Editor’s note: This is the first of a periodic series of Health Affairs Blog posts discussing the Culture of Health. In 2014 the Robert Wood Johnson Foundation announced its Culture of Health initiative, which promotes health, well-being, and equity. The initiative identifies roles for individuals, communities, commercial entities, and public policy that extend beyond the reach of medical care into sectors not traditionally associated with health. Health Affairs is planning a theme issue in November 2016 that will explore various aspects of the Culture of Health.

In the aftermath of the unrest sparked by Freddie Gray’s death in April 2015, Baltimore City was thrust into the national spotlight. Glaringly absent from the mainstream media discussion, however, was dialogue around systemic health disparities — an issue deeply intertwined with race, poverty, and social justice.

Baltimore faces a mortality rate 30 percent higher than the rest of Maryland and ranks last in the state on nearly all key health outcomes. This reality is compounded by a series of complex social, economic, and political determinants of health: more than one in three of Baltimore’s children live below the federal poverty line, and more than 30 percent of Baltimore households earn less than $25,000/year.

Baltimore houses some of the best health care institutions in the country, yet significant disparities exist. We know that this is largely because health care alone cannot drive health. While 97 percent of health care costs are spent on medical care delivered in hospitals, only 10 percent of what determines life-expectancy takes place within the four walls of a health care facility. Where we live, work, and play each day drives our health and well-being.

As the oldest, continuously operating health department in the country, the Baltimore City Health Department (BCHD)’s mission and mandate is to promote a culture of health throughout the city via a comprehensive spectrum of service delivery, advocacy, education, and strategic partnerships that bridge the gap between the clinic and the community.

Our Culture of Health approach contains four key prongs:

Building Unconventional, Cross-Sector Coalitions To Leverage Best-Practice Models

B’More for Healthy Babies is a city-wide public-private partnership developed to decrease the city’s infant mortality rate. Drawing upon the unique expertise of local businesses, foundations, and faith/community-based organizations, the program has reduced the infant mortality rate in the city by 28 percent, decreased the teen birth rate by 36 percent, and closed the disparity between black and white infant deaths by almost 40 percent.

Engaging And Empowering Communities To Tackle Health

BCHD deploys peer-based models that draw on community expertise while increasing economic opportunity. For example, our Safe Streets program takes a public health approach to violence prevention. Safe Streets uses ex-felons who know their surrounding communities intimately to serve as “violence interrupters”; their lived experience allows them to build relationships with local youth and intervene directly at the point of conflict. In 2014, Safe Streets facilitated 15,000 client interactions and mediated 800 conflicts, more than 80 percent of which were deemed likely or very likely to have resulted in gun violence.

Connecting Health Care And Public Health

As a neutral convener, BCHD brings together hundreds of local stakeholders to create city-wide alignment around topics including opioid prescription best practices, high-utilizer case management, and trauma interventions. Our Local Health Improvement Council, which consists of hospitals, federally qualified health centers, community-based organizations, and faith leaders enables us to break out of our silos and move forward on shared, city-wide health priorities. In response to the opioid epidemic sweeping our country, we have convened thousands of physicians, pharmacists, and city outreach workers to develop one of the nation’s most aggressive opioid overdose prevention and treatment campaigns.

Making Health A Shared Value Across Policies

Health is foundational to every issue: Unhealthy children cannot learn in school; unhealthy adults cannot be a productive part of the workforce. BCHD’s cutting-edge overdose prevention strategy leverages collaborations with the police department, the local behavioral health authority, emergency medical services, and others to ensure that we are treating addiction as a disease and focusing on saving lives.

Developing a robust culture of health requires significant paradigm shifts in how we approach the roles of public health and local health departments. BCHD has learned the following lessons in how health departments can lead the way:

1. Health-in-All-Policies

Health impacts all sectors, and we believe it is crucial to incorporate the public health perspective into all policy development and decision-making. For example, significant attention has been paid to criminal justice reform here in Baltimore and throughout Maryland. Too often, however, those conversations focus only downstream, on what happens to an individual after they have already intersected with the jails or courts.

To truly break the cycle of violence, we must focus farther upstream. For example, if kids are unable to see in school, they cannot learn, increasing the likelihood that they will drop out and turn to violence. This spring, we launched Vision for Baltimore, a comprehensive program that will enable Baltimore City students in Kindergarten to Eighth Grade to receive vision screenings and glasses.

2. New Funding Mechanisms

To build a true culture of health, we must ensure that our innovative public health models are sustainable. As the policy and financial landscape continues to swing towards population health, we are exploring multiple models for long-term funding, from Medicaid reimbursement to community financing and loan programs.

Key to these funding partnerships is a business approach to public health. We know that our work provides value not just in terms of health outcomes but also workforce productivity, improved social outcomes, and more. Our goal is to capture the long-term return-on-investment of our public health interventions and make this case to policymakers, philanthropists, and private funders.

3. Public Health Data

Now more than ever, it is essential that we link across existing health and social service data silos. Data can serve as a powerful tool in targeting and delivering services, but this requires overcoming the fragmentation of existing systems.

As a Robert Wood Johnson Foundation Data-Sharing Across Sectors for Health (DASH) grantee, BCHD is building a data ecosystem to predict and prevent falls amongst seniors. We will do so by identifying and integrating data sets from across city agencies, health care institutions, and community organizations, as well as tackling the legal and partnership frameworks that go with that work.

At BCHD, we have moved beyond the traditional role of the local health department to convene others in the city around innovative public health models that directly address upstream factors of health. We are building a 21st century vision of public health that will make our city healthier and more productive.