Cities Are Growing More Powerful, And That May Be Good For You

The world is becoming more and more city (as opposed to any other word that may rhyme with the word "city"). And that could be good for your health, if the impact of the Bloomberg Philanthropies' Partnership for Healthy Cities continues to grow.

When billionaire businessman and philanthropist Mike Bloomberg first became Mayor of New York City (NYC), the 2nd most populated city in the world, he was asked whether extra security was needed at the United States Conference on Mayors in NYC. Bloomberg responded, "I told them I didn't think any of the mayors would be that dangerous." Well, during his 12-year term as Mayor of NYC, he found the opposite: a mayor can actually do quite a lot to help prevent death and suffering. He introduced a number of public health initiatives such as banning trans fats from restaurants, requiring restaurant chains to post calorie counts for their food items, and banning smoking in bars and restaurants. Even initiatives that didn't pass have had positive effects like his failed attempt to ban the sales of extra-large fountain drinks (the so-called "Big Gulp Ban"). This attempt brought more attention to the dangers of sugar sweetened beverage (SSB) consumption and created a cascade effect that has led to a greater movement to reduce SSB consumption, such as SSB taxes passing in various locations such Mexico City, Berkeley, San Francisco, Philadelphia, and Seattle. As Bloomberg related, during his term as Mayor "the life expectancy of New Yorkers increased by three years and became two years longer than the national average." These experiences helped him realize that Mayors of large cities could play major roles in preventing and controlling non-communicable diseases (NCDs) around the world.

That's in part because if you aren't already living in a city, a city may be coming to you sometime soon. According to the United Nations (UN), in 2016, over half (54.5%) of the people in the world lived in urban areas and by 2030, this number is expected to reach 60%. Also, between 2016 and 2030, the number of cities with populations of at least 1 million people is expected to jump from 512 to 662. During the same period, the percentage of the world's population who live in cities with at least a million inhabitants is likely to grow from 23% to 27%, and the number of "megacities" (defined as those with over 10 million people) is projected to go from 31 to 41.

Moreover, NCDs aren't just the result of your genetics, your body, or your behaviors. They are system problems, caused by the systems (e.g., social, environmental, economic, and cultural) around you interacting with you and your body. Self-help author Napoleon Hill once said "You are the master of your destiny. You can influence, direct and control your own environment. You can make your life what you want it to be." Not quite, when considering NCDs. Instead, a more accurate quote would be: "While you should still try to take actions to prevent NCDs, you aren't completely the master of your destiny. You are influenced, directed, and controlled by your own environment such as the food and beverages that are around you and the physical layout of your community. Without help, you can't always make your life what you want it to be because NCDs are now the leading cause of death and suffering around the world, resulting in 70% of 56.4 million global deaths in 2015." Yes, the latter alternative may not play as well as a career motivation speech, a bumper sticker, an Internet meme, or an inspirational business quote from Forbes. No, it doesn't mean that you should just give up losing weight or improving your lifestyle and sit around watching The Jersey Shore. However, it does mean that you shouldn't just blame individuals for obesity, being overweight, or suffering from diabetes, heart disease, stroke, and other chronic diseases. Properly addressing the current global epidemic of obesity and other NCDs also requires larger action from society to change the systems around everyone to offer more of a fighting chance.

With this perspective, Bloomberg, who is the World Health Organization's (WHO's) Global Ambassador for NCDs, discussed with Margaret Chan, MD, who was the WHO's Director General at the time, the possibility of forming a network of cities around the world that would agree to implement interventions to prevent NCDs. As Kelly Henning, MD, who has led the Bloomberg Philanthropies Public Health program since its inception in 2007, explained, "The WHO agreed that they would be well-placed to put forward such a cities initiatives and could serve as the implementing partner. The WHO representative for each country where each city is located has since been on board."

The next step then as Dr. Henning described, was to select the cities that would participate. The main selection criteria were cities that had over 1.5 million people and whose Mayor would be in place for at least a couple years so that any policies and programs could be sustainable. Dr. Henning relayed that the response was enthusiastic as many Mayors quickly saw the benefits of such a movement. Eventually over 50 cities submitted letters of intent to join this network, including the following:

• Buenos Aires, Argentina
• Melbourne, Australia
• Dhaka, Bangladesh
• Fortaleza, Brazil
• Rio de Janeiro, Brazil
• São Paulo, Brazil
• Ouagadougou, Burkina Faso
• Phnom Penh, Cambodia
• Montreal, Canada
• Toronto, Canada
• Santiago, Chile
• Shenzhen, China
• Tianjin, China
• Bogotá, Colombia
• Cali, Colombia
• Medellín, Colombia
• Santo Domingo, Dominican Republic
• Quito, Ecuador
• Addis Ababa, Ethiopia
• Paris, France
• Accra, Ghana
• Ahmedabad, India
• Bangalore, India
• Mumbai, India
• Bandung, Indonesia
• Jakarta, Indonesia
• Kingston, Jamaica
• Amman, Jordan
• Almaty, Kazakhstan
• Kuala Lumpur, Malaysia
• Guadalajara, Mexico
• León, Mexico
• Mexico City, Mexico
• Ulaanbaatar, Mongolia
• Casablanca, Morocco
• Yangon, Myanmar
• Kathmandu, Nepal
• Lima, Peru
• Quezon City, Philippines
• Kigali, Rwanda
• Cape Town, South Africa
• Seoul, South Korea
• Barcelona, Spain
• Bangkok, Thailand
• Kampala, Uganda
• Kiev, Ukraine
• London, United Kingdom
• Boston, United States
• Chicago, United States
• Philadelphia, United States
• San Francisco, United States
• Montevideo, Uruguay
• Ho Chi Minh City, Vietnam
• Lusaka, Zambia

Each city could then choose one NCD or injury prevention intervention from the following list of 10:

1. Create a smoke-free city: introducing, passing, and enforcing legislation to make all public places 100% tobacco smoke-free.
2. Ban tobacco advertising: Initiating or implementing laws banning tobacco advertising, promotion, and sponsorship.
3. Reduce sugary drink consumption: Establishing policies to reduce sugar sweetened beverage (SSB) consumption such as taxes on the production or sale of sugary drinks.
4. Healthy food for all: Implementing key components of the evidence-based WHO SHAKE package for salt reduction.
5. Create walkable, bikeable, livable streets: Adjusting street design to protect pedestrians and bicyclists, and promote walking and cycling.
6. Reduce drunk driving: Increasing enforcement of drunk driving laws.
7. Cleaner fuels for cleaner indoor air: Improving access to cleaner fuels, such as liquid petroleum gas (LPG).
8. Reduce speeding: Lowering speed limits or improving enforcement of existing speed limits.
9. Increase seat-belt and helmet use: Increase enforcement of seat-belt and 2-wheeler helmet use.
10. Monitor NCD risk factors: Conducting surveying of risk factors for NCDs, such as smoking, alcohol consumption, eating habits, and physical activity.

Dr. Henning said that the Bloomberg Philanthropies and WHO chose these 10 possibilities because the first 9 "are backed by strong scientific evidence" and the tenth would provide important data for the city to determine how best to tackle NCDs. Some cities who were already implementing road safety measures via the Bloomberg Initiative for Global Road Safety “(BIGRS)” used this first phase of the Partnership for Healthy Cities to further expand such efforts. 

Running such a complex Partnership has entailed extensive communications, coordination, and data collection (to document progress) efforts, which Vital Strategies has helped facilitate. As Dr. Henning emphasized, "this has involved a lot of tailoring to the specific context of each city. You can't just broadly apply the same general approach to each city. Moreover, different cities were starting at different places." 

With a tight timeline and ambitious goals, the Partnership for Healthy Cities has already seen significant change and in many cases change is urgently needed. As Enrique Penalosa, Mayor of Bogota, Colombia, who chose the "Healthy Food for All" intervention related:

As populations are emerging from poverty, there's still the thought that 'chubby' children are healthier. Here 10% have obesity and 70% percent are overweight. Columbia is a big producer of sugar. There are powerful business groups behind unhealthy food. There is also a culture of potato chips and junk food as well as fried food that needs to be overcome. Since a lot of these habits start young, the Secretary of Education has been working to get schools to serve healthy foods.

Mr. Penalosa added that this aligns well with other interests in improving health that are occurring in Bogota: "There have also been investment in sports facilities. We have built almost 50 soccer fields with synthetic turns. And on Sundays, we close streets so that people can ride bicycles throughout the city."

The Partnership also is a global network of cities that can share information, insights, and experiences via a variety of channels including social media, listservs, websites, and meetings. Dr. Henning explained, "The utopia would be mayors and heads of health of cities around the world actively engaging the public, making true policy progress, moving beyond to others, and starting a movement of mayors. Starting local with behavior change can eventually lead to more national movements. For example, several cities in China became smoke-free which has helped inspire more national efforts."

Forget then the outdated stereotype of city living as unhealthy compared to the clean living of the country. Sure there can be congestion, noise, crime, pollution, and rats (people and rodents) in the city. But studies from the Centers for the Disease Control (CDC) and others have shown that, in the United States, people living in rural areas are now at significant higher risk for NCDs and earlier death than those living in urban areas. With the growth of cities, Mayors are becoming more and more powerful.  And just because your life is city, doesn't mean that it can't be healthy.