T E D
P HYSICAL
AC T IVIT Y INFR AST RU CT U R E

AND
P OL ICIE S: 9.7 miles of
conventional bicycle lanes, 6.7

miles of new buffered bike lanes,
2.0 miles of green bicycle lanes
and 8.9 miles of sharrows (shared
bicycle lanes) installed; and
Wellness Councils in 171 public
schools serving 100,000 students
have incorporated physical activity
into the school day.
L E D TO P OL ICY CHANGE :
healthy living and health impact

assessments are integrated into
Philadelphia 2035, the citys new
comprehensive plan, and into five
district plans; Mayoral executive
order
establishing
nutrition
standards for all 22 million meals
and snacks purchased and served by
city agencies passed; and
LAU NCHE D M ASS M E DIA
campaigns
have
been implemented to focus on
reducing sugary drink and sodium
consumption.
E F FORT S:
To make Get Healthy Philly truly

effective, we needed to have
interventions in several settings, says
Mallya. This required partnerships
across government and with the private
sector. The effort works on many levels,
including a big emphasis on media and
public awareness, policy changes from
healthy vending standards to removing
barriers in the operations of the citys
robust farmers markets, and youth-
based initiatives that include offering

free, healthy meals in summer and
after-school programs. Public health
officials also work with retailers and
manufacturers to improve healthy
eating options: collaborate with city
planners to make walking-and bikingfriendly improvements, and work
with employers, insurers and health
care providers on ways to control
hypertension and diabetes.
The results are awesome, notes
Yael Lehmann, executive director of
The Food Trust, one of the many Get
Healthy Philly partners. The success lies
in the efforts focus to remove as many
barriers as possible, while looking at the
larger context.
While Philadelphia public health
officials have made substantial progress,
Mallya knows there is a long way to
go to make healthy lifestyles the easy
option for residents. While the city has
seen drops in youth obesity rates overall
and among some racial/ethnic minority
groups, reductions among girls have
been more limited, particularly among
Hispanic girls. Already, city officials are
partnering with key organizations to
develop initiatives and gather insight on
how better to reach these groups.
91
5.5
po i nt d ecr ease
O BES ITY
RAT E S
AMONG
S O U THE R N
N EVADA ADU LT S H AV E D E C RE A S E D FROM

3 1 .3 % IN 2 0 0 8 TO 2 5 . 8 % I N 2 0 1 2
92
Source: Southern Nevada Health District
Winnable Battles Case Studies Southern Nevada Health Department
G E T T I N G P H YS I C A L LY A C T I V E A N D
CUTTI N G CA LO R I ES V I A M O B I LE A PPS,
S O C I A L M E D I A A N D T E C H N O L O GY
3600
D OW N LOA D S
OF
SOUTHERN
THE
N E VA DA
H E A LT H D I S T R I C T S N E O N
TO
N AT U R E
A L LOW S
AND
A P P,
USERS
TO
C U S TO M I Z E
AC RO S S
1,000
WHICH
FIND
RO U T E S
MILES
OF
WALKING , HIKING , BIKING

AND EQUESTRIAN TRAILS.
Source: Southern Nevada Health District.
The Southern Nevada Health District

(SNHD), which serves 2.1 million
residents of Clark County and more than
40 million visitors annually to Las Vegas,
has added new, innovative strategies
to the Office of Chronic Disease
Prevention and Health Promotions
Get Healthy Clark County campaign
in the form of mobile applications. The
apps one focused on finding walking,
biking, and other trails throughout
southern Nevada; and another that lets
the public calculate the amount of sugar
in soda, juices, and energy drinks are
among the most recent free, consumerfriendly tools that many public health
departments are employing to make
their campaigns not only more effective,
and but also increasingly resonate with
the public.
SNHD is fortunate to have an
innovative Information Technology
Services program that collaborates
across SNHD to create these popular
apps, says Cassius Lockett, director of
community health for the district. This
mutual relationship launched the Neon
to Nature app in late 2014, which allows
users to find and customize routes
from more than 1,000 miles of walking,
hiking, biking, and equestrian trails in
Southern Nevada. The app supports
department efforts to reduce the

prevalence of obesity and to get more
residents of Las Vegas and several other
area communities to become more
active. Department efforts in recent
years have helped to reduce the rate of
obesity among adults from 31.3 percent
in 2008 to 25.8 percent in 2012. Officials
expect the app to help their efforts.
The Neon to Nature app has been
well received by the community, says
Lockett. The app has been downloaded
nearly 3,600 times. I love this app,
notes resident Laura Fucci in a user
review. It takes me quickly to trails
close to me so I can plan a walk or ride.
Very convenient.
The department also released its Sugar
Savvy app in 2014 to support and expand
its annual summer campaign, called
Soda Free Summer, to get school-age
children and their families to reduce
their intake of sugar. The Soda Free
Summer campaign and other efforts
have helped to reduce sugary drink
intake among Clark County adolescents
from 23.3 percent in 2007 to 15 percent
in 2013. Officials believe the new app,
which has been downloaded nearly 200
times already, will help further reduce
sugar intake among residents. In early
93
2015, the department also released an

app that allows Nevadans to see the
letter grades resulting from health
department inspections of 14,500
restaurants. Within six months, more
than 3,000 people have downloaded the
app.
In the next five years, most companies,
including public health organizations,
will have to invest moderately in
information technology, says Lockett.
The use of mobile technology and open
data portals is driving public innovation
and encouraging essential collaboration
with public partner agencies and the
private sector to develop mobile apps
to promote and protect public health.
While public health agencies have
developed many free mobile apps,
increasingly theyll have to be prepared
to improve apps and measure their
scientific effectiveness. Continuous
improvement
and
application
evaluation of technologies therefore
must be indispensable components
of all future public health mobile app
development.
To be sure, public health departments
nationwide are introducing apps as
the CDC has recognized their value, and
now offers several to consumers and
health care clinicians as complements
to brochures, television ads and other
traditional public outreach efforts.
According to the Pew Research Center,
nearly two-thirds of Americans owned
a smartphone as of late 2014. Further,
more than 60 percent of smartphone
users have looked for health-related
The use of mobile technology and open data portals is driving public
innovation and encouraging essential collaboration with public partner
agencies and the private sector to develop mobile apps to promote
and protect public health.
Cassius Lockett, Ph.D.,

Director of Community Health at Southern Nevada Health District
information on their smartphones

more than for any other reason.xxxv
Apps not only allow public health
officials to get messages and helpful
information to the community and
subpopulations, but mobile technology
can track analytics about how the apps
are being used and provide insight for
developers to enhance the experience
for users. In the future, the technology
may also provide metrics for public
health officials to use for planning
and evaluation activities. And the
department continues to look at
expanding its stable of apps. Currently
in development at SNHD are the Walk
Around Nevada and Nutrition Challenge
program app, and we are in the early
stages of exploring resources to produce
or adopt an existing salt intake app in
the future, says Lockett. Clark County
has seen hypertension prevalence jump
in the last decade, from less than a
quarter of area adults in 2003 to nearly
one third in 2013.
N E VA DA S
S O DA
SUMMER
HAS
C A M PA I G N
HELPED
S U G A RY
AMONG
FREE
DRINK
CLARK
ADOLESCENTS
REDUCE
I N TA K E
COUNTY
F RO M
23.3 PERCENT IN 2007

TO 1 5 P E R C E N T I N 2 0 1 3 .
Source: Southern Nevada Health District
94
L A S V E G A S ( C L A R K C O U N T Y ) I S N T T H E O N LY B I G C I T Y H E A LT H
D E PA RT M E N T D E V E LO P I N G A P P S . OT H E R S I N C LU D E :

Ne w Yo rk C it ys De p a rt me nt o f He a lt h a nd Me nt a l Hyg i ene
N Y C He a lt h sma rt p ho ne a p p s a re co nne ct ing re side nt s t o ser vi ces

a n d info rma t io n fro m t he ir mo b ile de vice s a t no cost, f r om
A B C Ea t s, w hich give s Ne w Yo rke rs a nd visit o rs inst a nt access to
h ea lt h insp e ct io n gra de s o f cit y re st a ura nt s; t o C a lC ut ter , whi ch
e s ti ma t e s t he numb e r o f ca lo rie s fo r sub mit t e d fo o d reci pes; to
N Y C C o ndo m, w hich finds fre e co ndo m dist rib ut io n lo ca ti ons; and
T ee ns in NYC , w hich discre e t ly links yo ung p e o p le w ith near by
s exua l he a lt h se rvice s.

S a n Fra ncisco a nd L o s Ange le s a re a mo ng se ve ra l ci ti es that
h ave t e a me d up w it h Ye lp , t he w e b -b a se d p la t fo rm t ha t connects
peo p le w it h lo ca l b usine sse s, t o p o st cit y he a lt h of f i ci al s
re s t a ura nt insp e ct io ns re p o rt s a nd le t t e r gra de s. The p ar tner shi p
to g e t re st a ura nt gra de s int o t he ha nds o f co nsume rs i s among
th e la t e st e ffo rt s t o re duce incide nt s o f fo o db o rne illness, whi ch
s i c ke ns mo re t ha n a n e st ima t e d 48 millio n p e o p le a ye a r, accor di ng
to C DC e st ima t e s. xxxv
tu rn e d
to
so cia l
Me a nw hile , C hica go he a lt h o ffici al s have
me dia ,
info rma t io n
t e chno lo gy,
a nd
smar t
c omp ut ing t o q uickly ide nt ify fo o db o rne illne ss a nd t o squ el ch

potent ia l fo o d-p o iso ning o ut b re a ks t hro ugh Fo o db o rne Chi cag o,
a we b sit e a llo w ing re side nt s t o re p o rt ca se s o f fo o d poi soni ng .
Ci ty o fficia ls mo nit o r so cia l me dia t o invit e t ho se w ho di scu ss
i s s ue s o f fo o d p o iso ning t o lo dge a co mp la int o n t he websi te.

S a nt a C la ra C o unt y (S a n J o se a nd it s imme dia t e surrou ndi ng s)
V ect o r C o nt ro l Dist rict s S C C VEC TOR mo b ile a p p le t s r esi dents

re po rt p ro b le ms a nd ge t he lp de a ling w it h p o ssib le di seasec ausing ve ct o rs fro m mo sq uit o e s, ra t s, fle a s, mit e s, w ildl i f e, and
o th er a nima ls.
95
50%
i n cr ease
TH E IN C IDE N C E O F T Y PE 2 D I A BE T E S
H AS D O UB LE D TO N E A RLY 1 2 PE RCE NT
IN R ECEN T Y E A RS I N F U LTO N C O U NT Y,
G EO R G IA.
96
Source: Fulton County Department of Health & Wellness
Winnable Battles Case Studies Atlanta (Fulton County)
A C O L L E C T I V E I M PA C T G A I N S T R A C T I O N
I N AT L A N TA ( F U LT O N C O U N T Y )
Seeing the incidence of Type 2 diabetes
double to nearly 12 percent in recent
years,xxxvi Fulton County, Georgia health
officials are targeting elementary
school-aged children to stem the
tide. They are hoping to reach 20,000
students in the Atlanta area within the
first year of a focused effort officials say
is essential to turning off the faucet on
a fast-expanding epidemic.
Unless we turn the tap off, we cant
reduce the prevalence, says Nazeera
Dawood, deputy chief of staff for
operations, at the Department of
Health and Wellness. The focus is
unique. We didnt see anyone focused
on the prevention of the future cases
of diabetes among youth specifically,
she says, although there are other,
more general efforts underway to
address obesity and diabetes. Diabetes
prevention is sometimes included in
broader anti-obesity campaigns or
similar efforts, but the health risks of
diabetes are often overshadowed. Fulton
County officials wanted to zero in on
changing habits among the youngest
of school-aged children to best impact
prevalence.
What makes Fulton Countys approach
unique is that the effort is a non-
budgeted model that pulls disparate

community players together for a
common purpose, with public health
officials facilitating rather than leading
the effort. To be sure, an effort that prides
itself on lacking a hierarchical structure
and that relies on bringing together
committed-yet-busy stakeholders
ultimately requesting them to pony up
resources has a high risk for failure.
Fulton County is far from achieving
tangible results, but stakeholders are
planning a pilot for late 2015.
But dont bet against Fulton County
or Dawood, who has started six similar
coalitions focused on managing
asthma, diabetes, heart health, and
other health challenges. The asthma
coalition, for example, connected the
health departments preventive services
with the clinical services at a major
metropolitan community hospital to
reduce asthma emergency room visits by
90 percent and school absenteeism by 92
percent, according to Dawood.
The seeds were planted and now they
need to be watered to produce fruit, or
long-term outcomes, says Dawood of
the six very functional coalitions. The
approach Fulton County health officials
are taking tapping and organizing
97
local partners and resources, often doing

so with no or very limited budgets, and
being comfortable giving up the reins
is one other public health departments
would like to emulate.
A lot of us in the community touch
diabetes in some way, and whats
tragic is we dont talk to one another,
says Lucienne Ide, CEO of Rimidi, an
Atlanta company developing chronic
illness management solutions. Thats
before Dawood pulled together Rimidi
and a dozen other key team members,
including Emory Universitys business
school, Georgia Public Broadcasting,
and an urban and community design
firm. We wont move the needle
dramatically if we dont work together,
says Ide.
In starting the coalitions, Dawood uses
the Collective Impact Model, which
focuses on getting the commitment of
a group of stakeholders from different
sectors to a common agenda for solving
a specific social problem, and doing so by
using a structured form of collaboration.
I already knew the power for collective
impact, says Karl Smith, program
manager at the Georgia Campaign
for Adolescent Power & Potential,
a nonprofit working to improve the
overall health and well-being of young
people by focusing on teen pregnancy
prevention, physical activity and
nutrition, and healthy relationships. I
was onboard on day one.
In order for the team to meet its mission
to reduce the prevalence of Type 2
diabetes among Fulton County children

through education, policies, systems,
and environmental changes, assessors
from the Rollins School of Public Health
at Emory University recommended
that efforts be focused on improving
connections with schools and afterschool providers to, among other things:
Develop hands-on and interactive
lessons and activities, and use
technology when available;
Promote a curriculum infusion
approach to health education;
Involve parents via PTAs,
providing children with take-home
material to engage families, and
have parents run school gardens
and bring in fresh fruit to school
regularly; and
Ban food as a reward in schools
and make school lunches more
nutritious and appealing.
Under Dawoods initial guidance,
different stakeholders are onboard
that can advance the strategies and
goals toward achieving the teams
mission. For example, Emorys Goizueta
Business School is developing the
measures to track kids eating habits,
soda consumption, and other healthrelated behaviors to guide the efforts
success, while Rimidi is developing
technology, such as gamification and
social media, to engage young students
in the diabetes prevention effort.
Smiths organization can contribute
90%
DECREASE IN ER VISITS
A s thma co alitio ns in Fulton
Co unty,
as thma
v is its
by
GA
have
reduced
e me rge n cy
90
pe rcent
room
and
s cho o l abs e nte e ism by 92

pe rce nt.
Source: Fulton County Department of
Health & Wellness
98
The biggest lesson here is county government and non-profits and

for profits can work together for a common goal and as a result,
good things can get done.
Karl Smith, program manager

at the Georgia Campaign for Adolescent Power and Potential
programming around healthy eating, cooking demonstrations, and physical activity

programs that it already sponsors for a range of community-based organizations in
the county.
This is not a government intervention, its a team intervention, says Dawood, who
also has told each partnering organization to put up seed money to support the
coalitions ongoing efforts. Everything is there. Every ingredient is in a different
room, and you want to create a tasty dish so youve got to bring it together.
There are a lot of people in the community across sectors who really care
about the community in the same way public health officials do, says Ide, adding
that Dawood knows how to bring the parties together, leverage commitments and
resources, and then set an environment where the public health officials step back
and let stakeholders collaboratively run efforts to achieve improvements. Nazeera
is a force because shes decided to do the right things despite all the bureaucracy in
the way, and she saw a gap in how diabetes is being addressed in the community and
wanted to fix that.
99
"
About 80 percent of New
York City smokers started
before the age of 21.
"
KE V IN S C H ROT H , S E N I O R LE G A L C O U NSE L
IN TH E D EPARTM E N T S BU RE AU O F C H RONIC
D ISE AS E P R EV EN T I O N A N D TO BAC C O C O NT ROL .
100
Winnable Battles Case Studies New York City
P R EV EN T I N G T H E H A B I T A N C H O RS T H E
BIG APPLE'S TOBACCO 21 AND MINIMUM
P R I C E L AW S
Seeing youth smoking rates stall at 8.2
percent in 2013 after slashing them by
half in the early 2000s, New York City
took big steps in 2013 to regain the
upper hand in fighting tobacco use. The
Big Apple boosted the minimum sales
age for tobacco products from 18 to 21
the first big city to do so and raised the
minimum sales price on cigarettes and
little cigars to $10.50 a pack throughout
the five boroughs.
MORE THAN 100,000

YO U N G
A D U LT S
( AG E S 1 8 - 2 4 ) I N N E W
YO R K
CITY
A LO N G
WITH
ADDITIONAL
PUBLIC
SMOKE,
HIGH
AN
21,000
SCHOOL
STUDENTS.
The Tobacco 21 minimum age law

along with another law that sets
minimum pricing and prohibits
discounts, rebates and other pricing
workaroundstook effect in August
2014. More than 100,000 young adults
(ages 18-24) in New York City smoke,
along with an additional 21,000 public
high school students, according to the
citys Department of Health and Mental
Hygiene.
About 80 percent of New York City
smokers started before the age of 21, says
Kevin Schroth, senior legal counsel in the
departments Bureau of Chronic Disease
Prevention and Tobacco Control. The idea
was to help delay and prevent initiation,
notes Schroth, adding that the transition
from experimental to regular smoking
frequently occurs around age 20.
In the spring of 2015, department

officials said it was too soon to see
any impact of the changes, but data
from elsewhere provides reassurance.
A 21-minimum-age effort in Needham,
Massachusetts, for example, cut youth
smoking rates more than 50 percent
between 2006 and 2012.
The Institute of Medicine projected
in its March 2015 report, Public Health
Implications of Raising the Minimum
Age of Legal Access to Tobacco Products,
that if the rest of the nation followed
New York Citys lead and raised the
minimum legal age to 21, there would be
a 12 percent decrease in the number of
smokers by the time todays teenagers
are adults. In other words, there
would be approximately 223,000 fewer
premature deaths, 50,000 fewer deaths
from lung cancer, and 4.2 million fewer
years of life lost for those born between
2000 and 2019, the IOM estimated. xiv
The Tobacco 21 law prohibits retailers
from selling cigarettes, cigars, chewing
tobacco, powdered tobacco, other
tobacco products, and electronic
cigarettes to customers under age 21.
At the same time, the city approved a
sensible tobacco enforcement law,
says Schroth. Along with establishing
Source: New York City Department of

Health & Mental Hygiene
Tobacco
101
a price floor on cigarettes and small

cigars, the law includes provisions to
deter unintended consequences of
having high prices, such as the practice
of shifting to use tobacco products that
are less expensive than cigarettes or
dual-use cigarettes and other tobacco
products. The law also:
Sets a flat minimum price of
$10.50 on packs of cigarettes and
requires changes in packaging of
little cigars (which have to be sold
in packs of at least 20 and for at
least $10.50 per pack) and cigars
(which have to be sold in a pack of
four, among other changes);
Prohibits city retailers from
redeeming manufacturers coupons,
multi-pack deals,
buy-one-getone bargains or any other pricereduction promotions, as well as
giving away or discounting lighters
and other tobacco-related swag;
Clamps down on cigarette tax
evasion in several ways, including
by increasing the monetary amount
of individual penalties and by
decreasing the number of penalties
that can result in the suspension
or revocation of a license to sell
cigarettes; and
Requires the clear posting of an
age-restriction sign and a tax stamp
sign by retailers.
Schroth says that while nearly half the

states have minimum-price laws for
tobacco, they were designed to prevent
unfair competitionnot to promote
public health. As a result, those laws
involve complex pricing and mark-up
schemes, making them less effective
than New York Citys flat and easy
law. Another benefit of the price floor:
Scroth says it alerts people to the black
market, which can lower the price of
cigarettes for youthundermining the
deterrent of higher pricesand robs the
city of tax revenue to the tune of more
than $500 million annually.
If
the re s t o f
fo llow e d
N ew
the nation
York
C itys
le ad and rais e d the minimum

le g al s mo k ing a ge to 21, by
the time to day s teena gers
The department continues to use the

tobacco control playbook which
highlights the use of high taxes,
legal authority and actions, cessation
programs, education, and evaluation
introduced by then Mayor Michael
Bloomberg and Thomas Friedan, the
citys former health commissioner and
current director of the U.S. Centers
for Disease Control and Prevention.
Tobacco control had a real strong
evidence base, notes Elizabeth Kilgore,
the bureaus communications director.
Starting in 2002, she continues,
we had a very supportive Michael
Bloomberg, who was a game changer
in tobacco control. Along with vibrant
collaborations with community partners
and flexibility given to the department,
the citys innovative approach to
tobacco lives on.
are adults, the re would be:
A 12 PERCENT
DECREASE IN SMOKERS
223,000 FEWER
P R E M AT U R E D E AT H S
5 0 , 0 0 0 F E W E R D E AT H S
F R O M LU N G C A N C E R
4.2 MILLION FEWER YEARS

O F L I F E LO S T F O R T H O S E
BORN BETWEEN 2000 AND
2019
Source: The Institute of Medicine
102
Tobacco
M A S S M E D I A W I E L D S M I G H T I N TO BAC C O C O N T R O L
New York City residents and visitors may be familiar with Ronaldo Martinez,
aka the man with the hole in his throat, from the powerful anti-smoking public
service announcements run on television by the citys Department of Health
and Mental Hygiene. Produced in Massachusetts, the ads ran in the mid2000s, building what became the departments decade-long mass media
campaign to show the impact of smoking. Ads show Martinez, who had his
larynx removed and talks via an artificial voice box, cleaning the hole in his
throat, showering, and showing the effects of his smoking. We had never
seen our call volume to 311, our general information line, for quit smoking
assistance go up like we did then, says Elizabeth Kilgore, the Bureau of
Chronic Disease Prevention and Tobacco Control communications director.
Since 2006 the department has rolled out four or five different media
campaigns a year. We have a lot of ads that range from the graphic to the
emotionally provocative, she says. The mass media effort became a staple
at the department when evidence emerged from Australia and Massachusetts
in the mid-2000s on the efficacy of campaigns that aggressively show the
health effects of smoking.
In the spring of 2015, Santa Clara County raised the legal age to purchase tobacco
products from 18 to 21 years old, though this law only applies to unincorporated
areas of the county, not the cities, such as San Jose. xxxvii As of August 2015, more than
90 cities and one state (Hawaii) have passed Tobacco 21 laws.
Tobacco
103
In the wake of the Great

Recession,
Washington
State's tobacco cessation
dollars were slashed
from $29 million a year
in 2008 to less than $1
million in 2014.
104
Source: Public Health Seattle & King County
Winnable Battles Case Studies Seattle
E A R LY E - C I G A R E T T E B A N R E I G N I T E D
S E AT T L E - K I N G C O U N T Y ' S E F F O R T T O
SNUFF OUT TOBACCO SMOKING
ONLY
10%
SMOKED
IN
OF
ADULTS
THE
COUNTY,
ONE OF THE LOWEST RATES

IN THE NATION.
1 IN FIVE BLACK ADULTS

LIT UP A RATE DOUBLE
THAT OF WHITES.
LOW-INCOME
HOUSEHOLDS
WERE THREE TIMES MORE

LIKELY
TO
SMOKE
THAN
In 2010, when electronic cigarettes were

little more than novelties, King County,
home to Seattle,, restricted their sale
and use, along with nicotine electronic
juices and other unapproved nicotine
delivery devices. In doing so, Seattle
became the first big-city to: (1) prohibit
the sale of e-smoking devices to those
under 18; and (2) ban the devices in
restaurants and other public places and
workplaces, mirroring tobacco smoking
restrictions already in place.
The ban aims to protect youth from
nicotine addiction and preserves county
public spaces as smoke -free zones. Use
of e-cigarettes is slightly lower among
middle and high school students in
King County versus the rest of the state.
Just as important, the e-cigarette ban
represented something even bigger for
Seattle public health officials: it jumpstarted a moribund effort to reduce
tobacco use in the county.
HIGH-INCOME ADULTS.
1 IN 4 HIGH SCHOOL SENIORS

WERE USING CIGARETTES OR
OTHER TOBACCO PRODUCTS.
Source: Public Health - Seattle & King
County
Tobacco
After seeing smoking rates get cut in

half over the decade ending in 2007,
officials at the Seattle & King County
public health department watched
smoking rates flatten for several years.
State tobacco funding shriveled from
about $29 million a year in 2008 to
less than $1 million in 2014. Turning
to grants to help fill the void, officials

feared they may be rejected, as smoking
rates in King County were among the
lowest in the nation only 10 percent
of adults smoked.
A closer examination of the data
revealed that King County had the
most extreme smoking disparities of
the 15 largest metropolitan counties
in the country, says Scott Neal,
tobacco prevention program manager
at the county health department. The
smoking rate for black adults in the
county more than one in five smoked
was double that of whites, while
King County adults in low-income
households were three times more
likely to smoke than were high-income
adults. Nearly 20 percent of lesbian, gay,
bisexual, or transgender adults were
smokers. And by 2010 smoking among
local youth became common, with one
in four 12th graders using cigarettes or
other tobacco products.
While the e-cigarette ban potentially
could have a spillover effect on tobacco
rates, local health officials won several
grants in a strategy to address smoking
among vulnerable populations. Grants
from the Centers for Disease Control
and Preventions (CDC) Communities
105
Putting Prevention to Work, a national

initiative to prevent chronic disease and
promote health through policy, systems,
and environment changes, allowed
county health officials to collaborate
with others to snuff out smoking. As a
result, health officials have:
Seen
all
local
housing
authorities and many low income
housing
providers
implement
smoke-free
policies,
creating
nearly 14,000 smoke-free units.
Now officials are looking to expand
smoke-free policies to market-rate
housing complexes. Any exposure
to second hand smoke is bad, says
Neal, adding that most high-end
apartment operators already ban
smoking. But for any smoke-free
policy to work, Neal says, tobacco
users need access to cessation
programs. To that end, officials are
working with local health plans to
standardize cessation benefits.

Made
inroads
integrating
tobacco treatment in publicly
funded mental health and substance
abuse
agencies.
Forty-seven
provider agencies, representing
more than 100 publicly funded
treatment sites in King County, have
implemented tobacco screening
and treatment policies. Nearly all
provider agencies have tobacco-free
campus policies. People who have
a mental health and/or substance

abuse disorder use tobacco up to
four times more than the general
population, so making inroads
among provider agencies is crucial.
Taken other steps to target
smoking among youth and
young adults, including leading
the effort to get the county and
13 area cities to adopt tobaccofree parks policies. Health
officials also are working with
the many college, university,
and technical campuses in King
County to adopt tobacco-related
policies. Currently, about half
have some policy in place. As 95
percent of smokers start before
age 25, and as the tobacco
industry targets this age group,
Neal says that de-normalizing
smoking on campus is essential
in preventing future tobaccorelated death and disease.
While health officials continue to
target the root of some of the countys
smoking-related disparities, Neal says
its also time to step up efforts on
e-cigarettes, as their overall use has
jumped both locally and nationally. For
example, the CDC reports e-cigarette
use tripled among youth between 2013
and 2014.xxxviii As of spring 2015, the
Obama administration had not finalized
e-cigarette restrictions.xxxix, xl
LO C A L AU T H O R I T I E S A N D
LO W I N C O M E H O U S I N G
P R O V I D E R S C R E AT E D
N E A R LY
14,000
smoke-free
housi ng uni t s.
Source: Public Health- Seattle & KIng
County
106
Tobacco
Seattle-area businesses were concerned in 2010 when suddenly

people particularly youth seemingly lit up both inside and outside
stores, snubbing a well-respected ban on public and workplace
smoking. We got a lot of complaints, recalls Scott Neal, tobacco
prevention program manager at Public Health - Seattle & King County.
As it turned out, e-cigarettes were becoming a trend. For example,
e-cigarette use now eclipses tobacco use by youth, according to the
CDC.xlix But e-cigarettes did not fall under public smoking bans, and
Seattle businesses wanted local health officials to take the lead. We
knew e-cigarettes were addictive because of their nicotine, says Neal.
Will they transition young users to tobacco? We dont know, but thats
a concern, he notes. Between e-cigarettes nicotine content and that,
kids were being able to buy these things pretty easily, Neal says.
Department officials worked with the King County Board of Health
on the ban on electronic smoking devices and unapproved nicotine
delivery products, which the Board unanimously passed in 2010.
E-CIGARETTE
TRIPLED
AMONG
USE
YOUTH
BETWEEN 2013 AND 2014,

AND
E-CIGARETTE
USE
NOW ECLIPSES KIDS USE

OF TRADITIONAL TOBACCO
Because of the dramatic increases in

e-cigarette use among youth, the health
department is looking into potential
strategies that will reduce youth access
and use of these addictive products.
Now that recreational marijuana is legal
in Washington, the health department
also is considering how this impacts the
use of tobacco and e-cigarettes. Many
e-cigarettes can now be refilled with
liquid marijuana so its difficult to tell
exactly what people may be vaping in
their e-cigarettes and that adds a layer
of complexity to the situation, says
Neal.
Several other BCHC jurisdictions have

also passed laws to regulate e-cigarettes,
including: Boston,xli Chicago, xlii Los
Angeles, xliii Minneapolis, xliv New York,
xlv
Philadelphia, xlvi Sacramento, xlvii and
San Francisco. xlviii
PRODUCTS.
Source: U.S. Centers for Disease Control
and Prevention
Tobacco
107
"
Having
supportive
leadership is essential
and has been key to our
success... Overall, our big
picture is that violence
is a preventable outcome.
"
S ASH A CO H EN , YO U T H V I O LE N C E PRE V E NT ION
COOR D INATO R AT T H E M I N N E A PO LI S H E ALT H
DE PA RT M E N T.
108
Winnable Battles Case Studies Boston, Kansas City and Minneapolis
THREE CITIES' APPROACHES TO

V I O L E N C E A S A P U B L I C H E A LT H I S S U E
Violence, particularly among youth, is

an epidemic in American cities. Youth
violence is the leading cause of injury
and death for people aged 10-24 years
oldl and in many of the countrys largest
jurisdictions, homicides and violent
crime rose significantly in the first
half of 2015. Meanwhile, the Attorney
Generals National Task Force on
Children Exposed to Violence reports
that 46 million of the nations 76 million
children - roughly 60 percent - are
exposed each year to violence, crime,
and abuse.li The result: the nation pays
a high price in lives, money, and in lost
potential.
Those who experience repeated
exposure to violence can begin to process
Violence
those experiences as something that is

part of normal social life.lii Consistent
exposure to violence at home or in the
community can become desensitizing
to individuals. Violence makes it hard to
feel safe, leading to anxiety, depression,
less physical activity in communities,
and social isolation.
Many cities look to law enforcementdriven policies to stem violence, but
in recent years more and more cities
have taken a public health approach
to violence. Boston, Kansas City, and
Minneapolis are among those showing
that when violence and its root causes
is addressed as a contagious disease,
significant progress can be made in
reducing and preventing it.
109
T r a u m a a w a r e n es s h el p s Bo st o n re du ce t h e
c o mm u n i t y i mp a c t o f v io le n ce
In Boston, where violence is the leading
cause of death among black and Latino
children, and nearly 50 percent of
high school students report knowing
someone who has been shot or killed,
the Boston Public Health Commission
(BPHC) has been working hand in hand
with the police department and other
city agencies to address and prevent
youth violence. Its Division of Violence
Prevention has invested in strategies
that prevent violence through skill
development for children and youth,
training and capacity building among
providers, effective service delivery
to individuals who have experienced
violence, and resident leadership.
In 2012 BPHC received a grant from
the Department of Justices Defending
Childhood Initiative, to take a traumainformed
approach
to
violence
prevention. The extra resources helped
the city develop and test practical,
sustainable strategies for implementing
trauma-informed practices in six
early care and education centers. The
trauma-informed practices, policies and
environments were deemed a success by
evaluators. Using grant funds, officials
developed tools to make it easier to teach
and learn about trauma, and initiated a
3-day training institute that has reached
110
thousands of health care providers,

teachers, parents, and others. Similarly,
BPHC programming also includes a
network of eight community health
centers with specially trained staff who
lead activities in the neighborhoods
with the highest rates of violence. Staff
provide trauma response and recovery
services to affected residents and lead
prevention-oriented events through
the health center. The focus: provide
specialized support to residents and
give them the skills and resources they
need to recover from a violent incident.
BPHC has undertaken a number of
other activities to help stem the tide of
violence and address those impacted by
events, including:
Building out services for survivors
of violence to ensure that they get
needed support to recover from
such an event.
This includes
partnering with Boston Medical
Center, the citys primary Level 1
trauma center, to implement a case
management program for survivors
of shootings and stabbings and
their family members.
Violence
Boston is beginning to see evidence that this multisector approach to

violence prevention is having an effect. Rates for nonfatal assault-related
gunshots/stabbing emergency department visits have fallen since 2008,
and, importantly, rates for black and Latino residents also decreased from
2008-2012. And, from 2011 through the end of 2014 homicide rates have
decreased by 16%, and overall violent crime has decreased by 9%.
Working with the Boston Police Department to identify and provide services
for the 300 young men identified as being at high risk of being a victim or
perpetrator of gun violence. This initiative Partners Advancing Communities
Together (PACT) is a multidisciplinary, comprehensive service delivery
strategy targeted at high-risk youth. Partners work together to connect youth
to long-term, meaningful relationships with trusted adults and to education
and employment services. A 2014 evaluation found that a dollar invested in
Bostons PACT program could be expected to gain a savings of nearly $7.40 in
crime-related cost savings.
Violence
111
Mi n n e a p o li s : T a k i n g o n y o ut h vio l e n ce
From 2002 to 2011, homicide was
the leading cause of death among
Minneapolis residents, aged 15 to 24,
accounting for 39 percent of deaths in
this age group.liii Nationally, homicide
was the third-leading cause of death for
this age group during that time. liv
In 2008 Minneapolis implemented
a multi-faceted, multi-sector plan,
called Blueprint for Action: Preventing
Youth Violence. The Blueprint takes
a population-based, public health
approach to violence, treating it as an
epidemic, like tuberculosis or polio.
The public health approach promotes
strategies that reduce the factors that
put people at risk of experiencing
violence and that increase the factors
that protect or buffer people from risk.
Multiple efforts involving nearly 80
Minneapolis agencies and organizations
have achieved impressive results:
In 2013 and 2014 combined,
two children under age 18 were
homicide victims in Minneapolis,
whereas a total of nine died by
homicide in 2006;lv
From 2006 to 2012, violent
crime among youth (under 18) in
the city fell 57 percent, incidents
with guns among youth dropped 67
percent, youth homicides decreased

60 percent and youth gun-related
assault injuries decreased 62
percent. lvi
For youth age 24 and under,
homicides dropped almost by half,
from 25 in 2006 to 13 in 2013. lvii
Overall, our big picture is that
violence is a preventable outcome,
says Sasha Cohen, youth violence
prevention
coordinator
at
the
Minneapolis Health Department. The
Blueprints collaborative approach
brings local government, schools,
juvenile corrections, nonprofits, and
philanthropy organizations together
to identify problems, design solutions,
set goals, and measure results. Thats
the strength of our program: we bring
partners together. We cant police
ourselves out of a youth violence
problem, says Cohen.
Every other Monday, a core group of
the Blueprint partners meets to gather
intelligence and ensure that the city
and involved partners are working
toward common goals of reducing
youth violence. Tweaks are made
when needed. The initiative boasts
an array of innovative efforts to tamp
down violence, including the Juvenile
Supervision Center (JSC).
FROM
2006
TO
2012,
VIOLENT CRIME AMONG

MINNEAPOLIS
YO U T H
F E L L 5 7 P E R C E N T.
Source: Minneapolis Health Department
112
Violence
U P DAT E D I N 2 0 1 3 , M I N N E A P O L I S
B LU E P R I N T S E T S F O RT H F I V E G OA L S :
1) Fo st e r vio le nce -fre e so cia l e nviro nme nt s
2) Pro mo t e p o sit ive o p p o rt unit ie s a nd co nne ct io ns to tr u sted
a dult s fo r a ll yo ut h
3) Int e rve ne w it h yo ut h a nd fa milie s a t t he first sign of r i sk
4) Re st o re yo ut h w ho ha ve go ne do w n t he w ro ng p a th
5) Pro t e ct childre n a nd yo ut h fro m vio le nce in t he commu ni ty
The JSC provides supervision and

referral services to youths aged 1017 picked up by police officers in
Hennepin County for truancy, curfew
and minor offenses that do not warrant
admission to the Hennepin County
Juvenile Detention Center. Open around
the clock, the JSC attempts to assess
and address juvenile delinquency risk
factors, while reconnecting kids with
their families. The JSC provides a range
of servicesfrom assisting with parental
involvement,
providing
enriching
activities and information on rights
and responsibilities, and connecting
kids and families to resources, case
management services, housing and
mental health counseling.
wrong track get put back on the straight

and narrow. In 2014, the JSC had visits
from nearly 1,400 young people. Of
those, nearly 500 participated in case
management aftercare services. Among
those receiving case management
services, 83 percent decreased highrisk behavior, 88 percent did not reenter the JSC within six months of case
closure, and 86 percent increased school
attendance by at least 5 percent, says
Peterson.
Weve seen great success with this

program, says Josh Peterson, youth
intervention coordinator at the health
department, adding that 80 percent of
young people who show up dont come
back within the year. Thats the point:
Youth potentially heading down the
Violence
113
Kan s as C i t y : I t s a bo u t i n t er p e r so n al re lat io n ship s

Kansas City officials began addressing
violence as a contagious disease
a decade ago. Thats when a cityappointed commission issued a report
recommending that violence be treated
as a public health issue, not from a
traditional policing approach, in order
to reduce the citys consistently high
annual homicide rates.
Homicides, aggravated assaults, and
firearm assaults, were happening
at an epidemic level, says Tracie
McClendon-Cole,
justice
program
manager and director of the Aim4Peace
Violence Prevention Program at the
Kansas City Health Department.
Aim4Peace operates in the citys
neighborhoods with the highest rates
of killings and shootings. Rather than
believing violence is inevitable, Kansas
City officials today see violence as an
unacceptable learned behavior resulting
from preventable and controllable
factors, including family instability,
poverty, domestic abuse, educational
failure, and substance abuse.
Accordingly, officials have put in place
a series of strategies to cure violence,
especially retaliatory violence. Treating
violence as an epidemic has gotten eyecatching results in the city. For example,
Aim4Peace has seen a 70 percent
reduction in the number of homicides

between 2010 and 2014.lviii
Violence is definitely a public health
issue, notes McClendon-Cole, adding
that the sections of the city with the
highest violence rates also had some
of the highest health disparities and
inequities. We began to see some
patterns emerging, she says. For
example, retaliations and arguments
were the main reasons for homicides
and these were driven by firearms,
particularly handguns.
Public health officials know how to
stop
epidemics,
McClendon-Cole
notes. Putting in place a public healthfocused program that interrupted the
transmission of violence, prevented
it from spreading, and changed group
norms was essential. City officials
looked at the evidence and considered
50 different anti violence programs
worldwide. One stood out: a Chicagobased effort that today is called Cure
Violence, for both its potential to be
replicable and its focus on cultivating
interpersonal relationships.
Kansas City created Aim4Peace, which
looks at violence as a learned behavior
and sets out to rewire some of those
learned behaviors by those who are most
KANSAS
CITYS
AIM4PEACE
VIOLENCE
PREVENTION
PROGRAM
HAS SEEN A 70-PERCENT

REDUCTION
NUMBER
OF
IN
THE
HOMICIDES
BETWEEN 2010 AND 2014.
Source: Kansas City Health Department
114
Violence
prone to retaliate after a violent act.

We engage people in the community
who are at the highest risk of the
disease spreading, says Rashid Junaid,
the departments violence prevention
manager. We try to interrupt that
process.
In the citys East Patrol section, they
use a proactive team of first responders
who work to change the language,
expectations, and responses to violence
with those closest to the victims of a
violent act in order to prevent retaliatory
violence. Supported by a partnership
involving
schools, police, faithbased organizations, hospitals, and
neighborhood and civic associations,
the effort works to identify high-risk
individuals (loved ones of those who
have been the victim of violent crime,
for example), interrupt the spread of
retaliatory violence, change behaviors
of victims and offenders, and reshape
community norms around violent
behavior.
are notified as soon someone arrives with

an intentional penetrating injury (i.e.,
a gun or knife wound) in order to work
with victims and loved ones to mediate
conflict and change expectations
around retaliation. Aim4Peace is heavy
on conflict resolution and mediation
and does so via neighborhood outreach
teams as well as the hospital prevention
program.
Kansas Citys violence prevention
program has broad support and is funded
in part by a voter-approved health
levy. A 2013 Office of Juvenile Justice and
Delinquency Prevention grant is enabling
the city to expand the program beyond
the target area. In addition to reducing
homicides by 75 percent in the target
zone, the citywide homicide rate fell 28
percent between 2010 and 2014.lix
To do so, the city sends credible

messengers, respected individuals
from the community, who can help
calm
individuals
after
violence
erupts and broker peace in high-risk
neighborhoods. The city has 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
Centers trauma team. Program workers
Violence
115
RECOMMENDATIONS
116
Recommendations
I t i s o f t e n said, wh at g e t s m e asu re d, g e t s d one. But

i n t o o m an y are as o f t he co u n t ry, e ve n wi t h r ecent
a d va n ce s i n i n f o rm at io n t e ch n o l o g y an d data sour ci ng
a n d g at h e ri n g , t h e h e alt h o f a l o cal co m m un i t y ca nnot
be a c cu rat e l y m e asu re d. Basi c he al t h i n di cat o r d a ta is
o f t en n o t avail abl e at t he ci t y l e ve l .
Of the more than 30 health indicators
requested for this publication, only
two health departments were able to
provide all of them in a way that was
comparable enough to be included in
the data set. Further, five departments
were able to provide only countylevel data, even though their city has
separate political/jurisdictional lines,
while others reported a mix of city and
county data.
This is not the fault of any one health
department. America has a fragmented
governmental public health system in
which activities are funded mostly for
categorical programs (i.e. cancer or
diabetes) but few dollars are available
for infrastructure or technology. Thus,
data systems often do not keep up with
the times. Despite an approximately $30
billion federal investment in various
health care sector entities to incentivize
electronic health records and build data
capacity, that tide has not risen all boats.lx
In addition, by and large, governmental
public health departments have seen
Recommendations
no federal investment in associated

infrastructure to allow for data sharing
to better monitor the overall health of
the community and pinpoint emerging
health threats.
Collecting sufficient foundation data,
such as the information found in the
Behavioral Risk Factor Surveillance
System (BRFSS) and the Youth
Risk Behavior Surveillance System
(YRBSS) is a foundational capability
for governmental public health.lxi The
ability to access, analyze, and use data
from a variety of identified key health
data sources is also essential. If, for
various reasons, an LHD cannot collect
these data in a meaningful way, officials
need to ensure another entity is doing
so, with appropriate data access points
for the LHD and the community.
117
Recommendations
INCREASE
LOCAL
HEALTH
DEPARTMENT CAPACITY REGARDING

HEALTH INFORMATION T E C H N O LO G Y
(HE ALTH I T) THRO UG H TA RG ETED
DOLLARS AI MED AT BUIL D IN G IT
IN FRASTRUCTURE.
LHDS
N EED
TO N OT ONLY HAV E A S EAT AT

T HE TABLE BUT A L S O IN F LUEN C E
OT HE RS I N THEI R WO RK TO BUIL D
HEALTHI ER COMMUNITIES TH RO UGH
BE T T ER
DATA
CO L L EC TIO N
AND
USAG E.
NACCHO (the home of the Big Cities

Health Coalition) has consistently
pushed to ensure that LHDs
are
involved as health IT systems are
built. The importance of additional,
and then sustained, funding for public
health information infrastructure and
workforce development is the only way to
ensure that governmental public health
agencies have sufficient technology and
workforce capacity to fully participate
in local, regional, state, and federal
health IT efforts. Non-categorical
funding, i.e. money that could support
infrastructure rather than programspecific activities, will allow LHDs
to improve their data collection and
analysis capacity. Having this capacity
also includes a trained workforce to
advance informatics practice across
public health programs. lxii
118
Considerable time and resources

have been spent on building health IT
systems that focus heavily on individual
health records and conditions, but are
fairly meaningless to the health of a
community at large. LHDs must play a
key role to ensure that moving forward,
the systems that are built provide
information about the health of the
entire community. This populationwide lens is what LHDs bring to the
health IT movement.
While accessing data from electronic
health records is not a silver bullet
for overcoming public health data
challenges, these data are often more
current and are based on patient
encounters
rather
than
survey
responses. While each of those data
collection methods serve their purpose,
having more than one source of data,
particularly recent ones, will allow for
more targeted decision making. Some
cities are able to capture data from their
health and hospital systems already,
but more work needs to be done across
the board by all partners to identify
opportunities for data sharing. This
means LHDs must take a leadership
role in bridging the gap between, and
combining, various sources of data.
I N CR E A S E DATA AVA I L AB I L I TY F OR A
S E T O F K E Y H E A LT H I ND I CATOR S SO
T H AT A NA LYS I S CA N B E ACHI EVED
AT A N U M B E R O F L E VEL S - F ROM
CI T I E S
TO
CR E AT E
STREET
AND
CO N S E N S U S
COR NER S.
D I SSEMI NATE
D E F I N ITI ONS
F OR
CE RTA I N H E A LT H DATA WHER E THEY

DO
N OT
THOSE
TO
BE
ACRO S S
E X I S T,
T H AT
S TARTI NG
ARE
M OR E
DEFINED
LO CA L
WI TH
L I K ELY
D I F F ER ENTLY
J U RI SD I CTI ONS.
It cannot be said enough that effective

public health practice depends on
having reliable and current information
regarding the health of the community.
Data is critical to partnerships with
community based organizations, clinical
providers, and other government
agencies. Without it, the impact of
policy change cannot be measured or
targeted to the populations most in
need.
Most national reports on health status,
however, make comparisons at the
state level, and sometimes the county
level. Federal and local leaders have
expressed a continuing need for more
comprehensive data and comparative
perspective on the most pressing health
issues facing the nations urban areas.
Many of these jurisdictions struggle
Recommendations
Recommendations
with significant health disparities but

often lack the information needed to
help the public, policymakers, and even
health officials tackle key winnable
health battles. For highly diverse, urban
populations in particular, understanding
the root causes of inequities is essential
to improving the health of the overall
population and having the requisite
data to do so should not also be a
challenge.
need. This is neither timely nor a sure

way to get data into the hands of local
authorities who need it to best protect
the public.
R E CO G N I Z E
I N N OVATO R S
CI T I E S
AND
AS
L EAD ER S
THE
THEY
A R E A N D U S E T H E M TO BUI L D
M O R E RO BU S T A N D MEANI NGF UL
LO CA L P U B L I C H E A LT H SYSTEMS.
Further, particularly regarding emerging

public health problems, data that are
collected across cities vary and often
cannot be appropriately compared.
As mentioned in this report, the fact
that opioid-related mortality is often
defined differently across cities makes
comparing jurisdictions to each other
difficult. Consensus definitions and
data processing methodologies that
are disseminated and practical would
address this problem.
Finally, additional work needs to be done
to ensure that there is a set of baseline
indicators that every large urban health
department is able to collect. This task
requires having sufficient resources to
do so. LHDs would like to know more
about vaccination, obesity, and physical
activity rates, to name just a few
examples of indicators that often fall
by the wayside because of competing
priorities. Sometimes, data are also
collected or held by a state agency,
and LHDs need to request what they
Recommendations
While governmental public health as a

whole is under-resourced, large, urban
health departments often have more
flexibility and are better resourced in
terms of both dollars and staff. lxiii They
often have engaged, more pragmatic
leadership, a willingness to be nimble,
and an appetite for innovation.lxiv That
said, the 26 health departments included
in this report still struggled to collect
timely, accurate, and relevant data for
a number of health indicators. These
LHDs have the know-how to do this
but they need help. They need to be
recognized as the powerful innovators
they are, and they need more capacity
to do their good work. Indeed, if these
LHDs cant collect timely, appropriate
data, the rest of the field cannot either.
119
CONCLUSION
120
Conclusion
A s mo re p e o pl e i n t h e Un i t e d Stat e s are livi ng i n

met r op o li tan are as, l arg e , u rban he alt h de pa r t ment s
a r e play i n g i n cre asi n g ly im p o rtan t ro l e s i n p r ot ect i ng
a n d p ro m o t i n g t he p ubl i cs h e alt h.
The BCHC LHDs work day in and day
out to create and implement innovative,
effective programming to address the
health needs of their residents. They are
also active in addressing the policy and
systems changes needed to improve the
health of their communities. Too often,
however, they are limited by insufficient
funding, bureaucracy, and workforce
development challenges.
Over the past decade, large city
governments have increasingly become
incubators of policy innovation and
strong executive leadership.lxv In the
field of public health, local leadership
is critical, particularly during a time of
divided government at the federal level
and a lack of national consensus around
funding and policy priorities. Cities are
better positioned to respond quickly to
emerging threats than the often slowmoving federal bureaucracy and are able
to take strong stances on governance
and local issues when partisan gridlock
stalls federal efforts. Mayors across
the country have taken risky stands
on health issues from tobacco control
Conclusion
to childhood obesity to addressing the

opioids epidemic. And it is their efforts
that often become models for their peers
and are scaled up to the federal level.lxvi
Data such as those presented in this
publication and online are meant to
help cities target their scarce resources
(people and dollars) to achieve the most
impact among those most in need.
In a time of vulnerable public health
budgets, LHDs must seek out publicprivate partnerships and retrain the
workforce to be nimble and responsive
when mining Big Data for answers.
The BCHC will continue to build on this
work and support large, urban LHDs
in their efforts to develop, collect, and
analyze timely and important health
data.
121
APPENDIX
TECH N I CA L N OTES
122
Appendix
S O U R C E S O F D ATA
T h i s re po rt p re s e n t s app ro x im at e ly 34 hea lt h
i n d i ct o rs (n u m be rs vary de pe n di n g o n availa bili t y of
d a t a i n ce rtai n jurisdi ct io n s) f o r re side n t s i n t he t op
30 mo st urban are as i n t he co un t ry, acco rdi ng t o t he
U . S . Ce n su s Bu re au , lxvi i t hat al so po ss e ss a popula t ion
g r ea t e r t han 350,000.
There are six additional measures
that look at poverty, unemployment,
education
attainment,
household
income, and country of birth. The
indicators encompass nine broad
categories of public health importance:
HIV/AIDs; Cancer; Infectious Disease;
Maternal and Child Health; Tobacco;
Obesity, Physical Activity, and Nutrition;
Injury and Violence; Food Safety;
and Behavioral Health and Substance
Abuse. This is in addition to the socio
demographic characteristics described
above. These were chosen based on
their relationship to the leading causes
of morbidity and mortality in the United
States and their inclusion in the Healthy
People 2020 goals, or Winnable Battles
work. Data for 2012, 2013, and 2014
were requested from each jurisdiction,
recognizing that data years will vary.
For the most part, jurisdictions reported
their three most recent years of data.
Data prior to 2010 were not included,
even if it meant a jurisdiction would
Sources of Data
have only two years of data available for

inclusion.
All-cause mortality rates and life
expectancy estimates were requested
from the 26 jurisdictions that
participated. Where data are not
available, there are blanks. A few life
expectancy numbers were provided by
Virginia Commonwealth Universitys
Center on Society and Health (www.
societyhealth.vcu.edu/maps)
where
not otherwise available. Remaining
indicators are further described below
in the appropriate category.
The nature of the data that are in this
publication varies considerably. When
data were not provided or available,
the appropriate cell was left blank.
Not all health departments were able
to provide data for all indicators and,
in cases where dominators were too
small, certain rates for subpopulations
are not displayed. Whenever possible,
123
Appendix
unusual numbers were verified, either

by checking with the original sources or
through other means.
Some health departments were only
able to provide data at the county level
either because data are only collected
at the county level and/or because the
city accounts for most of the county
population.xlvi
Additionally, some
cities do not correspond to jurisdictions
of the local health department in which
the central city is located.
HI V/A IDS
HIV/AIDS data include HIV Diagnoses
Rate and AIDS Diagnoses Rate in a given
year, as well as a Persons Living with
HIV/AIDS Rate (which includes those
who have both HIV and AIDS). Each of
these indicators report the crude rate
per 100,000 population, using 2010 U.S.
Census figure (except where noted).
The HIV-Related Mortality Rate is also
reported per 100,000 people, using 2010
U.S. Census figures, age-adjusted to the
year 2000 standard population. In most
cases, these data are identified using
ICD-10 codes B20-B24.
CAN CE R
Mortality rates for all, lung, and female
breast cancers are reported per 100,000
people, using 2010 U.S. Census figures,
age-adjusted to the year 2000 standard
population (except where noted).
ICD-10 codes for all cancer include:
C00-C07; for lung cancer: C33-C34; and
for female breast cancer: C50.
124
I N F EC T IO US DISE ASE
Infectious disease indicators include
flu vaccination for children and adults,
pneumonia vaccination for those
age 65 and older, pneumonia and
influenza mortality rates, and incidence
(cases diagnosed in a given year) of
tuberculosis (TB). Percent vaccinated
for adults over age 18 means one dose
of annual flu vaccination in a given
year. Similarly, percent vaccinated for
children under 18 years of age means
a child received at least one dose in
a calendar year. Note that these data
were difficult to obtain and sources
vary. Where possible, Behavioral Risk
Factor Surveillance System (BRFSS)
data are reported for adults. Sources
for childhood immunization data
vary. Data on the percent over age 65
vaccinated for pneumonia were secured
wherever possible, and data that were
generally not comparable were left out.
Pneumonia and Influenza Mortality
Rate is reported per 100,000 people,
using 2010 U.S. Census figures, age
adjusted to the year 2000 standard
population (except where noted). TB
Incidence is reported as a crude rate per
100,000 people, using 2010 U.S. Census
figures (except where noted).
M A T E RN AL AN D CHILD H E ALTH
Maternal and child health indicators
include infant mortality rate, low
birthweight, and percent of mothers
under age 20. Infant mortality rate is
the mortality rate per 1,000 live births.
Percent low birthweight is defined as the
percentage of babies born under 2,500

grams. Percentage of mothers under age
20 reflects the birth mothers age.
TO BACCO
Data on cigarette use among both adults
(over 18 years of age) and youth (for the
most part, high school students) are
hard to obtain at the city level. The most
frequently used sources of data are the
BRFSS, the Youth Risk Behavioral Survey
(YRBS), or the Youth Risk Behavioral
Surveillance System (YRBSS). Many
cities/counties oversample to be able to
have accurate data for the jurisdictions,
but some do not. Sample sizes vary,
as do years of data available. Youth
tobacco numbers were included only if
they were secured via YRBS or YRBSS
or a comparable survey, both in terms
of population (high school students)
and question text. Readers should take
note of both source and year of data
availability when using the tobaccorelated data in this publication.
N UTRIT IO N , PHYSI CA L
ACT I V IT Y, AN D O BESIT Y
Comparable obesity and physical
activity data are difficult to find at
the city level. Where possible, the
adult obesity figure in this report is
the percentage of the population 18
years or over that is considered obese,
generally with a body mass index (BMI)
of 30 or above, and in most cases is
taken from BRFSS. Similarly, obesity
rates for children are difficult to collect,
Sources of Data
Appendix
though many jurisdictions know the

percent of high school students that are
obese, particularly in large urban school
districts. In children, the definition is a
BMI at or above the 95th percentile of
children of the same age or sex.lxviii As
with tobacco measures, readers should
take note of both the source and year
of data when using the obesity data
from this publication. Physical activity
data were taken from BRFSS or YRBS/S
based on CDC-recommended activity
levels. For adults: at least 2 hours, 30
minutes of moderate-intensity aerobic
activity every week for good health; 1
hour, 15 minutes of vigorous-intensity
aerobic activity; or an equivalent mix of
moderate and vigorous. For high school
students: physically active for a total
of at least 60 minutes per day. Where
possible, this publication relied on
BRFSS or YRBS/YRBSS so that data were
comparable. In most cases, if data were
not comparable, they were excluded.
Heart disease and diabetes mortality
rates are per 100,000 people, using 2010
Census figures, and are age-adjusted
to the year 2000 standard population.
ICD-10 codes: I00-I09, I11, I13, and
I20-I51 for heart disease, and E10-E14
for diabetes.
I NJU R Y an d V IO LE N CE
Homicide, suicide, and firearmrelated mortality rates are per 100,000
population, using 2010 Census figures,
age-adjusted to the year 2000 standard
population. ICD-10 codes are: X85-Y09,
Y87.1 for homicide; X60-X84 and Y87
Sources of Data
for suicide; and W32-W34, X72-X74,

X93-X95, Y22-Y24, and Y35 for firearmrelated mortality (except where noted).
Motor vehicle mortality rate is per
100,000 people using 2010 Census
figures, age-adjusted to the year 2000
standard population. ICD-10 Codes:
V02-V04,
V09.0-V09.2,
V12-V14,
V19.0-V19.2, V19.4-V19.6, V20-V79,
V80.3-V80.5, V81.0-V81.1, V82.0-V82.1,
V83-V86, V87.0-V87.8, V88.0-V88.8,
V89, and V89.2 (except where noted).
F O O D SAF E T Y
DE MO G RAP HI CS
Laboratory-confirmed infections caused

by salmonella or Shiga Toxin-Producing
E. coli are crude rates per 100,000
people, using 2010 Census figures.
B EH A V IO RAL H E AL TH
S U BS TAN CE ABU SE
and the drug-abuse related inpatient

hospitalization rate were based in
part on how individual jurisdictions
compute these numbers, as a consensus
definition could not be reached in the
time period necessary. For this reason,
data should not be compared across
jurisdictions. While most cities used
a combination of ICD codes and/or
hospital databases, specific sources and
methodologies are noted in the online
data platform. Special attention should
be paid when using these numbers.
AN D
The percentage of adults who binge

drank is based (in most cases) on the
BRFSS question about how many drinks
a person had on one occasion in the
past 30 days. Women who answered
four and men who answered five
are considered binge drinkers. Similarly,
percent of high school students is based
(in most cases) on the YRBS/YRBSS
question regarding five or more drinks
within a couple hours on one or more
occasions in the past 30 days. As with
other indicators, if BRFSS or YRBS/YRBSS
data were not available, a comparable
survey was used or the data were left out
if not completely comparable.
The opioid-related mortality rate
Data for children living in poverty,

median household income, foreignborn residents, high school graduates,
those living below 200% of the
poverty line, and the unemployment
rate were calculated using the U.S.
Census Bureaus American Community
Survey 1-year estimate tables with a
few exceptions. A research assistant
accessed the data files and created
estimates based on a micropolitan code
of statistical areas defined by the Office
of Management and Budget February
2013 Delineation Files, which may
be different from jurisdictional lines
used for other data in this publication.
County data for Fort Worth (Tarrant
County), Las Vegas (Clark County), and
San Diego County were secured via the
American Community Survey online
data tables.
125
Appendix
DEFINITIONS
Race & E t h n i c i t y
Where sample sizes allow, indicators are broken down into subpopulations for race
and ethnicity categories. For most jurisdictions, the default options were white (non
Hispanic), black (non Hispanic), Hispanic, Asian/Pacific Islander, Native American, and
other. In areas where certain populations were too small, the various subpopulations
were included in the other category with any additional racial/ethnic minorities.
In many of the California cities, as well as Seattle, reported numbers only represent
Asians; Pacific Islanders are not included. Some jurisdictions also report mixed-race
numbers, and where they do, those numbers are reported as multi racial.
Rat es & pe r c e n t a g e s
As is customary, communicable disease indicators are reported using crude rates.
Mortality rates are age-adjusted to compare relative mortality risks among cities,
different demographic groups, and over time. In most cases, the 2000 standard
population age was used. All mortality rates are presented per 100,000 people.
Jurisdictions that used more recent population counts than the year 2010 are noted.
126
Definitions
127
Appendix
End N Ot e s
See http://www.healthypeople.gov/2020/
topics-objectives/topic/social-determinantshealth.
xv
Institute of Medicine, For the Publics Health:

Investing in a Healthier Future (Washington, DC:
The National Academies Press, 2012).
i
United Nations Department of Economic and

Social Affairs, World Urbanization Prospects:
The 2011 Revision; File 1: Population of urban
and rural areas and percentage urban (table),
published 2012, http://esa.un.org/unup/CDROM/Urban-Rural-Population.htm.
xvi
Big Cities Health Inventory.
xvii
Ibid.
ii
See http://Stateofobesity.org/obesity-ratestrends-overview.
xviii
xix
Allen N. Koplin, The Future of Public Health:

A Local Health Department View, Journal of
Public Health Policy 11, no. 4 (1990): 42037,
doi:102307/3342922.
iii
Jennifer L. Pomeranz, The Unique Authority of

State and Local Health Departments to Address
Obesity, American Journal of Public Health 101,
no. 7 (2011): 119297.
iv
See prevalence rates at: https://oasis.

state.ga.us/oasis/oasis/qrymorbmort.aspx;
and Lawrence E. Barker et al., Geographic
Distribution of Diagnosed Diabetes in the U.S.,
American Journal of Preventive Medicine 40, no.
4: 43439, which gave Fulton County pause and
motivated officials there to address the problem.
xxxvi
See http://kron4.com/2015/06/09/santaclara-county-officials-vote-to-raise-legal-age-tobuy-tobacco/.
xxxvii
Ibid.
See http://www.cdc.gov/media/
releases/2015/p0416-e-cigarette-use.html.
xxxviii
National Institutes of Health, National Institute

on Drug Abuse, Overdose Death Rates, February
2015, http://www.drugabuse.gov/related-topics/
trends-statistics/overdose-death-rates.
xx
See http://www.bigcitieshealth.org/opioidsprescription-drugs.
See http://www.fda.gov/NewsEvents/
Newsroom/PressAnnouncements/ucm394667.
htm.
xxxix
xxi
See http://www.healthypeople.gov/2020/
About-Healthy-People.
See http://www.fda.gov/NewsEvents/
PublicHealthFocus/ucm172906.htm.
xl
xxii
Lawrence O. Gostin, Bloombergs Health Legacy:

Urban Innovator or Meddling Nanny? Hastings
Center Report 43, no. 5 (2013): 19-25, http://
ssrn.com/abstract=2334823.
v
xxiii
Ibid.
American Cancer Society, The Effects of

Secondhand Smoke on Worker Health, http://
action.acscan.org/site/DocServer/EffectsSecondhand-Smoke.pdf?docID=5161.
Boris Shor and Nolan McCarty, The Ideological
Mapping of American Legislatures, American
Political Science Review 105, no. 3 (2011):
53051.
vii
Paul A. Diller, Why Do Cities Innovate in Public

Health? Implications of Scale and Structure,
Washington University Law Review 91, no. 5
(2014): 175.
viii
Neil Kleiman et al., Innovation and the City (New

York: Center for an Urban Future, 2013), http://
wagner.nyu.edu/files/labs/Innovation-and-the-City.
pdf.
ix
U.S. Centers for Disease Control and

Prevention, CDC Winnable Battles 20102015; Progress Report 2014, http://www.
cdc.gov/winnablebattles/targets/pdf/
winnablebattles2010-2015_progressreport2014_.
pdf.
x
See https://www.cityofchicago.org/city/en/
depts/cdph/supp_info/tabacco_alcohol_drug_
abuse/smoke_free_illinoisact.html.
xlii
See http://www.cdc.gov/winnablebattles/
targets/pdf/winnablebattles2010-2015_
progressreport2014_.pdf.
xxiv
vi
See http://www.bphc.org/whatwedo/tobaccofree-living/Pages/TOBACCO-REGULATIONS.aspx.
xli
See http://www.huffingtonpost.
com/2014/03/05/la-bans-e-cigarettes-publicplaces_n_4905735.html.
xliii
See http://www.cdc.gov/winnablebattles/
targets/index.html.
xxv
Paul A. Simon et al., Impact of Restaurant

Hygiene Grade Cards on Foodborne-Disease
Hospitalizations in Los Angeles County, Journal
of Environmental Health 67, no. 7 (2005): 32-6.
xxvi
See
http://ga.healthinspections.us/georgia/search.cf
m?1=1&f=s&r=name&s=&inspectionType=Food&s
d=05/09/2015&ed=06/08/2015&useDate=NO&
county=Fulton.
See http://www.ci.minneapolis.mn.us/health/
living/free/housing.
xliv
See http://www1.nyc.gov/nyc-resources/
service/1591/electronic-cigarettes-law.
xlv
xxvii
See http://www.phila.gov/health/pdfs/
Philadelphias_Clean_Indoor_Air_Worker_
Protection_Law_1_2.pdf.
xlvi
See http://www.dhhs.saccounty.net/PUB/
Pages/Tobacco-Education-Program/SP-TobaccoEducation-Program.aspx.
xlvii
See https://data.cityofchicago.org/HealthHuman-Services/Food-Inspections/4ijn-s7e5.
xxviii
See http://www.nyc.gov/html/doh/html/
services/restaurant-inspection.shtml.
xxix
See http://www.maricopa.gov/envsvc/
envwebapp/Tabs/reports.aspx.
See http://2gahjr48mok145j3z438sknv.
wpengine.netdna-cdn.com/wp-content/uploads/
SF-Health-Code-Article-19N-20141.pdf.
xlviii
xxx
See https://www.sfdph.org/dph/EH/Food/
Score/default.asp.
See http://www.cdc.gov/media/releases/2015/
p0416-e-cigarette-use.html.
xlix
xxxi
According to the U.S. Census Bureau,

urbanized areas of 50,000 or more people
form the urban cores of metropolitan statistical
areas. Additional information can be found at:
https://www.census.gov/geo/reference/ua/urbanrural-2010.html.
xi
xii
See http://www.healthypeople.gov/.
xiii
See http://www.cdc.gov/winnablebattles/.
See https://www.sccgov.org/sites/cpd/
programs/fsp/Pages/Placarding.aspx.
xxxii
U.S. Centers for Disease Control and

Prevention, Estimates of Foodborne Illness
in the United States, http://www.cdc.gov/
foodborneburden/.
xxxiii
xiv
128
See http://www.justice.gov/defendingchildhood/
cev-rpt-full.pdf.
li
See http://www.bphc.org/healthdata/health-ofboston-report/Documents/HOB-2014-2015/11_
Violence_HOB%202014-2015.pdf.
lii
xxxiv
Big Cities Health Inventory: The Health of Urban

USA 2007, edited by Nanette Benbow et al.,
(Washington, DC: National Association of County
and City Health Officials, 2007).
Corinne David-Ferdon and Thomas R. Simon,

Preventing Youth Violence: Opportunities for
Action. (Atlanta: U.S. Centers for Disease Control,
National Center for Injury Prevention and Control,
2014).
l
Ibid.
Pew Research Center, U.S. Smartphone Use in

2015, http://www.pewinternet.org/2015/04/01/
us-smartphone-use-in-2015/.
xxxv
Interview with Sasha Cohen, youth violence

prevention
coordinator,
Minneapolis
Health
Department.
liii
Ibid.
liv
See http://www.ci.minneapolis.mn.us/www/
groups/public/@citycoordinator/documents/
webcontent/wcms1p-132615.pdf.
lv
lvi
U.S. Centers for Disease Control and Prevention,

Basics about Childhood Obesity,
citing Barlow SE and the Expert Committee.
Expert committee recommendations regarding
the prevention, assessment, and treatment of
child and adolescent overweight and obesity:
summary report. Pediatrics 2007;120 Supplement
December 2007:S164-S192,
http://www.cdc.
gov/obesity/childhood/basics.html.
lxviii
Ibid.
Ibid.
lvii
Kansas City Police Department data made

available through a partnership with the Health
Department.
lviii
Interview with Tracie McClendon-Cole, justice

program manager and director of Aim4Peace,
Kansas City Health Department.
lix
Comments by U.S. Sen. Lamar Alexander, http://

www.help.senate.gov/chair/newsroom/press/
alexander-information-blocking-is-standing-inthe-way-of-patients-promise-of-electronic-healthrecords.
lx
Public Health Leadership Forum, Defining

and Constituting Foundational Capabilities
and Areas Version 1 (V-1), http://www.resolv.
org/site-healthleadershipforum/files/2014/03/
Ar ticulation-of-Foundational-Capabilities-andFoundational-Areas.v1.May_.pdf.
lxi
See
http://naccho.org/advocacy/positions/
upload/07-05_EHR-HIE-Interoperability-6-12.pdf.
lxiii Big Cities Health Departments: Leadership
Perspectives,
Journal
of
Public
Health
Management & Practice 21, supplement 1
(January/February 2015), http://journals.lww.
com/JPHMP/TOC/2015/01001.
lxii
Big Cities Health Departments: Leadership

Perspectives,
Journal
of
Public
Health
Management & Practice 21, supplement 1
(January/February 2015), http://journals.lww.
com/JPHMP/TOC/2015/01001
lxiii
lxiv
Ibid.
lxv
Ibid.
lxvi
Ibid.
According to the U.S. Census Bureau, urbanized

areas of 50,000 or more people form the urban
cores of metropolitan statistical areas. Additional
information can be found at: https://www.census.
gov/geo/reference/ua/urban-rural-2010.html.
lxvii
129
130

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BIG CITIES HEALTH COALITION

BIG CITIES HEALTH INVENTORY

Charon Gwynn, PhD; Deputy Commissioner, Division of Epidemiology, New

Kinjia Hinterland, MPH; Director, Data Communications, New York City

Giridhar Mallaya, MD, MHSP; Director of Policy and Planning, Philadelphia

Nik Prachand, MPH; Director of Epidemiology, Chicago Department of Public

Margarita Reina, MPH; Senior Epidemiologist, Chicago Department of Public

Marguerite Ro, DrPH; Chief, Assessment, Planning, Development and

In addition, de Beaumont-supported research consultant, JP Leider, PhD, provided

About The Big Cities Health Coalition

27 MEMBER CITIES (COUNTIES)

LAS VEGAS (CLARK COUNTY), NV

SAN JOSE (SANTA CLARA COUNTY), CA

OAKLAND (ALAMEDA COUNTY), CA

FORT WORTH (TARRA NT COUNTY), TX

PHOENIX (MARICOPA COUNTY), AZ

PORTLAND (MULTNOMAH COUNTY), OR

About The Big Cities Health Coalition

About The Big Cities Health Coalition

ABOUT THE BIG CITIES HEALTH COALITION

Association of Coun ty an d City He alth Of f icials (NACCHO),

About The Big Cities Health Coalition

About the Big Cities Health

Wi nnable Bat t les

Digital Sleuthing, Engagement

Houston Hits Home with Youth

San Francisco Determined to

Selection of Cities, Indicators,

The Health of Our Cities

Disparities in Health Status

Healthy People 2020 Goals

Overview and Data Limitations

Getting Physically Active and

A Collective Impact Gains

Preventing the Habit Anchors

Early E-Cigarette Ban Reignited

Three Cities Approaches to

116 Recommendat ions

128 End Not es

Policy innovations at the local level do

cities are winning key health battles by

The purpose of this report is to provide a

The 26 jurisdictions included in this

This BCHI is the sixth report in a series

where available. (See Table 10: Selected

Selection of Cities, Indicators & Report Organization

Selection of Cities, Indicators & Report Organization

NUMBER OF CITIES EXPERIENCING AN INCREASE, DECREASE,

ARE CITIES HEALTHIER THAN

Overall mortality rates have decreased

NUMBER OF CITIES AT, ABOVE, OR BELOW NATIONAL

All Cancer 2012

Heart Disease 2012

HOW DOES THE HEALTH OF

In 2007, the BCHI showed that city

ARE CITIES ON TRACK TO MEET

Thirty years ago, HHS started creating

WHAT IS THE STATE OF RACIAL AND

O f t he 2 2 ci t i es repo rt i n g m o rt ali t y dat a fo r a l l

m o rt ali t y dat a bet ween 2 0 1 0 an d 2 0 14 , o nl y 6

1 29.2 deat h s /1 0 0 ,0 0 0 peo ple.

RACE / ETHNICITY MORTALITY RATE

(AGE-ADJUSTED; PER 100,000 PEOPLE)