Health officials of large metropolitan/urban areas, or big cities, are often asked to describe their typical day. If you have ever served in this role, you know there is no real answer to this question. If you have the opportunity to be introspective, you may find that you can describe the broad scope of the responsibility you have to the people you serve and the types of skills you use every day as surveillance, program and policy development, and visioning for the future.

City and county health departments that serve the nation's largest urban areas, specifically the 30 largest jurisdictions, serve nearly 1 in 5 residents of the US population.1 These local public health departments are often providing population health services to residents who are less likely than their rural peers to die of heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke.2 While metropolitan areas on average experience better population health outcomes than rural areas, the senior health officials who lead these health departments are all too familiar with the disparities and inequities that exist within their communities. Furthermore, they know that the racial and ethnic minority residents in their urban communities are more likely to experience health-related behaviors that are linked to chronic disease than whites who reside in rural areas.3 The masking of these inequities by the overall health and vitality in our big cities presents unique challenges for the contemporary public health leader as well as the public health workforce.

Improving the health of the nation has always required strong leaders in public health and accountability to the people we serve. Just as metropolitan areas and big cities grow and evolve, so do the tasks of creating effective solutions to improve population health. The reemergence of vaccine-preventable illnesses such as the multistate measles outbreak of 2015 and the growing interest in urban agriculture, including live poultry in backyard flocks, require public health leaders to reassess current policies for relevance.4 Recognizing that urban agriculture is often a solution many community members and advocates seek to implement as a means to address food security and access to healthful foods, public health leaders in big cities have the opportunity to implement innovative approaches to allow the practice while ensuring the health and well-being of their jurisdictions.

Large local health departments need to work with partners to address health inequities and emerging public health threats. The US Department of Health and Human Services' "Public Health 3.0: A Call to Action for Public Health to Meet the Challenges of the 21st Century,"5 challenges local government leaders to serve as the Chief Health Strategist to coordinate multisector partnerships to address the social and structural factors (eg, housing, transportation, education, economic development) that affect health and healthy equity. Local public health departments' knowledge of population-level health concerns and appreciation for the relationship between social and structural factors that impact health poise them as natural conveners of multisector partners to address health within their jurisdictions.

While there are challenges associated with playing this role, they are not insurmountable and the potential benefits are far reaching. Kansas City Health Department's plan that highlighted the large disparity in life expectancy between whites and African Americans catalyzed governmental agencies, community groups, nonprofit organizations, and businesses to address the social and structural factors that affect health. Seattle King County Health Department, other local government agencies, and community partners launched their Equity and Social Justice Initiative, which focused on creating livable wages, affordable housing, quality education and health care, and safe and vibrant neighborhoods.6 And, the Chicago Department of Public Health launched Healthy Chicago 2.0, which has led to several multisector, community-engaged, health equity-focused collaborations, including reducing traffic fatalities, increasing permanent supportive housing, and implementing and evaluating transit-oriented development initiatives.7 In Washington, District of Columbia, the DC Department of Health effectuates its health equity and Health in All Policies strategy through its DC Healthy People 2020 shared community agenda to improve population health and the DC Health Systems Plan. The DC Health Systems Plan, historically focused on the management of health care assets, now articulates a plan for hospital community benefits that is aligned with the health and social needs of the community driving investments into data-driven population health strategies. These strategies are outlined in DC Healthy People 2020 and create a new connectivity between public health program/policy and health care financing.

In addition to continuing to play traditional roles in surveillance, programs, and policy, large local health departments are embracing their roles as Chief Health Strategist to address social and structural factors that influence health. This shared vision for big cities where members of our community have the opportunity to achieve their best health is one we believe is possible through effective partnerships, political will, and a steadfast commitment to those we serve.

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