Six weeks after Li Wenliang blew the whistle in Wuhan on an emerging infectious disease in early 2020, cities around the world locked down and turned into hotspots. From Rome to Tokyo to San Francisco and Los Angeles, COVID-19 ripped through the most populated areas of the world. By the end of that year, America’s cities—Detroit, Boston, and New Orleans among them—had death rates from the virus 20 percent higher than other regions of the country.
In New York, where I serve as health commissioner, almost 50,000 residents died, the majority in the first three months, denting New Yorkers’ life expectancy by nearly five years. It was the steepest drop in lifespan in the world that year.
Public health institutions and the field as a whole learned much from our successes and failures during the pandemic. The critical nature of healthcare supply chains; supporting our public health workforce, especially at the front lines; the essential process of community engagement for healthcare promotion, vaccination, and disease prevention; the importance of combatting misinformation and disinformation online and in person; the need to tear down our data silos so we can make faster, better decisions. The list goes on and on.
However, as new threats arise and old ones intensify, there is still much to learn. Cities—concrete jungles that experienced the worst of COVID-19, and in some ways, struggled the most with the public health response in the early days of the pandemic—may be our best teachers on how to keep our world safe and healthy.
That’s because the sentinel cases for brooding public health threats, whether infectious or not, are often in cities. Cities are the canaries in the public health coal mine, for everything from mental health and homelessness, climate change to forced migration, substance use to sex trafficking. The way these challenges play out across our cities should not only drive national policy, but also serve as an important corollary for how to respond in less dense, less diverse, more rural areas. Yet when we consider the multilateral institutions where decisions are made and policymaking happens, cities rarely have any role in governance.
The reasons for city-as-public-health-epicenter are simultaneously obvious and not so obvious. For one, urban densification has accounted for the majority of population growth, even as land mass occupied by cities is growing. Today, around 56 percent of the world’s population live in cities—a percentage that experts expect will grow to 70 percent, with population doubling, by 2050. There is also the historic boom in airplane travel both domestically and internationally, which means communicable diseases (like SARS, swine flu, and mpox) can leap across borders faster than ever, quickly overtaking cities’ health systems.
An example of this in New York City in 2022 was when an old virus, mpox (formerly known as monkeypox), began circulating in explosive new ways among men who have sex with men. NYC had become the national and global epicenter.
Despite facing critical shortages of vaccine, in June 2022 we began vaccinating men who had the highest risk of getting infected, well ahead of the anyone else in the nation, including the federal government. This critical intervention to curb the virus’s spread helped bend the curve of mpox within a few weeks, by early August. Not only did our response set the tone for the rest of the national mpox response, it also influenced the way in which many other global centers responded.
The same happened with tuberculosis (TB), another old microbe—and one that remains a leading infectious killer in the world. Between 2022 and 2023, the U.S. has seen a dramatic 14 percent year-on-year increase in tuberculosis cases nationwide. NYC is once again at the country’s frontlines, with a 28 percent increase over the same period. The drivers of TB’s resurgence are manifold, but one is the shifting pattern of migration worldwide due to climate change, war, and economic and political instability.
NYC health officials again leapt into action. We not only increased investment into our TB program in response, but since 2014 have pioneered new and effective ways to control the disease including award-winning “video directly observed therapy” where a health worker observes the patient taking their daily medications. This telehealth protocol has now become a part of TB control guidance recommended by the World Health Organization.
But while cities like New York are battling disease threats with drive and innovation, a lack of formal representation in multilateral institutions means that cities are more susceptible to security concerns, bioterrorism, and economic disruption. Cities are largely expected to navigate their response to global health crises in silos, without a clear and dedicated means to exchange ideas between them. Moreover, they typically do not have a meaningful say in how their national counterparts navigate domestic responses or global deliberations.
That was New York City’s early experience during the pandemic.
As COVID-19 tore through our five boroughs in the early weeks and months—from Sheepshead Bay and Jamaica to Battery Park, Harlem and Hunts Point—New York’s public health authorities produced their own messaging campaigns; partnered with private corporations and others to source materials and protective equipment for healthcare workers to care for those in need; stood up a free testing network, and later; designed their own vaccine distribution system and engaged deeply with communities to promote vaccine uptake. These responses were—especially early in the pandemic—developed in the absence of clear national and international guidance, or resources. And our experience in the start-up phase of the pandemic response was not unique, with cities from Los Angeles to Chicago to Boston to Miami facing similar challenges.
If we don’t formally involve cities in our national systems for disease surveillance and public health response, we lose out. Best practices disappear into the archives. Innovative strategies collect dust in the pages of textbooks and journals. How can cities effectively respond to burgeoning health threats when institutional memory fades, and when protocols developed at national scale lack the specificity or practicality to actualize in our alleys or on our sidewalks?
A better strategy may pull from the discipline of political science: specifically, a concept known as “inclusive multilateralism.” This concept, which refers to the participation of non-nation states in multilateral institutions and processes, narrows the gap between the high-level authorities handing down policy decisions and the communities on the ground who are expected to make them come to life. It has allowed for civil society, nongovernmental organizations, the private sector, and other stakeholders to have a formal role in the most critical multilateral governance structures in the world, from international security to climate change bodies. It also creates a critical set of checks and balances, ensuring that special interests or anti-democratic actors, influencing national governments and elected leaders, do not have outsized sway in international decision-making by having representation of sectors outside of national politics.
In health, for instance, the Global Fund to Fight AIDS, TB, and malaria, among others, have since inception had official civil society and private sector representation on its governing board and country coordinating bodies.
There is a growing appetite for cities to have such a formal leadership role, not only to share local experiences, best practices, innovations, and data, but also to build collaborations for emergencies. In remarks made during an event honoring the United Nations’ 75th Anniversary in 2020, Secretary General António Guterres specifically called out the need to draw on the “critical contributions” of cities and regional governments. Similarly, the 2017 Partnership for Healthy Cities launch stated that “city leaders are uniquely positioned to drive policies and programs to help transform public health. And a recent McKinsey report suggests sizeable potential impact through a global focus on city-level work, not just for pandemic preparedness, but for overall health. They estimate that influenceable interventions at the city level could add more than 20 billion years of higher-quality life at a global level, while offering a critical opportunity to address health disparities and inequities, an important underlying driver of differential outcomes from pandemic disease, let alone chronic health challenges.
Following these leads, it is time national governments and multi-national organizations formalize the role of cities in global health governance and security. One proposal is that relevant multilateral institutions—such as the World Health Organization or World Bank—could establish seats for cities on their Executive Boards or Board Committees. These seats could even have city government representation from both donor and implementer countries. Additionally, each region could add representation for cities on their subcommittees or local oversight bodies, for example U.N. Country Offices or Country Coordinating Mechanisms.
Now, as the global health community gathers this week in Geneva for the World Health Assembly – the annual gathering of the official governing body of the WHO—there is an opportunity ripe for the inclusion of the local jurisdictions who will be at the forefront of the next pandemic. Negotiations on the Pandemic Accord, the global treaty intended to set international standards of preparedness, cooperation, and communication between nations in advance of the next global communicable disease threat, are set to conclude this week. It is essential that real-world lessons and insights from cities are incorporated into this document, to ensure well-meaning agreements translate to real-world action on the ground.
There are already glimmers of hope.
In the last two years, Tedros Ghebreyesus, director-general of the WHO, has invited New York City to attend the annual World Health Assembly, the official decision-making body for the WHO and the International Health Regulations. That inclusion has allowed us to share our hard-won experience with WHO and other officials, in regard to the forthcoming Pandemic accord, including our insights on building stockpiles of PPE, mobilizing the health workforce and managing health facility capacity, ramping up testing through public-private partnerships with commercial laboratories, building a rapid and locally-driven vaccination effort, and ensuring that equity and place-based work is incorporated at the start of a response, rather than in subsequent phases. And in return, we learned first-hand about many of the challenges faced by nations across the globe in pandemic response and disease surveillance, especially in light of a changing climate and critical health workforce shortages, and have incorporated learnings about the WHO’s data sharing capacities and early warning and advanced surveillance systems, into improving our own population health data system.
New York City’s presence at the World Health Assembly has also given us an opportunity to demonstrate our front-line expertise and innovation in mental health, urban preparedness, climate change adaption, data modernization, and emerging health issues related to the global migrant crisis, among other issues.
Designing formal mechanisms to include cities in deliberations of global scale will allow each of us to not only sound the alarm earlier, but also to better respond to emerging public health threats lurking in our streets and sewers. By ensuring that cities have a meaningful seat at the table in our global health governance models, we will be charting a better course for the world to respond to forthcoming crises.
Georgia Kinsley and Eli Cahan contributed to this article.
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