Rx for LA: The Future of Public Health
By Robin Keats
Published Jan 1, 2013 8:00 AM
The future will not be fat. L.A. will be greener and wetter. We'll move more. Breathe better. And support policies that promote urban health. It's all possible, say the experts whose job it is to ponder possible futures in public-health policy and practices in the City of Angels.
Los Angeles is a city of devotees: rival populations of refried bean aficionados and quinoa- and-kale crusaders (farm-fresh, organic please); opposing forces of couch potatoes and marathon runners, yoga-stretchers and Pilates-or-perish fanatics. Not surprisingly, in the City of Angels, what is and isn't healthy depends on whom you ask.
Building a healthy L.A. is not going to be easy. But it's vital if we're going to have any kind of future worth living in. Surprisingly, perhaps, the prognosis for a healthy L.A. is pretty good, in part because of the strides the city has made in reducing air toxicity and changes in the culture that contribute to disease reduction, and also because of ongoing positive changes in urban-health policy and scientific advances.
"When you're in public health, you better be optimistic," explains Dr. Jonathan Fielding, founding director of the Los Angeles County Department of Public Health, UCLA professor of health services and pediatrics and co-director of the UCLA Center for Healthier Children, Families and Communities. But there's a caveat, says Fielding, the visionary who created L.A.'s now-iconic alphabetical labeling system for rating city restaurants and co-benefactor with his wife, Karin, of the UCLA Jonathan and Karin Fielding School of Public Health: "I'm also impatient."
He's got plenty of company. Collectively, the Fielding School experts' blueprint for a healthy L.A. is simple: Plot a course, lay the plans and give the public a collective kick in the butt to get moving.
Still, they are keenly aware that huge challenges remain. For example, 25 years from now average temperatures in the Southern California region are expected to be four degrees hotter than they are now. And they know all too well that obesity threatens to decimate Los Angeles, and the nation, with the intensity of a super plague.
A River Runs Through It Again
At last look, the Los Angeles River still had a cement bed, and there's no monorail shuttling down the center of the 405—yet. Within the next decade or so, though, Fielding School experts think it's more than likely that a grassybanked, riverine park will run naturally through the city to the sea. Moreover, mass transit will have thinned out the freeway traffic.
Dr. Richard Jackson, chair of the Fielding School's Environmental Health Sciences Department, notes that in the near future, we will inhabit a Los Angeles even more builtout than it is today. However, the experts predict that the sprawling city/county of the future will reflect the past much more than it does now. The Los Angeles River will flow as it once did, forming one long park with grassy banks sloping down to waters coursing through a city that will need recreational oasis even more than it does right now.
Jackson envisions much more desert landscaping to help conserve what water remains available, as well as extensive capturing of rainwater. Building codes requiring "purple pipes" carrying recycled water for irrigation and non-potable uses will be in place. Our water will be put to much better use than the irrigating of lawns in the San Fernando Valley or for keeping gardens in bloom in Brentwood. Captured and recycled water will feed the rows of kale, spinach and other protein-rich crops that will sprout in backyards and atop those roofs not covered by photovoltaic panels.
Jackson points out that there used to be a wealth of healthy, locally grown food that fed Angelenos. In fact, postwar L.A. was the leading agricultural county in the nation. A return to such easily accessible, vitamin-loaded bounty untainted by chemical fertilizers—as well as exercise programs and a powerful focus on nutrition—will help initiate a gradual reversal of what the experts agree is the leading threat to public health.
It isn't an outbreak of some future pox or virulent bacteria riding a meteor to Earth that is most likely to do us in, they warn. It's fat.
Straight Skinny on Fat
"It isn't an outbreak of some future pox or some strain of virulent bacteria riding a meteor to Earth that is most likely to do us in. It's fat."
Obesity must be dealt with now, with no relenting as the years ensue, if it's not going to undermine the public's health as well as the economy. As Jackson pointed out in the Southern California Environmental Report Card issued last year: "The average Southern California adult has gained about 25 pounds over the last 30 years, and obesity has tripled in California teens and quadrupled in preteens."
National health and fitness expert Antronette Yancey M.P.H. '91 is a professor in the Department of Health Services at the Fielding School, co-director of the UCLA Kaiser Permanente Center for Health Equity and a board member of Partnership for a Healthier America. She also frames the specter of a population killing itself with sugars, fats and empty calories.
"Dealing with obesity is the foremost task facing us," she contends. "I envision, for Los Angeles as well as the nation, what I call a 'healthy by default policy' being in effect. By this I mean that the policy will incorporate behavioral economics and the physiology of why people make certain choices, and making the act of healthier choice easier."
Fielding worries about the strides made in the last 25 years being undone in the next 25 due to obesity. "We've had a remarkable, an incredible, reduction in most of the chronic diseases: stroke, complications of diabetes, heart disease. They're all down not just by double digits, but by 30, 40, 50 percent," he adds. "What's going on now [with obesity] bodes poorly in relation to continuing the progress and threatens to reverse it."
The U.S. Centers for Disease Control and Prevention estimate that by 2030, an astounding 32 million more Americans will have become obese. That would mean that 42 percent of all the people in the country will be obese in less than two decades—and by then, more than 1 in 10 Americans will be more than 100 pounds overweight. The results will be deadly.
In addition, public-health scientists warn, the cost of treating diabetes and other ills that come with obesity might crash our economy just as surely as junk bonds and bundled mortgages.
Yancey is planning exercise programs incorporated into offices, schools and churches so that they're impossible to avoid. Increased physical activity, catalyzed by these programs and such things as a citywide network of bike paths, won't totally negate the obesity problem, she admits, "but it will help reduce the soaring levels of diabetes and other ills that put millions ofpeople at risk."
A fitter future, of course, depends on social behavior. In fact, when asked what she would say if she could offer only one piece of advice individuals could follow to improve their health, Yancey brings up that figurative kick in the public butt mentioned earlier.
"The culture will shift to favor a more active lifestyle," Yancey continues. "At a baseball game, for example, there won't just be the seventh-inning stretch, but also the fourth-inning five-minute activity break." But she adds, "I'm kind of cynical about people making this change from the sedentary lifestyle to one of physical activity on their own. People will need to be at some organized setting for this to work."
Help from the federal government to implement her plans is on its way. In October, researchers at UCLA's Jonsson Comprehensive Cancer Center were awarded a five-year, $20-million federal grant from the Centers for Disease Control and Prevention to further their innovative efforts to curb obesity. The grant is intended to address health disparities among racial and ethnic groups across the country and is part of the agency's Racial and Ethnic Approaches to Community Health (REACH) initiative.
Health Care Logs On
Hospitals and caregivers, of course, will lead the way to a healthier city in many ways. "Health care is at a crossroads and hospitals will play an important role in improving the health of all Americans," says Benjamin Chu—group president for Kaiser Permanente Southern California and Kaiser Permanente Hawaii—who served as the Fielding School's commencement speaker in 2009. "We can take demographic information, clinical and pharmacy data, and scrub the information in an engine with algorithms that look at innovative ways to detect diseases earlier and keep people healthier. And we've put strategies in place that allow the front-line staff to address some of these issues."
And Now the Good News
"We will be dealing with other perils to public health besides obesity, but solutions are out there."
We will be dealing with other perils to public health besides obesity. Diana M. Bontá M.P.H. '75, Dr.P.H. '92, president and CEO of The California Wellness Foundation, notes, "We surveyed public-health clinics in the past and the results were startling. About 76 percent of those institutions report having staffing shortages."
And some challenges are completely new. Bontá also reports that "For the first time in the history of our country, women have fought in wars and we have a disproportionate percentage returning to California. For the first time, children have had their moms absent—sometimes both parents. What kind of effect does that have?"
But solutions are out there, for these and more familiar problems. For example, many antibiotics are no longer effective in large measure because of misuse, including putting them in low doses in animal feed. Jackson sees a future in which a statewide proposition is passed that requires feedlot livestock producers to label any infusion of antibiotics and hormones. He calls for "the labeling of all food about means of production."
Overall, says Fielding, "There will be a real understanding that educational attainment is the main determinant of health and that investments to improve graduation rates, and to improve health literacy, are investments in better health for multiple generations." The county's top public-health official also believes that we're going to have much better surveillance of health risks and diseases in the future, in part due to the universality of electronic health records and real-time surveillance of risks, costs, diagnoses and outcomes. "And," he predicts, "there will be increased attention in respect to chemicals, biologicals and dirty bombs."
So even though much work remains to be done, a better Los Angeles could be just over the horizon. If the public and policymakers continue to support the strides we've already made, the L.A. of tomorrow could be greener, leaner and bluer than ever before. With or without more Pilates studios.