By: Katrina Forrest
This year marks CityHealth’s 10-year anniversary; a moment to celebrate the incredible progress cities have made to advance health, equity, and opportunity, and a chance for me to reflect on what it truly takes to drive public health policy change.
Learn about CityHealth’s first five years in 2021 retrospective.
As CityHealth’s executive director, I’ve seen firsthand how CityHealth has worked alongside city leaders, advocates, researchers, and other key stakeholders to assess policies, elevate best practices, and help create healthier conditions for millions of residents. Along the way, I’ve learned a few lessons, some affirming and some humbling, about how public health policy change really happens.
Here are five that stand out:
1. Policy change is rarely linear, but that doesn’t mean failure.
I’ve spent my career working in local government, so policymaking is both familiar and continuously relearned. When you’re outside of government, it’s tempting to think of policy change as a straight line: identify the problem, propose a solution, pass a policy, measure success. In practice, progress is uneven. Cities advance, stall, slip, recalibrate, and try again.
Over the past 10 years, CityHealth has seen cities adopt strong policies only to struggle with implementation, while others make modest, incremental improvements that eventually lead to transformative change. The lesson is clear: setbacks are part of the work, not evidence that the work isn’t worth doing. Durable change often comes from persistence, iteration, and timing — not perfection.
2. Data opens doors, but relationships move policy.
CityHealth was built on the idea that clear, comparable data can motivate action, and it does. Our assessments have helped city officials see where they stand and what’s possible. But data alone rarely changes policy. Relationships do. Trust between advocates, policymakers, collaboration across departments, and sustained engagement with local leaders and community partners are what turn evidence into action. Data is not the final word but a conversation starter, one that’s most powerful when paired with local leadership and lived experience.
3. City leadership is catalytic.
One of the most striking lessons of the past decade is just how often cities step up when higher levels of government stall. Whether on Earned Sick Leave, housing protections, food access, or tobacco control, I’ve watched cities test and implement solutions long before they became mainstream.
In CityHealth’s first policy package, the initiative was advancing Tobacco 21 (T21), a policy that increased the minimum age of sale for all tobacco and nicotine products from 18 to 21. At the outset, we didn’t believe movement would be possible in our Texas cities. Yet on January 11, 2018, San Antonio adopted T21. The policy was then adopted statewide the following year when the Texas legislature passed its law, and on December 20, 2019, T21 became the law of the land when it passed federally.
Local leadership led the way. Through sustained efforts across cities nationwide, local action helped catalyze federal policy adoption.
City leadership matters because cities are closest to the people most affected by policy decisions. That proximity allows for faster learning, adaptation, and accountability. While city action alone can’t solve every structural challenge, it often sets the pace and the proof point for broader change.
4. Equity must be explicit, or it gets left behind.
Health inequities don’t disappear simply because a policy is labeled, “good for everyone.” I’ve seen repeatedly that unless equity is intentionally built into policy design, implementation, and evaluation, the benefits often flow to those who already have the most access and power.
This reality has pushed me and CityHealth to center equity more explicitly, not as an add-on but as a core measure of policy success. It has meant asking harder questions: Who benefits? Who is burdened? Who is at the table? Progress requires naming inequities clearly and designing policies that focus on outcomes, not labels.
In an environment where equity initiatives have faced political and legal pushback, the work requires both principle and pragmatism. The goal is to continue reducing disparities and addressing inequities in meaningful ways without losing sight of the communities we serve or undermining partnerships or compliance in a shifting regulatory landscape. Equity work today isn’t about avoiding controversy; it’s about being clear about what we’re trying to achieve, communicating those goals in ways that resonate broadly, and sustaining commitments.
5. Change happens because people choose to stay in the work.
The most important lesson I’ve learned is the simplest: public health policy change happens because people don’t give up. They stay the course.
CityHealth’s story is ultimately the story of mayors, councilmembers, health officials, advocates, researchers, community partners, and others who kept pushing—often in the face of political resistance, limited resources, or public skepticism. Ten years of health progress didn’t come from a single breakthrough moment, but from thousands of impactful decisions to keep showing up, keep learning, and keep improving.
Looking Ahead
As I reflect on CityHealth’s first 10 years, I’m proud of how far cities have come, and I’m clear-eyed about how much work remains. The challenges facing public health today are complex and evolving, but the lessons of the past decade reinforce what I know to be true: progress is possible when evidence, equity, and local leadership are aligned.
The next 10 years will require the same commitment to learning, to partnership, and to the unwavering belief that policy can and should improve people’s lives. As the landscape shifts, we’ll need focus, humility, adaptability, and resolve. While the road ahead will not be easy, I am excited to continue this work alongside the cities and leaders devoted to strengthening health and opportunity and delivering tangible results for the residents they serve.
Katrina Forrest, JD, is Executive Director of CityHealth.
