Could city-to-city relationships be the key to urban health?

The main street in the cultural and heritage precinct of Cape Town’s Langa neighborhood, Lerotholi Avenue, has a lot going on — a community cultural center, kitchens and gardens, an agriculture cooperative, a contemporary art gallery, and traditional food market. It’s the country’s oldest township — established nearly 100 years ago. The community gardens have been around for many years. Many are tended to by “gogos” — the Zulu word for grandmother — and include herb gardens used for healing. The community kitchen is referral-based — where health or social workers can refer those who especially need nourishment because they are on medication. “There's a lot of resilience and a lot of energy happening in Langa — of course, constraints and challenges as well,” said Kurt Ackermann, chief executive officer of the South African Urban Food & Farming Trust, which supports collaborative urban food gardens, social farms and markets to strengthen community resilience. While the ideas behind these projects are generated locally, nongovernmental organizations are supporting these efforts — such as providing training on regenerative farming and improving the conditions under which informal food traders work. The South African Urban Food & Farming Trust is working with the city on measuring the impact of these projects on community well-being. It’s sort of a sandbox for the city, Ackermann said, where the city can explore, innovate, trial, and pilot different strategies in partnership with external organizations before rolling out on a wider scale. And these efforts were on display on a recent afternoon, as members of city governments across the world toured Langa as part of a summit for the Partnership for Healthy Cities. It’s an initiative working to prevent urban populations from contracting noncommunicable diseases and experiencing injuries. The organizations running the partnership said that 74 cities with over 320 million residents are involved and it’s helped dozens of cities adopt policies. At its core is a peer-to-peer network of cities aiming to learn from each other on what’s worked, what hasn’t, and receive guidance. Cities also receive seed funding to kick-start this work. “We've been successful in elevating the profile of mayors and city governments and using their authority to address these health topics,” said Ariella Rojhani, director of the partnership at Vital Strategies, a New York City-based global health organization. Pick your intervention Noncommunicable diseases, such as cancer, diabetes, heart disease, stroke, and chronic lung disease, account for 74% of deaths worldwide. People living within cities are especially vulnerable due to pollution, exposure to commercial promotion of unhealthy foods and tobacco, and inadequate levels of exercise. Unwieldy traffic also leads to traffic deaths. More than half of the world's population live in cities. By 2050, that’s expected to rise to about two-thirds. The partnership launched in 2017 and is funded by Bloomberg Philanthropies, an organization founded by Michael Bloomberg — one of the wealthiest men in the world and a three-term mayor of New York City. During his time as mayor, he instituted bans on smoking and large sugary drinks, and redesigned the city's streets to make them safer. By the end of his term, life expectancy of New York City dwellers increased by nearly three years. His dedication to these issues led to his appointment as the World Health Organization’s global ambassador for noncommunicable diseases and injuries. Cities in this partnership are given a choice of 14 interventions — in areas such as nutrition policies, air quality monitoring, road safety, tobacco control, and overdose prevention. Vital Strategies and WHO serve as the implementing partners and guide the cities around best practices and provide technical support and feedback on their proposals. The partnership hosts a policy accelerator program that focuses on developing policies and getting them adopted and implemented. More broadly, WHO is building up its urban health programs and has a research agenda to support that growth, said Dr. Etienne Krug, director of the department of social determinants of health at WHO. “For us, urban health becomes more and more of a priority,” he said. Closing the gap Adopting legislation at a national level requires consensus building in countries that are often very diverse culturally and religiously, Krug said. While there’s also diversity in cities, there’s often more uniformity and closer proximity between city leaders and the population, to make multisectoral collaboration easier, he said. Mayors often direct a number of departments, often in the same building. “That's what makes a little bit of difference between the national and the city level — but both are very important and they complement each other,” Krug said. The work done in this partnership often aims to close the gap between legislation that national governments pass and the implementation process and localized policies. “Our program fits right into that gap — to help close the distance between policies adopted from the Ministry of Health and the way people actually experience their lives every day,” Rojhani said. A key tactic is evaluating what part of cities local governments control — such as public schools and hospitals — to ensure service delivery is done in a health-conscious way, she said. This could include ensuring hospitals don’t serve unhealthy food or controlling where cigarettes are sold and advertised. The partnership works to support city leaders to understand legal tools at their disposal. “Whether it's an executive order, or an executive decree — oftentimes, it's just a sign of a pen,” Rojhani said. “An empowered city authority, empowered executive, knowing what legal channels they have to actually issue policy is a huge part of our work.” City efforts Several cities in Latin America including Cali, Quito, Bogotá, Lima, and Córdoba in Argentina have used the partnership to focus on improving nutrition in schools. Some of the work through the partnership includes taking steps to ensure sugary drinks aren’t offered in public schools and children aren’t exposed to advertising campaigns for unhealthy foods. Some are also working to ensure these schools have the infrastructure to serve healthy food. It’s common for school canteens to not have a refrigerator or sink to store and prepare fresh foods — and that’s why the default is packaged foods with high levels of salt, sugar, and fat, Rojhani said. In West Africa, Abidjan, Ouagadougou, Freetown, and Dakar have also collaborated around adopting nutrition standards for schools, hospitals, and other public settings. West Africa is a part of the world where the epidemiological transition from infectious disease to chronic noncommunicable diseases is taking place — with rises in stroke, hypertension, and diabetes, Rojhani said. “That means it's prevention in the truest sense,” she said. “You don't often see an opportunity to truly do prevention where you're not already playing catch-up.” Accra has implemented road safety changes that reduced road traffic crashes by 22% from 2021 to 2022. Addis Ababa and Lusaka have also worked on this area. Some of the interventions are trickier than others — such as tobacco control, where cities are up against powerful industries. This includes interventions in areas such as ensuring smoke-free public places, education campaigns, banning tobacco advertising, promotion and sponsorship, and increasing taxes. “To get smoke free, you need to get high-level political will and buy-in from city officials. We have expertise in that area, and can provide that to the cities,” said Kelly Larson, injury prevention lead at Bloomberg Philanthropies. City-to-city camaraderie The partnership includes a mix of low-, middle- and high-income cities. Cities are brought together for peer-to-peer learning — helping them avoid repeating the same mistakes, and directing them to the most effective strategies. And while this network function is at the crux of the partnership, it wasn’t always, Rojhani said. “Maybe in the early days, we didn't necessarily see this first and foremost as a network. We saw it as a collection of cities that were oriented around the technical interventions,” she said. But this changed as they recognized a large appetite for the partnership to serve as a convener to assist in forging relationships between city workers in public health departments and transportation departments around the world. This includes city-to-city visits, regional meetings, and virtual calls. "They're learning from one another — they're replicating ideas. They're not having to start from zero in terms of a policy idea,” Rojhani said. It’s also the second year the partnership has hosted a global summit of city government workers. Last year it was in London — which included 13 mayors and city technical teams. This year it was in Cape Town, involving only technical teams — apart from the city’s mayor. Some 200 people from 52 cities attended, where they toured Cape Town’s green spaces, cultural and historical sites, and Langa township. Bloomberg Philanthropies’ Larson said that when they started the partnership, they also thought cities would want to engage with a wide variety of other cities and that there would be interest in an exchange of learnings from the global north to the global south. “But what we found is cities with say 1 million people want to talk to cities with 1 million — not other cities that maybe have 20 million — because it's not really comparable,” she said. “Within the regions, they're very interested in collaborating together, because they have some of the same dynamics in their city.” Lasting impact Finding fiscal space in public budgets to take on these programs can be a challenge for cities. But when they first join the partnership, they receive a seed investment of up to $100,000. This could go toward expenses such as human resources or contracts for communications campaigns. It could help fund meetings bringing together city officials. That amount of money won’t go far in a large-scale media campaign in purchasing airtime. But in that case, the partnership would guide a city to consider areas the city already has ownership over advertising space and can leverage their own resources, Rojhani said. When a city completes its policy objectives, it can move on to another intervention, and the partnership will provide another $50,000. Most cities have received support on several interventions, Rojhani said. And then cities are encouraged to use demonstrated successes to advocate for more sustained, predictable resources within public budgets, Rojhani said. “It's all about making the case for budget allocation at the end of the day, because you know, these additional resources aren't going to be around forever,” said Dr. Natacha Berkowitz, epidemiologist for the City of Cape Town. “It's actually utilizing the resources we have already just in the right direction, to drive that change.” While there’s an initial need for resources for the 14 intervention areas, once they’ve scaled, they can start bringing money back to the city, WHO’s Krug said. Street speed bumps, for example, are inexpensive but save cities from the costs of the aftermath of road crashes. Turnover of politicians also challenges sustainability. Managing that is the “million-dollar” question, Rojhani said. “One can say that politics are sort of the ultimate enemy of public health, where the change in politics often means that policies that were in place are then walked back,” she said. But there are strategies to fortify this work, she said, such as building capacity of public health and transportation departments — because experts within these departments may outlast the turnover. If the interventions are added to a recurring budget line, it’s easier to keep the work going. Also, building community support creates public demand for these services, and then community organizations can hold public officials accountable for their continuation. Editor's note: The Partnership for Healthy Cities facilitated Devex’s travel and logistics for this reporting. Devex retains full editorial independence and control of the content.