City Health through Pre-K – Learning from Our Peers and Building Relationships Across Sectors is Key to the Success of Our Cities’ Young Children

Tim Burgess, Former Mayor of Seattle and City Councilmember

Tim Burgess, Former Mayor of Seattle and City Councilmember

CityHealth and the National Institute of Early Education Research (NIEER) recently convened Pre-Kindergarten policy leaders from cities across the country to exchange ideas and best practices on how to establish high quality, accessible early childhood education programs in localities. This blog presents a read-out of that session.

By Tim Burgess, Former Mayor of Seattle and City Councilmember

I have spent much of my political career working to expand access to high-quality, affordable Pre-K for Seattle’s young children, and I am proud of the Seattle Preschool Program that came out of that work. I also recognize that our work is far from over, as thousands of children – many of them low-income or children of color – enter kindergarten unprepared to succeed. When the opportunity arose to participate in the CityHealth through Pre-K Summit, and spend 2 ½ days in Detroit learning about evidence-based strategies to develop a quality Pre-K program and engage with early childhood leaders from around the country - I jumped at the chance to do so.

When I arrived at the opening reception, hosted by the Kresge and W.W. Kellogg Foundations, on behalf of Hope Starts Here, Detroit’s early childhood initiative, I knew I would leave the summit with more tools in my toolbox than when I arrived. Looking around the room, I felt like the future of young children was in good hands. Leaders of city Pre-K programs, policy advisors for mayors, representatives from school districts, a parent advocate, workforce leaders, and philanthropists all took time out of their busy daily schedules to think about how to improve their city’s education system for their earliest learners and, more importantly, they did so by talking across sectors and geographic lines in search of commonalities and partnership.

Throughout the next two days, cities just building their Pre-K programs were able to learn from cities that have been successful at doing so, like Boston and San Antonio. Political appointees were able to learn from NIEER researchers about the evidence behind what makes a quality early child education program effective, and implementers were able to learn from beneficiaries – parents and workforce representatives – about what is needed on the ground so they can think through how to get there.

From San Francisco to Philadelphia, Albuquerque to Detroit, Austin to Seattle, Fresno to Dallas, we all know that all children deserve high-quality Pre-K to prepare them for kindergarten and a successful future, and need teachers who are prepared to teach them and are well-compensated for doing so. By building strong relationships and a learning community with the people working within our own cities, and across the country, we will all return to our day jobs as stronger advocates for our city’s children.

In small and large groups, we explored the importance and the challenges of building strong relationships between city government and school districts, of aligning various programs, and of using evidence to replicate what works. We discussed how to build data systems to ensure the information that is needed to reach these goals is accessible to all who would benefit from it.

As one participant said, “Quality Pre-K is the social justice issue of our day.” We raised the hard questions of equity – for our students, our families, and our early childhood workforce. We examined what quality means and who needs to be involved to get there. We thought about how to make early childhood inclusive for our dual language learners and for those who learn differently. We started these conversations and recognized how critical it is to continue them – inside and outside of City Hall.

Further Learning:

That’s a Wrap: Texas Legislative Session Produced Progress in the Lone Star State

As the dust settles after the 2019 Texas legislative session, we are reflecting on the significant strides that Texas policymakers made in advancing public health policies. CityHealth congratulates state and city officials for their continued leadership in improving people’s lives and helping communities thrive. This post highlights just a few updates from this year’s legislative session on Tobacco 21, access to high-quality Pre-K, and earned sick leave and shares where to catch CityHealth next in the Lone Star State.

Tobacco 21 is on the Move Across America

On this year’s World No Tobacco Day, I am excited to acknowledge the momentum of policy change in the country right now. There is a movement with real power to pass laws to protect people, especially children, from tobacco and its harms. Tobacco 21 laws, which raise the minimum legal age of sale for tobacco from 18 to 21, are passing in cities and towns all over America. This is something to be proud of – this stunning groundswell of support was simply unthinkable only a few years ago.

How More of Us Can Bike to Work Safely – Today and Everyday

Emiko Atherton

Emiko Atherton

By Emiko Atherton, Vice President, Thriving Communities, Director, National Complete Streets Coalition, Smart Growth America

May 17 is Bike to Work Day--a day celebrated as part of National Bike Month. Here in the Washington, D.C. area, local bike enthusiasts will encourage their fellow residents to join their ranks, fill the streets, and pedal their way to work. Biking to work has several different benefits and allows us all to interact with our communities in new and different ways but it all starts when cities implement comprehensive Complete Streets policies.

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Complete Streets is one of the nine policies our partner, CityHealth, advocates for, as a powerful policy that local leaders can put in place that can transform health for their residents. It helps those who live in cities walk, bike, ride, drive or take public transit safely.

A strong complete streets policy includes street lighting to illuminate the path home from after school activities in the winter, or crosswalks for mothers and fathers to use with strollers and toddlers on the way to the community park, or bike lanes to provide commuting options for those throughout the community.

Additionally, these policies:

· Promote healthy living by helping to reduce the risk of obesity and healthy problems such as diabetes, heart disease and high blood pressure.

· Provide an economic boon to a cities, helping them to avoid a total of $18.1 million in collision and injury costs in one year alone.

· Improve public safety by reducing traffic speed and the risk of injury for pedestrians and cyclists.  

· Enhance a sense of community, improve greenspace and help reduce crime and stress.

The package of local policies that support Complete Streets helps to make communities accessible to all for work and play. As we all dust off our helmets and map our route to work this Bike to Work Day, I hope that all cities stand committed to traveling all of the routes we can to create the healthiest cities possible. 

Find out whether your city has a solid complete streets policy here.

About Smart Growth America and the National Complete Streets Coalition

The National Complete Streets Coalition, a program of Smart Growth America, is a non-profit, non-partisan alliance of public interest organizations and transportation professionals committed to the development and implementation of Complete Streets policies and practices. A nationwide movement launched by the Coalition in 2004, Complete Streets is the integration of people and place in the planning, design, construction, operation, and maintenance of transportation networks. To date, over 700 agencies have adopted Complete Streets policies.

Smart Growth America is the only national organization dedicated to researching, advocating for, and leading coalitions to bring better development to more communities nationwide. From providing more sidewalks to ensuring more homes are built near public transportation or that productive farms remain a part of our communities, smart growth helps make sure people across the nation can live in great neighborhoods.

In the Zone: Women, Alcohol and Violence

By David Jernigan, PhD, CityHealth Senior Policy Advisor

David Jernigan, PhD

David Jernigan, PhD

Study after study has found that concentrations of alcohol outlets – particularly those that sell for consumption off-site – are associated with greater violence and other problems in the neighborhoods around them. Homicides, assaults, robberies and other crimes go up when the number of alcohol outlets in a neighborhood increases.

 Included in this list are intimate partner violence, sexual assault and rape. One study even found that the advertising sexualizing women that often covers the exterior of such establishments was associated with increased assaults on women in those neighborhoods.

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Women are already at a significant disadvantage to men when it comes to drinking. Because of differences in the way male and female bodies metabolize alcohol, the same amount of alcohol will have greater effects on a woman than a man, when drunk at the same pace and by persons of similar body size and drinking history. 

Other consequences of drinking specific to women include higher risk of breast cancer – 15% of U.S. breast cancer cases and deaths from breast cancer are considered attributable to alcohol use. There is no safe level of consumption for alcohol-attributable breast cancer – one study found that a third of the cases happened at levels of consumption of one and a half drinks per day or less.

Drinking among women has been rising in recent years. The amount and frequency of drinking and high-risk drinking by women increased between 2002 and 2012, at the same time that men’s frequency fell. Binge drinking (four or more drinks within two hours for women) rose more than three times as fast among women as among men.

These differences are showing up in local emergency rooms, where visits involving alcohol consumption have risen significantly faster for females than for males in recent years. Between 2002 and 2012, alcohol dependence (addiction) rates fell among men, but not among women. Alcohol causes an estimated 25,693 deaths per year among women nationwide.

Studies have repeatedly connected alcohol outlet density with violence against women. In Bloomington, Indiana, higher off-premise outlet density in a block group was associated with greater intimate partner violence in that block group. In Milwaukee, density of both on- and off-premise alcohol outlets was associated with greater non-intimate partner-related violence against women.

Bars and restaurants, selling for on-premise consumption, have smaller effects on public safety than off-premise outlets, but the effects can still be there. Atlanta found that a three percent drop in on-premise alcohol outlet density in one popular neighborhood was associated with twice as large a drop in exposure to violent crime than two comparable neighborhoods where the number of alcohol outlets increased.

Off-premise outlets, however, seem consistently to have a higher impact on the neighborhood around them, possibly because they increase the supply of alcohol without providing any kind of supervision for the drinking that ensues.

Beginning in the early 1990s, cities across California began to use local zoning tolls to reduce the proliferation of alcohol outlets in their neighborhoods. While licensing of alcohol outlets is often the responsibility of state agencies, zoning in many states is a local power. The best practice has involved setting new, local zoning-based standards for all alcohol outlets, and using a fee on those outlets to fund enforcement of those standards. 

Among the nation’s 40 largest cities, CityHealth has found that just 8 have explicitly taken the kinds of local zoning authority that permit them to control the number of alcohol outlets in a neighborhood. This authority ideally gives local communities the right to a say in the number of outlets that sell for on- or off-premise consumption, and to exercise that right both going forward, for new outlets, and over the number of outlets currently in place.

Taking and exercising cities’ right to a voice in the number, placement and sales and service practices of alcohol outlets within their borders could play a significant role in helping to win that battle.


Too Many Cities Missing Opportunities to Create Lasting Benefits for their Youngest Learners


By Shelley Hearne, President of CityHealth and Ellen Frede, Senior Co-Director at the National Institute for Early Education Research at Rutgers University

Our new national report, Pre-K in American Cities, finds a growing number of large US cities enacting new local funding streams to establish and support Pre-K, yet many programs fail to meet minimum quality standards or serve only a small percentage of eligible children.

Pre-K is a proven policy that every city should employ to ensure all children get a strong and healthy start. High-quality Pre-K provides benefits that go beyond the early years and lays a stronger foundation for later social and economic success and even improved physical health. Most of the large U.S. cities included in the report have a Pre-K program in place, but there is still work to do. To provide children and families the full benefits of Pre-K, city leaders need to design and implement high-quality programs based on research that children and families can readily access.

Based on analysis by NIEER using the same 10 quality standards benchmarks cited in NIEER’s national State of Preschool reports, CityHealth has awarded 5 gold, 8 silver, and 20 bronze medals to cities for Pre-K.

A bronze medal signals that a city meets the criteria for access, a silver represents a city program that mandates quality but provides low accessibility, and a gold medal means that a city earned points for both quality and accessibility in its Pre-K program.

The report is intended to assist localities in determining next steps for providing early learning experiences that improve long-term benefits for children and families. Key findings include:

I. Access is Still Too Low

Access to Pre-K programs is limited in most cities. Only 24 of the 40 largest U.S. cities (60%) offer a Pre-K program that reaches more than 30% of the 4-year-old population.

II. Class Size and Teacher-Student Ratio are Uneven

Just over half of the largest U.S. cities (23 of 40 or 58%) meet quality benchmarks for Pre-K class size, which is one teacher and one teacher assistant for every 20 students.

III. Teacher Preparation is Adequate, but Professional Development and Salary Requirements Are Lacking

Almost two thirds of city programs (25 of 40 or 63%) require Pre-K teachers to have a bachelor’s degree with specialized training in teaching young children, and most programs (34 of 40 or 80%) require at least some specialized training. Only a small fraction of city programs (6 of 40 or 15%) require that all teaching staff receive ongoing professional development. Only 15 (38%) of the rated city programs require that all teachers be paid comparably to those in the K-12 system.

IV. Too Few Cities Conduct Health Screenings

Fewer than a quarter of cities (9 of 40) ensure that children receive vision, hearing, health, and developmental screenings and referrals. The benefits of these screenings are widely recognized by the U.S. Centers for Disease Control and Prevention (CDC), the Institute of Medicine, and the American Academy of Pediatrics.

To see how your city performs in the report, click here.

The report was written in partnership between CityHealth and the National Institute for Early Education Research (NIEER) at the Rutgers University Graduate School of Education. CityHealth, an initiative of the de Beaumont Foundation and Kaiser Permanente, works to advance evidence-based policy solutions with the potential to help millions of people live longer, better lives in vibrant, prosperous communities. One of these policy solutions is access to high-quality Pre-K, which can have significant health benefits for all children, regardless of family income or zip code, when the program’s design adheres to proven practices.

Going for Gold in Texas


By Dave Lofye, CityHealth Texas Director

Everything is bigger in Texas. With a population of 28 million people, Texas is home to six of the 40 largest cities in the country and many of the fastest growing metropolitan areas in the nation. From El Paso to Houston to San Antonio to Fort Worth, every Texas city is unique. Which is why local leaders are taking diverse approaches to adopting public health policies that work for their communities. All eyes were on the Lone Star State last week, as the Texas legislature kicked off its 86th session, and lots of new local leaders took seats at the table across the state. I want to share some of the top developments in Texas that we are watching here at CityHealth.

Local public health leadership is critical. Why? Because Texas communities face big challenges. The state does not perform well on a number of health measures, with some of the highest uninsured rates, obesity rates, and physical inactivity rates nationwide. Since the state is so large and diverse, local governments play an especially crucial role in creating solutions. As Texas cities continue to grow rapidly, building healthy localities where all residents can thrive becomes even more important.

CityHealth is here to help. As Texas Director, I support local leaders who want to adopt a pragmatic and achievable, yet aspirational, package of policies that align with their priorities and needs.  Our nine evidence-based policies help residents lead healthier lives, make communities thrive, and should be among the tools that mayors, city councils, health directors, and city managers use in the pursuit of healthy communities. 

At the 86th Annual Meeting of the U.S. Conference of Mayors in Boston, CityHealth held a medal ceremony to celebrate the cities that show the greatest commitment to policymaking that supports the health and quality of life of their residents over the past year. Mayor Ron Nirenberg of San Antonio was honored by by President of CityHealth, Shelley Hearne, CEO of the de Beaumont Foundation, Brian Castrucci, and Senior Vice President and Community Health Officer of Kaiser Permanente, Bechara Choucair.

At the 86th Annual Meeting of the U.S. Conference of Mayors in Boston, CityHealth held a medal ceremony to celebrate the cities that show the greatest commitment to policymaking that supports the health and quality of life of their residents over the past year. Mayor Ron Nirenberg of San Antonio was honored by by President of CityHealth, Shelley Hearne, CEO of the de Beaumont Foundation, Brian Castrucci, and Senior Vice President and Community Health Officer of Kaiser Permanente, Bechara Choucair.

In 2018, three of the six CityHealth cities in Texas earned an overall CityHealth medal. Austin and Houston earned bronze medals while San Antonio earned a silver medal. Austin and San Antonio have earned an overall medal since 2017, showing that Texas cities are on the move when it comes to adopting the CityHealth package. The remaining three cities—Dallas, Fort Worth, and El Paso—have not yet earned an overall CityHealth medal but are well positioned to do so in the future. As we enter 2019, we reflect back on some of the biggest accomplishments in Texas on CityHealth-aligned policies and take a look at what to expect in the next year.

To see which medal your city earned, click here.

New Developments in Texas Cities. San Antonio remains the first city in Texas to adopt a Tobacco 21 ordinance, meaning someone must be age 21 to purchase tobacco products in San Antonio. This new law went into effect in October 2018 and is providing significant momentum for adoption of a statewide Tobacco 21 law during the 2019 legislative session. (To learn more about the Tobacco 21 ordinance in San Antonio, check out our Policymaker Webinar with Dr. Colleen Bridger, the Health Director of the San Antonio Metropolitan Health District.)

In Dallas, residents approved a ballot measure in November to increase funding for schools, including Pre-Kindergarten programs. The funding will go to the Dallas Independent School District, which previously released data showing that students who attended pre-kindergarten programs outperformed their peers on third grade standardized tests. Dallas currently earns a bronze medal for its pre-kindergarten program; the program meets enrollment standards but only five of CityHealth’s 10 quality benchmarks identified by the National Institute for Early Education Research.

Over the past year, the city councils of Austin and San Antonio approved earned sick leave ordinances. These laws require employers to allow employees to take paid time off for illnesses or injuries for themselves or their family members. These measures have been controversial, resulting in legal challenges in both cities and the threat of preemption by the state legislature. CityHealth will continue tracking these developments as they occur.

Other Texas cities continue to promote public health-focused policies that are aligned with CityHealth. Fort Worth recently received certification as a Blue Zones Community—which was the culmination of a five-year initiative to improve the well-being of city residents—and additional honors for Mayor Betsy Price’s FitWorth initiative. El Paso’s Department of Public Health was recently awarded for its leadership in addressing chronic disease and promoting healthy lifestyles. The Houston Health Department was also recognized last year for efforts to help residents improve the health and well-being of their communities through advocacy.

What’s Next in Texas? Over the past year, CityHealth is proud to have worked with local leaders, community partners, and other key stakeholders—from MD Anderson to the American Heart Association to local chambers of commerce to elected officials. We were honored to cosponsor a Texas Tribune health care panel in El Paso that featured members of the El Paso delegation to the state legislature and thrilled to see CityHealth highlighted at the Healthier Texas Summit by Dr. Karen DeSalvo when discussing her vision for “public health 3.0.”

Over the next year, CityHealth will continue to build partnerships, support local leaders, and help advance evidence-based public health policies that Texas cities need. We’ll keep an eye on the state legislature and keep you posted on the progress being made as Texas’ largest cities move to adopt CityHealth policies that give residents an equal opportunity to live full and healthy lives.

A Tale of Two Cities: The Catastrophic 1918 Flu Pandemic Can Guide City Policymakers Today

Shelley headshot.jpeg

By Shelley Hearne, DrPH, President of CityHealth

One hundred years ago, in 1918, a novel virus swept the globe, infecting at least 500 million people – one third of the world’s population –and killing an estimated 50 million people worldwide.  Sometimes referred to as the “Spanish Flu,” it was one of the deadliest disease outbreaks in recorded history.  About 675,000 people in the United States died in the pandemic, according to the U.S. Centers for Disease Control and Prevention.

Scientists know that it is simply a matter of time before another new viral threat emerges. As such, in addition to basic medical preparedness, vaccine development, and global surveillance, we must remember to learn from history to ensure not to repeat past missteps. Some of those century old lessons can save lives today. 

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Let’s take a look back at how two cities that acted differently when faced with a health risk can provide insights for today’s leaders.

In Philadelphia, on September 28, 1918, nearly 200,000 people attended a parade for the war effort, even though 10 days earlier, the city’s naval shipyard was infested with the influenza virus. The city’s leadership allowed the parade to go on, despite the health risks, and they experienced the consequences of doing so in lives lost.   Within the two weeks after the parade, more than 600 Philadelphians died from the virus. At the peak of the Philadelphia epidemic, 1,700 citizens died on a single day.

Now, let’s go to St. Louis, which back then was one of the top ten largest U.S. cities. Under the leadership of its Health Commissioner, Dr. Max Starkloff, the city canceled public gatherings, from football games to Halloween parties, closed schools for ten weeks, and even stationed police officers in department stores to keep people from lingering. While businesses bitterly complained, the commissioner was a long-term, well-trusted health expert who had the courage to champion bold actions that other cities resisted.

St. Louis took action within a day of the first cases arriving. Philadelphia waited for over a week before taking infection prevention steps.

Based on a 2007 Journal of the American Medical Association article, researchers found St. Louis experienced one of the lowest excess death rates in the nation: 358 per 100,000 people. In contrast, Philadelphia’s was over twice as high, with 748 excess deaths per 100,000.

Why are we now talking about this tragic event that occurred a century ago?  While the world is different today, lives are still at stake when policies are not put in place from the top down to prevent the spread of disease or create healthy living conditions. Strong health leadership matters in making sure smart policies are put in place.

One policy that can help encourage people to stay home when they are sick – and prevent the spread of disease – is an earned sick leave law.  This law requires employers to allow people to take paid time off for illness or injury for themselves or their family members.  By allowing people to take time off when they are sick, the spread of infectious disease is reduced.  This is an especially important issue for people who work in the food industry or care for children or the elderly. 

 We don’t need a global pandemic to see that policy saves lives. The current hepatitis A outbreak hammers home the importance of earned sick leave policies for all workers. For instance, in 2018, San Diego County experienced a public health crisis, with the nation’s largest hepatitis A outbreak in years. County officials took a range of actions to reduce risks, and now San Diego has one of the best sick leave policies in the country, earning a gold medal from CityHealth. Other cities are now fighting hepatitis A, norovirus, and other outbreaks that could be better limited with widespread earned sick leave policies. Last year, a Detroit resident who worked as a crewmember at McDonald’s was diagnosed with hepatitis A, exposing countless customers to the virus. CityHealth reports no medal for earned sick leave in Detroit.  

Look here to see whether your city has a strong earned leave policy.

So, what are the lessons today of the Spanish Flu of 1918?

  • Policies matter.  Policies such as earned sick leave, affordable housing to avoid unsafe, overcrowded conditions or restaurant grading can create healthier urban environments.

  • Leadership matters. The lead health official should be the city’s chief health strategist - a trusted, respected, knowledgeable professional who is engaged with policymaking at the cabinet level, empowered to be a health champion, and skilled in difficult decision-making situations.

  • Sharing resources and strategies is critical.  Information and resources must be shared between cities, counties, states and the federal government. Strong relationships between health leaders – like those fostered by the Big Cities Health Coalition – allow innovations, successes, and failures to be learned quickly.

At the 100th year anniversary, let’s reflect back on the profound, devastating impact the “Spanish Flu” had on this country’s cities and have it serve as an important reminder for today’s metropolitan leaders. Smart policies and strong leaders will better protect our health and our families, whether it's a moment of medical crisis or for our long-term well being.