The Bloomberg American Health Initiative

In September 2016, Bloomberg Philanthropies made a $300 million gift to the Johns Hopkins Bloomberg School of Public Health on the occasion of the school’s 100th anniversary. The gift’s purpose was to improve health in the United States by focusing on 5 areas: addiction and overdose, violence, obesity and the food system, environmental challenges, and risks to adolescent health. All 5 areas of focus are serious health problems facing the nation, with deep connections to economic and social factors; none have quick fixes. In making this gift, Bloomberg Philanthropies sought to stimulate broader and more effective public health responses to these problems.

It is no coincidence that the gift arrived at a time of dispiriting headlines about the state of health in the United States. Despite enormous progress during the last century, with major declines in infectious disease, noncommunicable diseases, and injuries, as well as a dramatic increase in life expectancy at birth, progress is stalling. Life expectancy has stopped growing; indeed, it declined for 2 consecutive years. ¹ The opioid epidemic is claiming more than 40 000 lives per year, ² suicide rates are rising, ³ and obesity rates among adults are increasing. ⁴ These and other issues are complicated by unfortunate shifts in health disparities ⁵ and by deteriorating physical infrastructure in both urban ⁶ and rural ⁷ areas.

How can a school of public health support the field of public health in addressing these complex health and social problems? This question is at the heart of the Bloomberg American Health Initiative (hereinafter, the Initiative), the program launched with the new funds.

During its first 2 years, the Initiative has convened partners from across the country, both inside and outside of academia, to identify key issues and opportunities for making meaningful progress on each of the 5 targeted public health challenges. Many of these issues and opportunities are captured in the detailed articles included in this supplemental issue of Public Health Reports. Initial areas identified for action included: stigma that impedes treatment seeking and shapes societal beliefs about appropriate community responses to the opioid epidemic ⁸ ; underappreciated connections among intimate partner violence, suicide, and community violence ⁹ ; systems approaches to the obesity epidemic ¹⁰ ; changes to infrastructure and community design that enhance environmental health ¹¹ ; and programs and policies to prevent high-risk young people from becoming disconnected from school and work. ¹²

Faculty engaged in the Initiative have also identified cross-cutting themes that are critical to success. One theme is the need for relevant evidence to drive policy. ¹³ However, the kind of evidence produced through academic research and the way that evidence is packaged and communicated do not always meet the needs of policy makers and practitioners. In addition, critical analyses are often limited by inadequate, poorly integrated longitudinal data and lack of useful evaluation of policies and programs. The Initiative is seeking opportunities to develop stronger collaborations between schools and programs of public health and policy makers to coproduce research that will lead to evidence that is accessible, applicable, and impactful.

A second theme is that the field of public health alone cannot succeed in addressing problems that reflect deep inequities in our society. ¹⁴ This theme is a central insight of the Robert Wood Johnson Foundation’s Culture of Health action framework, in which “health become[s] a national priority, valued and advanced by collaborators among many sectors of society.” ¹⁵ A focus on equity, community engagement, and leadership ¹⁴ is necessary to address the role of what have been described as “the social, political, and economic foundations that determine population health.” ¹⁶ Public Health 3.0, an initiative launched by the US Department of Health and Human Services in 2016, calls for health agencies to serve as strategists for the cross-sectoral collaboration needed for meaningful improvements in health. ¹⁷ This vision has important implications for training public health students today. More than ever before, it is important that students learn effective communications and health advocacy skills, leadership and negotiation skills, and a systems approach for identifying sustainable public health solutions.

A third cross-cutting theme recognizes that public health can assume a more prominent role in creating policy change. ¹⁸ Many individuals and organizations across multiple fields have tried to tackle such issues as addiction, violence, and obesity; few have succeeded. Energetic policy engagement by public health practitioners, as well as by faculty at schools and programs of public health, can point the way to greater use of evidence-based strategies. For example, several faculty involved in the Initiative worked closely with subject matter experts at Boston University and a group of police chiefs to formulate 10 “standards of care” for policing to address the opioid epidemic. ¹⁹ These standards include training on stigma, advocating for medication-assisted treatment, supporting syringe exchange programs, and encouraging community dialogue on other harm-reduction strategies, among others.

These insights have informed investments by the Initiative in education, research, and practice. Of the $300 million gift, $120 million is endowing a structured scholarship program at the Johns Hopkins Bloomberg School of Public Health. Each fellow will be recruited from an organization working to address 1 of the 5 targeted public health challenges. After graduation, these students will return to their organizations for at least 1 year, during which the Johns Hopkins Bloomberg School of Public Health will seek to engage the graduates and their organizations in ongoing collaborations. The Initiative’s goal is to recruit fellows from organizations both inside and outside the traditional boundaries of public health. To address violence, for example, the Initiative aims to recruit fellows from among criminal justice and community leaders. To address obesity and the food system problems, students recruited from state and local planning agencies may prepare reports on gaps in access to healthy foods—and then return to their agencies to implement the strategies to close these gaps. To improve adolescent health, the Initiative aims to train teachers and educators to develop and implement successful strategies that reduce absenteeism, risky behavior, and dropout rates.

By following this approach, the Initiative is expanding on efforts by the Centers for Disease Control and Prevention in 2003 to train non−public health professionals, such as police officers and prosecutors, in the principles of epidemiology. ²⁰ Organizations with fellows in the first 2 years include Outside In, which runs a syringe exchange program in Portland, Oregon; Centro SOL (Center for Salud/Health & Opportunity for Latinos), which promotes health equity as well as social and economic opportunities for the Latino community in Baltimore, Maryland; the New York/New Jersey High Intensity Drug Trafficking Area Office; and the health departments of Philadelphia, Rhode Island, and Frederick County, Maryland. The endowment provides full tuition for 50 master’s students and 10 doctoral students every year.

The Initiative also aims to advance research and practice efforts in and across the 5 focus areas. A $100 million endowment will support 25 junior and senior faculty to help lead the Initiative in developing deep connections with researchers and practitioners across the country. A complementary $25 million endowment will fund research at the Johns Hopkins Bloomberg School of Public Health and its partner organizations on the causes of and solutions to the targeted challenges.

The remaining support will be spent during the next decade on a series of projects including higher-risk, innovative efforts to spark new ways of responding to urgent public health challenges. For example, the Initiative supported a collaboration between researchers at Johns Hopkins University and Brown University to assess technologies for field-based identification of fentanyl, a high-potency opioid responsible for more than 20 000 overdose deaths in 2016. ²¹ The study found that test strips, originally developed for urine samples, had high sensitivity and specificity for detecting fentanyl in illicit drugs. ²² Interviews with more than 300 people who use drugs and with people who work in syringe exchange programs and other harm-reduction organizations indicated interest in incorporating this technology as part of a consumer safety strategy to save lives. Numerous federal, state, and local public health agencies and community organizations have already expressed interest in learning more about or adopting this approach.

The Initiative aspires to narrow the gap between evidence and policy in the 5 focus areas. Efforts so far have included assistance with the development of opioid epidemic response plans in Delaware, ²³ West Virginia (with faculty from West Virginia University and Marshall University), ²⁴ Staten Island (with faculty from New York University and Yeshiva University), ²⁵ and Rhode Island (with faculty from Brown University). ²⁶ The Initiative has funded faculty at Johns Hopkins to help 2 rural counties understand the scale of the problem of intravenous drug use and what can be done to help those who are affected; to help 2 states implement new laws that permit temporary removal of guns from people who are a threat to themselves or others; and to work with Baltimore leaders to develop effective approaches to gun law enforcement that are also acceptable to local communities.

To provide opportunities for researchers and practitioners to share knowledge and experience, and to highlight specific needs for future work, the Initiative will host its first annual meeting in November 2018. In the future, the Initiative will also regularly review its processes and outcomes in education, research, and practice.

A century ago, the nation’s health was worse than it is today. Average life expectancy at birth, which had barely crossed 50 years for white Americans, had not yet reached 40 years for African Americans. ²⁷ Many people died too young of infectious disease because of unsanitary conditions; among the top causes of death were pneumonia, tuberculosis, and diarrheal disease. ²⁸ About 675 000 Americans died from the devastating influenza pandemic of 1918 and 1919. ²⁹ Yet a historic commitment to the new field of public health was laying the foundation for a brighter future. Local government agencies, such as those in New York and Michigan, and private philanthropists led by John D. Rockefeller invested in public health research, education, and programs. Within 75 years, advances in hygiene and sanitation—including improved nutrition, child labor laws, injury prevention programs, and the development of vaccines and antimicrobials—had changed the world. The scourge of smallpox had been eradicated, and average life expectancy increased by more than 2 decades. ²²

Although it can be dispiriting to contemplate the health challenges facing the United States today, it is the nature of public health to tackle seemingly impossible tasks. The Bloomberg American Health Initiative aims to tap into this spirit and support organizations, researchers, and leaders across the country in bringing the power of public health to bear on some of the nation’s greatest health challenges.