Healthy Cities Rankings

There is something about human nature that makes us want to compare ourselves with others. When I was in school I used to hate it when classmates would ask what I got on the test, but I was guilty of doing it as well. An extension of this tendency is that we even compare things in which we are involved only indirectly or not at all. We compare the best and worst dressed celebrities, the most attractive rag top autos, the best beaches. This is an indoor sport for many people, and makes for pleasant off the clock chatter.

Among all the types of comparisons and list making, rankings of the healthiest places to live appear in the media or online from time to time. Like all listings and rankings, identifying the most and least healthy places is an inexact science, to say the least. The label "healthiest city" is not valid because there is no universal standard. In fact, there are several different lists, and each one defines and measures "healthiest" in different ways. It may include death rates, infant death rates, rates of hospitalization and average length of stay in hospitals, the proportion of people who smoke, the median body mass index (BMI) as an indicator of prevailing overweight and obesity, number of people for each physician, dentist, and mental health counselor, miles of bike lanes per person, and many more considerations. Depending on which variables are included in the determination of healthiest, and how those variables are weighted, the ranking will vary greatly for the same city.

The rankings don't explain why a city is high or low on the list. For example, the city of Louisville ranks low on at least one listing, due to a high smoking rate, compared to many other communities. The ranking doesn’t explain why there is so much smoking here. On the other hand, New Orleans also ranks low, in part because its infrastructure is crumbling, due to poverty, disruption of community services stemming from Hurricane Katrina, and now the economic turmoil caused by the BP oil spill. While Louisville’s ranking is low, it is not a reason for someone to not want to live there because the smoking mostly effects smokers. On the other hand, the problems in New Orleans effect all residents. Rankings should be probed to understand what they mean to present or potential residents.

Within each city there is a great diversity in health status between individuals. Individual level health status tracks with education, income, housing and neighborhood qualities, as well as personal lifestyle habits. Even in places judged to be unhealthy over all will have some very healthy persons. Those cities considered very health will have some people in very poor health. The common rankings don’t adjust for population differences which may be important. For example, because Tampa has a lot of retired, older people, we would expect its health profile to be different than cities like Seattle or Anchorage, AK, which tend to have a much younger population. Somehow it is not quite right to judge Tampa as an unhealthy city, just because of an aging population.

What, then, is the practical value of these rankings. In a broader sense there is good reason to assess a community’s health and well being. This is routine practice in health promotion and public health, so that we take a periodic community pulse to see if progress is being made. It is also useful data to serve as the basis for making program decisions. For example, what health problem deserves the most attention in your neighborhood or community? Is it HIV, childhood asthma, skin cancer, or teen pregnancy? An answer has to be based on data, not just arbitrary choices.

Just the concept of healthiest city implies that we are all connected, and that there are aspects of health which are group concerns. There is a lot about your health which depends on your choices and actions as an individual. For example, you have to decide portion size and what foods you eat. The community can influence but ultimately you decide. To a greater extent than most people realize, your health is also dependent on community decisions and policies which provide circumstances under which all people can thrive. It is not just about me or just about you, it is often about us.