Jo Ivey Boufford, MD, and Anthony Shih, MD
Population density is one of the defining characteristics of cities and is also one of the dominant challenges in addressing COVID-19 and likely future pandemics. In normal times, urban density allows for cost-effective service delivery, acts as a magnet for jobs and the generation of wealth, and nurtures innovation. Coupled with diversity—another core characteristic of cities—urban density also yields the cultural variety in urban neighborhoods, fosters global connections, and makes cities like New York attractive and exciting. However, in the midst of a pandemic, the very thing we love about cities becomes their apparent weakness: our urban density allows for more rapid spread of infectious disease and makes policy interventions such as social distancing much more difficult to follow—even with the best of intentions. Our cultural diversity can also make the need for such interventions more challenging to communicate and manage.
This has all led some commentators to speculate about the death of cities, including the potential for a mass exodus once the pandemic is over. While this is not an economic option for most, it also ignores the reality that urbanization is a major global trend that will likely not be stopped by this or another pandemic. Four out of five Americans live in urban areas; across the world, over half of the population does, and the number is growing. In the midst of a pandemic, it’s easy to focus on the risks of living in cities. What’s not as easy—but just as critical—is ensuring that we learn from this experience and consider how best to address these challenges in the future and how to prevent or greatly reduce the negative health and socioeconomic effects of pandemics like COVID-19.
Two other characteristics of cities have been thrust in the spotlight by COVID-19. One is complexity—the interdependence of the multiple systems that make cities run well and the challenge of governing across sectors for better health. For example, in transportation policy, mass transit can act as a hub for the spread of coronavirus but also has a positive effect on air quality and related reductions in rates of asthma. Housing policy can either advance or impede safe and affordable dwellings. The other key urban characteristic is the existence of disparities within cities. The wide discrepancies in mortality from COVID-19 in New York City can be mapped to geographic communities that have long suffered from structural inequalities in housing, education, access to parks, recreation and health care, food security and socioeconomic opportunities. In effect, COVID-19 is demonstrating to the public what urban health researchers, practitioners, and policymakers have known for decades: housing policy is health policy, transportation policy is health policy, education policy is health policy, and political leadership for health improvement can make cities engines to improve health.
One positive outcome that should emerge from this pandemic is a broader appreciation for and investment in the public health infrastructure that monitors and reports outbreaks, provides critical public information, and tests and tracks infection and immunity in the community. Our hospitals and health care workers have been amazing in their responses and should be made whole. But as we think about the configuration of our health care system going forward, additional investment is needed in primary care, telemedicine, better and more affordable internet connectivity in disadvantaged neighborhoods, and critical community-based organizations that have the trust of communities and can provide crucial social supports to families. We also need a reimbursement system that rebalances our delivery system to focus on prevention and overall health, while also supporting hospitals to do what they do best—manage emergencies and diagnose and treat complex diseases.
All of this would be wonderful and welcome. However, we also hope that there will be a newfound appreciation of how all the sectors that form the core of city life affect the health and well-being of New Yorkers, as well as a commitment to overall governance for health. To effectively promote the health and well-being of the city’s residents, we need to align health care, transportation, education, housing, economic development, and other areas. There are examples of cities around the world that have taken on and successfully met these challenges.
As a global city, New York can set a bold example. We can go from being the epicenter of a pandemic to an international model of a city whose systems and leadership act to ensure the health of its residents.
Dr. Jo Ivey Boufford is Clinical Professor of Global Health at the NYU School of Global Health and a vice chairman of United Hospital Fund’s board of directors. She is past-president and current board member of the International Society for Urban Health, and past-president of New York Academy of Medicine. Anthony Shih, MD, MPH, is president of United Hospital Fund.
United Hospital Fund has a long history of bringing together diverse perspectives to address critical challenges in health care in New York. In the current crisis, it’s more important than ever to hear from all parts of the health care system. Today’s commentary from Dr. Jo Ivey Boufford and me looks at the connection between COVID-19, cities, and health. – UHF President Tony Shih