A Healthy Regard for L.A.
Published Jul 1, 2014 8:00 AM
Jonathan Fielding is an acclaimed UCLA professor and the top public health official for the County of Los Angeles.
When he entered Harvard Medical School planning to become a pediatrician, Jonathan Fielding didn't expect that he'd one day oversee the health of more than 10 million "patients." But that's what he has done since 1998 as founding director of the Los Angeles County Department of Public Health. Best known as the man whose signature appears below every L.A. restaurant letter grade, Fielding and his 4,000-person staff are charged with working to prevent or react to health threats such as food-borne illnesses, infectious disease outbreaks, natural and man-made disasters, toxic exposures and preventable injuries, while also reducing the burden of heart disease, cancer, diabetes and other chronic diseases through health-promotion strategies. On top of all that, Fielding remains an active faculty member at the UCLA Jonathan and Karin Fielding School of Public Health — renamed in 2012 in recognition of a $50-million gift from the public health icon and his wife.
The epiphany that redirected Fielding to a career in public health came during his pediatric training, when he was struck by the limitations of clinical practice. "I saw problems of poverty and families that couldn't afford enough food," he says. "I saw terrible mental-health problems that weren't getting attention. I saw parental substance abuse that was affecting kids. I saw neglect and lack of stimulation. And there was precious little I could do to solve these problems on an individual level."
Nearly a half-century later, Fielding observes, many people continue to think of health only as what occurs in the doctor's office. Health care accounts for roughly 20 percent of the equation — but about 97 percent of investments to improve health.
In fact, Fielding notes, a big piece of the health puzzle — accounting for about 40 percent of the health differences among populations — is social environment. Another 10 percent of the differences stems from the physical environment — whether there are walkable and bikeable neighborhoods and efficient mass transit, etc. Thirty percent is individual behavior. (Do you smoke?) And these decisions, too, are influenced by environment: Are you surrounded by fast-food restaurants? Is fresh produce readily available in your neighborhood? If so, can you afford it?
Making the Grade
Under Fielding's leadership, L.A. County's public health department has earned a reputation for innovative initiatives. The department's chronic disease control program has forged partnerships with community based organizations to promote healthful nutrition, physical activity and tobacco prevention, while working with city governments to advance policies on everything from antismoking ordinances to developments that encourage walking and bicycling. The county's aggressive emergency preparedness programs — for both natural disasters and the threat of terrorism — have been widely emulated, as has the restaurant-grading program, which Fielding implemented shortly after taking the job. "We wanted to provide the information consumers needed to make better-informed decisions about where they ate," he says. In addition to reducing foodborne illnesses, the system of inspections and mandatory posting of results has motivated establishments to remain pristine, because a higher grade equals improved business.
More recently, with overweight and obesity rates high on the list of public health concerns in Los Angeles, as elsewhere, Fielding's department has worked with restaurants to reduce portion size, include fruits and vegetables in kids' meals, and inform customers of calorie counts on their menu options. (Fielding hasn't been willing to go as far as former New York City Mayor Michael Bloomberg's controversial big-soda-cup ban; the portion-size initiative is voluntary. "We have to be careful not to overstep our bounds," he says.)
Fielding has told his staff that when it comes to improving health in the nation's most populous county, impatience is a virtue. "We still have such an enormous, preventable burden of disease and injury that it's important always to look at what more needs to be done, rather than focusing on our accomplishments," he says.
Among the items high on his to-do list: better integrating mental-health and substance-abuse services into the healthcare system and moving toward universal early-childhood education, as well as addressing the wide disparities in health. "When an African-American male in Los Angeles County lives on average 18 years less than an Asian-Pacific Islander female, that tells you there's a lot of work to be done," he says. "Right now, your ZIP code may be more important than your genetic code."
Abhorring a Vacuum
"We need to let people in education know that one of the most important things we can do to improve health is to increase the graduation rate," Fielding contends. "We have to work with people in transportation, senior centers and consumer protection. We have to be concerned about commerce and a vital economy."
From our tax policy and social welfare system to the transportation infrastructure and what we do or don't do in response to climate change, virtually everything has health implications. And Fielding is a leading voice arguing that health issues can't be addressed in a vacuum. Policies made in all sectors — education, transportation, housing, agriculture, energy — should consider the public health consequences, much as environmental impact reports are required for construction projects and land developments.
Making the Case
For much of Fielding's career, the nation has grappled with the seemingly impossible task of trying to rein in health-care spending while maintaining quality and extending access to the millions who have lacked it. Meanwhile, Fielding and his colleagues continue to argue that we'll get a far better return from investments in education, social welfare, and early identification and treatment of mental-health and substance-abuse disorders, along with other initiatives aimed at keeping people healthy and productive.
Part of the problem in attracting sufficient funding to public health efforts is that when they're effective, the results are often invisible. You're unlikely to thank your local public health officer when you don't get food poisoning, when an infectious disease epidemic doesn't break out, or when you and most of the people around you are no longer smoking.
"People need to understand what public health is and what it does for them," Fielding concludes. "If they understand that very small investments can yield very large returns, we will gain much more support."