Should cities have more say in our health?

'This city is going on a diet.' So proclaimed the Oklahoma City Mayor Mick Cornett on New Year’s Eve in 2007. Cornett had come to the realisation that he was obese and that his city was one of the fattest in the US. Five years later the city had hit its weight loss goal of one million pounds.

Cities are places of extremes. They breed health problems from poor air quality to drug abuse. But they are also critical to improving health.

30 years ago the Word Health Organization launched the Healthy Cities movement. From a soda tax in Berkeley to urban planning in Curitiba, cities are now the real health innovators.

Four reasons help explain why.

The first is sheer demography. In 1950 just 30% of the world’s population was urban. In 2008 we hit the ‘Urban Millennium’ – the tipping point at which the world became more urban than rural. By 2050 nearly 70% of us will live in urban areas.

Second, from housing to transport, alcohol licensing to parks and recreation, cities control some of the most important determinants of health for the people who live there.

Third, cities catalyse innovation. We need new ways of tackling ‘wicked’ public health problems and the human, financial and physical assets of cities can help us find the answers to these challenges.

Finally, cities get things done. Nation-states tend towards the abstract. Cities are concrete. Political paralysis can bring government to a halt at the national level (witness the 2013 shutdown in the US). Cities, particularly those with mayors, get on and do things.

The great city health story of modern times is New York. Over more than a decade, Mayor Bloomberg took on big public health issues: from calorie counts on restaurant menus to restricting the use of trans-fats. Smoking in restaurants and bars was banned in 2003. In 2011 the ban was extended to include city parks and other public spaces. It didn’t always work – famously Bloomberg failed to ban ‘Big Gulp’ drinks. But some of it had a real impact – New York’s smoking rates fell from 22% of adults to around 15%. And New York had a signalling effect: the smoking ban was copied around the world.

The New York story was a big reason why the Mayor of London set up the London Health Commission. Whilst working for the Commission last year, I spoke to Tom Frieden, former New York health commissioner. He emphasised the importance of the Mayor’s personal role and the need for a simple and consistent plan – reflected in 'Take Care New York'.

Buoyed by New York and other global examples, it became clear to many of us that the London had a real role to play in health improvement.

London is no stranger to health reviews – it has averaged one a decade for the last century. But we took a different path. Rather than start with health services we began with people and place. We thought as much about London’s assets (from green spaces to the creative industries) as its problems. 

The recommendations were wide-ranging and ambitious: smoke-free parks and public spaces; mandatory traffic-light labelling on restaurant menus; restrictions on junk food outlets near schools; incentives for commuters to walk to work; new air quality measures. 

Now could be the right time for other cities in the UK to play a bigger role in health. The UK government is still highly centralised, but the debate on devolution provoked by the Scottish referendum could change this. 

Getting cities more engaged in health could be one of the benefits. In London we looked enviously at New York’s legislative and tax-raising powers (where property, income and sales tax make up 44% of city expenditure).

Already places like Glasgow and Newcastle are making important moves on a range of issues from the living wage to alcohol unit pricing – all ahead of the national curve. If more powers were devolved to city halls, think how much further they could go.   

Two obvious objections arise.

First, how would this fit in with the existing public health architecture? Public Health England has teams across the country. And local government has only recently taken on new public health responsibilities. Wouldn’t a more prominent city role in public health just confuse matters?

Some of this is down to local relationships. London’s 32 boroughs mean the politics play out quite differently than, say, Liverpool’s six authorities. But it’s also the case that for many population health issues the city may be the most appropriate geographical unit.   

Second, to be most effective, public health interventions need to be coordinated with local NHS services. London nodded in this direction by proposing a new Health Commissioner reporting to the Mayor, to lead the better health agenda between local government, public health and the NHS.

But, given the gap in NHS strategic planning since Strategic Health Authorities were scrapped, how about we let cities play a stronger role still?

Jacob West is a Harkness Fellow at the Harvard School of Public Health, www.twitter.com/west_jake