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When he entered Harvard Medical School planning to become a pediatrician, Jonathan Fielding didn't expect that he'd one day oversee the health of more than 10 million "patients." But that's what he has done since 1998 as founding director of the Los Angeles County Department of Public Health. Best known as the man whose signature appears below every L.A. restaurant letter grade, Fielding and his 4,000-person staff are charged with working to prevent or react to health threats such as food-borne illnesses, infectious disease outbreaks, natural and man-made disasters, toxic exposures and preventable injuries, while also reducing the burden of heart disease, cancer, diabetes and other chronic diseases through health-promotion strategies. On top of all that, Fielding remains an active faculty member at the UCLA Jonathan and Karin Fielding School of Public Health — renamed in 2012 in recognition of a $50-million gift from the public health icon and his wife.
The epiphany that redirected Fielding to a career in public health came during his pediatric training, when he was struck by the limitations of clinical practice. "I saw problems of poverty and families that couldn't afford enough food," he says. "I saw terrible mental-health problems that weren't getting attention. I saw parental substance abuse that was affecting kids. I saw neglect and lack of stimulation. And there was precious little I could do to solve these problems on an individual level."
Nearly a half-century later, Fielding observes, many people continue to think of health only as what occurs in the doctor's office. Health care accounts for roughly 20 percent of the equation — but about 97 percent of investments to improve health.
In fact, Fielding notes, a big piece of the health puzzle — accounting for about 40 percent of the health differences among populations — is social environment. Another 10 percent of the differences stems from the physical environment — whether there are walkable and bikeable neighborhoods and efficient mass transit, etc. Thirty percent is individual behavior. (Do you smoke?) And these decisions, too, are influenced by environment: Are you surrounded by fast-food restaurants? Is fresh produce readily available in your neighborhood? If so, can you afford it?
Under Fielding's leadership, L.A. County's public health department has earned a reputation for innovative initiatives. The department's chronic disease control program has forged partnerships with community based organizations to promote healthful nutrition, physical activity and tobacco prevention, while working with city governments to advance policies on everything from antismoking ordinances to developments that encourage walking and bicycling. The county's aggressive emergency preparedness programs — for both natural disasters and the threat of terrorism — have been widely emulated, as has the restaurant-grading program, which Fielding implemented shortly after taking the job. "We wanted to provide the information consumers needed to make better-informed decisions about where they ate," he says. In addition to reducing foodborne illnesses, the system of inspections and mandatory posting of results has motivated establishments to remain pristine, because a higher grade equals improved business.
More recently, with overweight and obesity rates high on the list of public health concerns in Los Angeles, as elsewhere, Fielding's department has worked with restaurants to reduce portion size, include fruits and vegetables in kids' meals, and inform customers of calorie counts on their menu options. (Fielding hasn't been willing to go as far as former New York City Mayor Michael Bloomberg's controversial big-soda-cup ban; the portion-size initiative is voluntary. "We have to be careful not to overstep our bounds," he says.)