Key Takeaways

• • The CityHealth project models how public health research and advocacy grounded in legal epidemiology principles can collaborate with city leadership to achieve policy changes with the potential to enhance health and equity.

• • Legal epidemiology plays a formative role, guiding policy criteria selection in what currently exists in city codes; an evaluative role, assessing whether policies meet empirically based criteria; and a consultative role, offering specific guidance on how cities can change policies to rise to the level of best practices nationwide.

• • The project awards medals to city leadership for putting promising policies in place, and since its inception in 2016 has contributed to more than one hundred policy changes, potentially affecting the lives of 43 million people.

This article describes a model for how attorneys, city leaders, public health subject matter experts, and public health advocates can collaborate to produce policy change that promotes health equity. The model described, CityHealth, has combined public health research, legal epidemiology, and targeted outreach to city leaders and staff with an approach that emphasizes rewarding cities for putting in place policies that address various social determinants of health, and that are likely to improve health equity.

The project works in the 75 largest US cities, home to approximately 1 in 6 US residents.Reference Toukabri and Medina ¹ With support from the de Beaumont Foundation and Kaiser Permanente, CityHealth curates and promotes a discrete, well-researched set of policies. To incentivize and recognize cities for adopting these policies, the project annually awards gold, silver, or bronze medals for each policy, along with overall medals for cities that implement multiple policies. In its first 5 years, CityHealth worked with the 40 largest cities on 9 policies, resulting in 86 policy changes. This commentary describes how the project works and focuses particularly on how, in its second 5-year cycle from 2022–2026, it sought to integrate equity more deeply into the policy package and thence into city policies themselves.

Role of Legal Epidemiology

Legal epidemiology, the scientific study and deployment of law as a factor in the cause, distribution, and prevention of disease and injury, is central to CityHealth’s work.Reference Burris, Cloud and Penn ² While CityHealth staff and consultants are in constant direct contact with city officials to educate them about the policy package, a team of lawyers at the Center for Public Health Law Research at the Temple University Beasley School of Law (CPHLR) works behind the scenes, examining laws at the state, county, and city level and assessing them against the project’s policy criteria. These criteria are based on public health research, which, as described below, guides the project towards identifying policies that research evidence suggests will have a significant impact across the population. This research identifies potential “best practices”, i.e., how policies should look to have the desired health impact.

However, these potential best practices, based on research, also need proof of feasibility in real-world settings. To this end, legal epidemiology plays a formative role informing policy criteria by assessing what cities are currently doing and using that assessment to identify existing best practices. It then plays an evaluative role, iteratively assessing the current state of the law in each city to identify policies that merit a medal. Finally, legal epidemiology plays a key consultative role, identifying concrete next steps for cities to take if they desire to improve their medal status and offering specific guidance and feedback on how cities can adopt or modify existing policies to meet policy criteria.

Because the project works directly with city leadership, it is critical that the legal team “get it right” in terms both of how they assess and how they advise regarding whether policies meet the designated criteria. Municipal codes can be both complex and diverse in organization, making finding and assessing relevant statutes challenging. The legal team has developed a rigorous methodology involving coding criteria that structure a shared database, along with coding checks by multiple coders, to increase and ensure accuracy. Cities review coding decisions prior to the assessments being made public, with an opportunity to respond and inform revisions if there is disagreement.

Role of Public Health Research and Advocacy Partners

The selection of the actual policies and accompanying criteria reflects findings from the public health research and advocacy community. As part of the planning for the 2022–2026 policy package, subject matter experts, from academic institutions as well as advocacy organizations, provided briefing papers as well as more informal consultation on major social determinants of health, including housing, transportation, education, economic security, mental health and substance use, public safety, and environmental sustainability. These organizations would be critical partners in disseminating the policy package to city leadership. Key initial criteria for policy selection included bipartisanship, within city jurisdiction, and evidence of potential to impact health disparities.Reference Castrucci, Galea, Ettman and Vlahov ³ Assessing bipartisanship for CityHealth again draws on the legal epidemiology — the project looks for evidence that the policy has been implemented in cities with leaders coming from across the political spectrum, not just from a single political party.

Having three levels of medals enabled the project to recognize cities for taking initiative and encourage and reward them for going beyond initial criteria (bronze or silver level) to adopting best practices (gold level) based on the research base and the policy experience of other cities. A transdisciplinary advisory committee, diverse by race and ethnicity, gender, geography, and occupation reviewed initial policy briefs, with a particular focus on three key areas: housing, climate change, and mental health and substance use. The selection of these three areas arose from experience with the initial nine-policy package, as well as the project’s assessment of current challenges facing cities.

Defining and Addressing Equity

As the COVID-19 pandemic made even clearer the significant health disparities extant in US cities, it was essential to ensure a second round of review of the possible policies and accompanying best practice criteria focused on health equity. This review was guided by the following internal definition of health equity:

With this definition in hand, subject matter experts and organizations provided feedback on possible policy criteria, lawyers researched existing city codes for whether and how cities were already achieving what could be considered best practices, and government relations staff at CityHealth, as well as a diverse external advisory group, provided perspectives from city officials. These diverse data informed specific criteria for each medal type. Medal criteria for those policies held over from the first package (six of the original nine would continue) were reexamined, to align them better with the project’s definition of equity. The final result was a set of policy recommendations to the 75 cities that were based on policies that legal research had already found in existence somewhere in those cities and thus were feasible and within most cities’ jurisdictions.

Equity can be an abstract concept. Table 1 below shows, policy by policy, how this process operationalized the equity definition by producing specific equity-addressing policy criteria.

Table 1.

Examples of CityHealth Medal Criteria Addressing Equity

The Role of Government Relations

A government relations team comprised of CityHealth staff and consultants with strong relationships in particular geographic regions cultivated relationships with city leaders to educate them about the policy package. CityHealth presence at meetings such as the US Conference of Mayors and the National League of Cities provided further opportunities to bring visibility to the policy package, and to begin or continue dialogues with city leaders about how the package could make a difference in their city. An algorithm awarded overall gold medals to cities with five or more gold medals across the package, overall silver to cities with five or more silver or gold, and overall bronze to cities with five or more medals of any level. This flexible structure facilitated collaboration between the government relations team and city leaders to tailor the package to their needs and priorities. Tracking the medals gave everyone involved concrete metrics against which to assess progress.

In 2023, cities earned 400 individual policy medals based on these and additional policy-specific criteria, and 46 of the 75 cities (61%) received an overall medal of some kind, potentially affecting the lives of 43 million people in those cities. This marked an improvement from the 49% of cities earning an overall medal in the package’s first year in 2022, signaling robust growth in adoption of the recommended policies.

Reflections and Conclusions

The CityHealth project models how legal epidemiology and intensive government relations work, in partnership with subject matter-focused NGOs, can educate and inform city leaders regarding best practices and experiences of other cities. The project’s popularity with city leadership contributed to the decision to expand from 40 to 75 cities in 2021. Two cities provide useful case examples of the project in action. In San Antonio, led by an Independent mayor and a committed health director, city leaders worked hard to attain an overall gold medal, achieving that status by 2019, the third year of legal epidemiology-driven assessments against the original nine policy criteria. However, the city lost that status in 2022, after CityHealth adopted the new policy package with revised and enhanced criteria addressing equity. Led again by the same mayor and a new and equally committed health director, the city worked closely with CityHealth and subject matter partners to reclaim gold-medal status by 2023.

New Orleans was an “expansion city,” not large enough to be included in the 40 largest cities assessed during the first policy package. In a Republican-led state, a Democratic mayor successfully navigated potential obstacles presented by state preemption of the city’s jurisdiction over various policy areas to take the city from an overall silver medal in the first year of the new package to an overall gold in 2023. One of the policies that contributed to that gold medal standing was a right-to-counsel ordinance for tenants in the city, passed in May 2022. As city health director Dr. Jennifer Avegno put it, “Stable, safe, affordable housing is a significant determinant of health…. Having CityHealth as a national standard was tremendously helpful.” ⁹ The majority of New Orleans residents — 52% — are renters. Reframing tenants’ right to counsel as a health issue changed city leaders’ understanding of the policy and contributed to its passage.

One limitation of the CityHealth project is the focus on policy passage rather than implementation. The goal is at least to get cities to the same starting line in terms of having policies permanently in place that research suggests will improve health and enhance equity —hence, the importance of legal epidemiology documenting the presence of policies in city codes. The health impact of these policies is assumed, extrapolating from the research base that guides their selection.

Expanding the project into more cities and revising the policy package provided a platform for increasing the potential for impact and moving more intentionally to address equity. However, updating the policy package every five years comes with challenges. Leaders who considered themselves “done” with policy areas in the original policy package were sometimes not eager to reopen the debate and consider revisions to those policies. Policies new to the package required CityHealth staff to develop new materials and partnerships, and to educate city leaders about why issues like a tenant’s right to counsel were, in fact, health issues.

At the same time, grounding the project in legal epidemiology enabled CityHealth to approach each city and policy area with broad knowledge of the state of that policy both in that city and nationwide. The project provides a model for how health equity-oriented policy change can happen by bringing together the unique skills, insights, relationships, and authority that attorneys, public health researchers and advocates, and city leaders possess to create vibrant, prosperous communities in which everyone can live their healthiest possible lives.