I had an auspicious start in public health: As a high school student in Westchester County, New York, I won a contest to be county public health commissioner for a day. At that time, my vague notions of public health were only that somehow it helped prevent diseases. As I prepare to retire from the position of Director of Public Health and Health Officer for our nation's most populous county, I reflect on the time that has passed between that day and now.

After my brief foray into public health for a day, I pursued a traditional medical education, receiving my MD degree from Harvard in 1969. However, as I completed my residency in pediatrics, it became clear to me that to solve the problems of the patients I saw day after day, medicine must be complemented by broader approaches to supporting health at individual, family, and community levels. I became convinced that I could make a greater difference in the health of patients and their families by working at the population level, although it meant giving up the gratification that comes from helping patients one at a time.

The Los Angeles County Department of Public Health: A Reflection

Persuading others that public health makes a contribution distinct from that of medical services has not always been simple. I saw the difficulties firsthand when I became Commissioner of Public Health for the Commonwealth of Massachusetts in 1975. Most of the population believed that public health was limited to public hospitals and clinics caring for the poor. Getting resources to address serious risk factors such as smoking, poor nutrition, and sedentary lifestyles was very difficult. At that time, most legislators in Massachusetts felt that bad health habits, including drug and alcohol abuse, were individual decisions and not within the purview of government to try to prevent or ameliorate.

Fast forward to 1998. After a year of consulting on how to improve governmental public health in Los Angeles County and collaborating with other public health experts to develop many recommendations that were adopted by the county governing body, I accepted the job as county Director of Public Health. Public health was housed within the larger County Department of Health Services and constituted a small portion of its workforce and budget. Public health issues and concerns were often overshadowed by constant crises in health services financing and quality of care. These uniformly took precedence over public health's efforts to hire new staff and to strengthen internal capacity in areas such as chronic disease control, environmental health, and analytics.

A high-profile breakdown in public health protection that occurred shortly after my arrival helped raise public health's profile. Local news channel KCBS-TV aired an investigative report that used hidden cameras to reveal egregious food safety violations in Los Angeles restaurants, attracting considerable media attention and provoking public outcry. The news coverage inspired strong public support for holding restaurants more accountable for food safety. A visible restaurant grading system, previously unfeasible due to almost certain opposition by the politically strong restaurant association, was now possible. We were able to develop a system that both changed the incentives for retail food establishments and protected the public's health. Restaurant letter grades (A, B, C), prominently posted at the entrance of all food establishments, quickly became an identifiable trademark of public health. These simple letter grades helped establish a public health “brand” and distinguished the field from the direct delivery of health care services. This event also illustrated the importance of our ability to respond rapidly to public health needs. Indeed, being nimble and politically sensitive are important keys to advancing public health programs, whether for health protection, disease prevention, or health promotion.

It took 8 years and extensive effort by both internal and external partners to convince the County Board of Supervisors, comprising 3 Democrats and 2 Republicans, that public health should be its own department. With close to 4000 employees and 40 programs, how could public health operate effectively as part of a parent organization with a different mission? We were gratified when the Board of Supervisors in 2006 voted to officially create a separate department with a mission to protect and improve the health of all 10 million residents.

For me, the realization of this goal was the most important of my tenure in Los Angeles. The new department asserted public health's independent legitimacy and promoted its visibility. The department's independence also gave us direct access to the county senior administrative leadership and to the Board of Supervisors, allowing us to argue directly for the resources, programs, and policies we needed to fulfill our mission. Finally, the vote to create a new, independent department elevated our strategic goals and made it easier for us to work with other county departments to improve our responsiveness to existing and emerging public health concerns and move forward with other critical activities.

Raising public health's visibility has meant, in one aspect, to be literally visible. For me, it was important for public health to have a face, and that the face was the Health Officer, who under state law had broad responsibility and authority. I believe that in every community, Health Officers should be seen as the leader responsible for protecting human health. In the role of Health Officer, I've made many media appearances focused on educating the public about current health issues and teaching people how to better protect themselves from infectious and chronic diseases, environmental hazards, and other health threats. Visibility has also meant increasing the department's presence at the state and national levels. The involvement of local Health Officers at state and national levels is critical because they give authoritative voice to health problems at local levels, from environmental threats to substance abuse to food. Such local-level problems are often difficult to address due to barriers embedded in state and federal laws or regulations.

Developing internal capacity is an ongoing process, the centerpiece of which has been hiring strong staff with good leadership skills. We have been fortunate to attract a cadre of experienced, mission-driven public health professionals to lead our programs. In addition, we are fortunate to be in a large metropolitan area with many excellent colleges and universities. To tap this talent pool, we created internship programs for students and now recruit both locally and nationally. Through this program, we have been able to identify, recruit, and train a wide range of talented individuals who eventually get hired as permanent employees.

With strong staff and a prominent public presence, our department has charted a course definitively distinct from that of Health Services. We have focused on opportunities for health promotion and worked to anticipate and prepare for emerging threats. Beginning after the September 11, 2001, attacks and continuing through the anthrax scare, severe acute respiratory syndrome, pandemic H1N1, bird flu, and Middle East respiratory syndrome, the department has recognized and embraced its pivotal role as a public safety agency. We have modeled how to be an ally in counterterrorism efforts, helping draft a memorandum of understanding with the FBI and staff the Joint Regional Intelligence Center, a cooperative effort to centralize federal, state, and local activities related to responding to suspected terrorist threats. These cooperative activities have become a priority as we anticipate emerging threats—including terrorism—and proactively position ourselves to respond.

In endeavoring to make many of these changes, I faced both criticism and controversy. I have been criticized for advocating for a visible role for public health on controversial issues such as limiting the marketing of sugar-sweetened beverages to children and for advocating that menus of fast food restaurants list calories and composition of their items. I have also been criticized for allocating too few or too many resources to a particular health problem or to 1 or more racial groups or geopolitical units and for not being sensitive enough to the concerns of the organizations we regulate. If you are committed to a proactive health-promoting agenda, you cannot avoid criticism. While a public health perspective or warning may not always be welcome or palatable, it is only by consistently basing policy recommendations and decisions on the best science that the department has become a respected resource for elected officials.

The Future of Public Health

In 2002, Tom Frieden, who then directed the New York City Public Health Department, and I organized the Big Cities Health Coalition (BCHC), based on the concept that urban centers share unique opportunities and challenges. The BCHC includes 20 of the largest local public health departments in the United States and is focused on building partnerships, exchanging ideas and best practices, and facilitating program and policy development by member departments. Just as I have focused locally on establishing my department in Los Angeles as the local voice of reliable health information and data, an important role for the BCHC is to identify and analyze the best science and collectively advocate for policies and programs that can improve health at the population level. To be an effective advocate for public health in big cities, the BCHC needs to be the “go-to” resource for questions from legislators on health-relevant policy and programmatic issues.

Public health departments in large metropolitan areas such as Los Angeles County play a very important role in advancing the goals of the larger public health enterprise. As local entities, they operate on the forefront of the most current issues. Furthermore, as large departments, they are relatively resource-rich in comparison with other counties. As such, large metropolitan area public health departments are often the first to recognize and develop strategies to address the most burning issues of the day. Big cities and counties thus have the opportunity and responsibility to provide leadership for the broader public health community, and the Health Officer is in the best position to communicate how to effectively meet both continuing and new challenges.

Coalitions such as the BCHC are critical players in addressing the challenges of the 21st century including climate change, water scarcity, and novel environmental threats. Such collaborations must take place not just with other public health departments but also with other local governmental and private agencies, legislators, and the public. Collaboration with different sectors is essential because society can only develop healthy environments through collaborative efforts of public health with others such as regional planning, mental health, public works, parks and recreation, fire, and law enforcement.

The department has encouraged the 88 cities in our large county to make health a central consideration in planning decisions, an effort that led to the development of a comprehensive chapter on health and wellness in the City of Los Angeles General Plan and similar health elements in the general plans of several other cities. Our work with the City of Los Angeles highlights the importance of support and vision from elected officials; we worked closely with local agencies on the development of the Health and Wellness chapter, as well as on other health-promoting initiatives. A specific example of collaborative planning is that we have made significant progress in transforming many Los Angeles neighborhoods to become more walkable and bikeable through strategic partnerships with other county agencies, local businesses, and community groups. These efforts, among others, have led to the recent recognition of Los Angeles as a bike-friendly community for the first time in 20121 after being referred to as “an almost pathologically bike-unfriendly city” by Slate Magazine in years prior.2

Working with elected officials requires sensitivities to their political needs and priorities. Most elected officials, whether in the executive or legislative branch of government, face reelection every 2 to 4 years. Compare this time horizon with those of public health initiatives such as those focused on reducing the rate of obesity, reducing the toll of combustible cigarettes, or reducing exposure to environmental carcinogens. Making changes that will impact these health problems can take decades to show results. Meeting both public health and political goals requires a balanced portfolio of programs and policies that includes those with a rapid political return to help politicians demonstrate progress aligned with the election cycle. For changes with long-term outcomes, public health officials must mobilize allies who can help convince politicians of the long-term benefits.

Public health's fundamental challenge is convincing the American people that their health, individually and collectively, is primarily determined by the social, physical, and economic environments in which we live. While the relative contribution of different environments to health is debated, a commonly used allocation for its contribution to health outcomes is between 10% and 20%.3 The public must also accept that health care, while important, cannot remedy many of our country's current health problems or improve our poor ranking in health status and key measures compared with other developed nations. Currently, the United States is ranked 26th in life expectancy and 31st in infant mortality out of 40 countries by the Organisation for Economic Co-operation and Development.4 To date, we have not yet succeeded in getting the layperson to grasp this critical issue. When asked to name the most important thing that can be done to improve health in Los Angeles County, my response is, “That's easy: Increase the high school graduation rate.” This response frequently elicits a blank look. People often do not understand the interconnection of education and health outcomes until they engage in discussions about income and literacy, and how these 2 factors are related to health and longevity. We must continue to initiate these discussions in the public sphere until these interconnections are universally understood and are the basis for political actions.

The Next Generation

It has been a privilege to be the Health Officer and Director of the Los Angeles County Department of Public Health for the past 16 years. As I leave the directorship to my successor, I look forward to returning to the School of Public Health at the University of California, Los Angeles, to train and mentor future public health leaders. It is to this new generation of professionals that we pass on our important work.

Looking back at my time in county service and my previous experience as a state Public Health Commissioner, a number of important lessons stand out. Some have already been mentioned but merit repetition.

Look carefully and extensively to find the best staff, both existing employees and new recruits. Make sure they have the resources to succeed, encourage them to take risks, and back them up.

Form coalitions with other sectors to support policies and resources that are wins for all concerned.

Understand the landscape. In your professional role, assess each aspect in which your organization is ahead or behind. Look to your peers to compare and contrast circumstances and opportunities, taking into consideration community health status, programming, and the policy and economic environment. Consider how to best prioritize opportunities based on this assessment.

Borrow and lend ideas, challenges, successes, and failures. As the saying goes, imitation is the sincerest form of flattery. What might be considered infringement in the private sector is ideal in the public sector. It is gratifying when other jurisdictions borrow from a policy or program that Los Angeles has implemented and make it their own. And we haven't hesitated to borrow innovations from other public health agencies.

Practice humility. Sometimes it is important to apologize, even for mistakes you may not believe you have made. The perceptions of your bosses can be as important as facts, and if they perceive that you've made a misstep, take responsibility.

Two principles have guided me in my leadership positions. First, focus on your passion, not your career. Careers are rarely a progression of obvious next steps. In deciding whether to take advantage of a new job opportunity, focus less on your career trajectory and more on whether new opportunities give you the chance to learn and grow. We're all in public health because of personal conviction. Follow that conviction.

The second principle is more difficult because it entails substantial short-term professional and financial risk. Do your job like you don't need it, making clear that scientific evidence and adhering to core public health principles trump ideology and political expediency. In other words, act in the manner that benefits the entire population you serve and whose taxes support your position, not just those who appointed you and to whom you report.

Public health made considerable gains in the last century, making a significant contribution to the expansion of life expectancy in the United States by an eye-popping 30 years.5 Now, the scope of public health has evolved to include new threats, especially terrorism and climate change. What is most important for all of us is to realize that our vision of healthy people in healthy communities cannot be achieved without understanding that our social, physical, and economic environments are the major determinants of health. This concept is nowhere better appreciated than in our largest metropolitan areas, within which wide variations in social and built environments are mirrored by variations in health, disease burden, and mortality. And both alone and as part of coalitions from multiple sectors, big cities, counties, and metropolitan areas can be in a position to adopt effective initiatives that will improve those environments and make demonstrable progress toward health equity.