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Victor G. Rodwin

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Health and Megacities:
A Neglected Dimension of U.S. Health Policy

 

Victor G. Rodwin, Professor of Health Policy and Management

Abstract
       This project aims to: 1) improve U.S. health policy by strengthening capacity for public health surveillance and response to health crises in megacities worldwide; 2) develop a conceptual framework and indicators for comparing public health infrastructure, health systems and health among megacities, based on a synthesis of relevant literature in public health, epidemiology, urban planning and the social sciences; 3) complete case studies, drawing on this framework, for New York, London, Paris and Tokyo.

       There are four reasons for choosing New York, London, Paris and Tokyo: 1) They have more information about their public health infrastructure, health systems and the health of their population than megacities in developing nations; 2) The history of their public health movements and evolution of their public health infrastructure has never been systematically compared with a view to learning about best practices; 3) Since they are the gateways through which the principal health risks from the rest of the world are most likely to enter their countries, and the U.S., these cities are important models of public health infrastructure. They must renovate their surveillance systems, protect the quality of food and water, assure effective waste disposal and promote health education. Moreover, they must provide health services to recent immigrants and diverse population subgroups; 4) They often influence significantly, their counterparts in developing nations due to their relative wealth and dominance, their ties to the global economy, and their concentration of business, cultural and scientific activities.

       The book resulting from this comparative research would: 1) synthesize the literature on the evolution and current organization of each city's public health infrastructure and health system; 2) compile indicators across the four cities, based on comparable data, on health outcomes; and 3) draw inferences from interviews with local health officials and experts, on their perceptions of public health risks; the problems of public health infrastructure and health system organization; and local capabilities for epidemiologic surveillance systems, control mechanisms and emergency response to health crises.

1. Background, Problems and Specific Questions to Explore

       A comparative analysis of public health infrastructure, 1health systems and health in the four principal megacities of the industrially advanced world - New York, London, Paris and Tokyo - would fill major gaps in knowledge. These "world cities" are not only the largest urban centers of the wealthy OECD nations; they also play a special political and social role as the "cultural capital of a wide orbit, generally heir to a long history, and alwaysÉ(belonging) to the entire world as much as toÉ(their) own country." 2Over time, New York, London, Paris and Tokyo have survived devastating infectious disease epidemics. In response, they developed systems of public health infrastructure reflecting their distinctive institutional and cultural characteristics.

        New York, London, Paris and Tokyo share a recent history of relative success in assuring their population's health and confront a range of common characteristics and problems. They are great centers for prestigious university hospitals, medical schools and research institutions. They have been the source of many innovations -- in bio-medical research, medical practice, health care delivery systems and administrative technologies. Despite the success of public health reformers and urban planners in improving their quality of life, they still confront onerous health risks -- albeit to different degrees -- for at least six problems: 1) the re-emergence of infectious diseases (e.g. tuberculosis, and the arrival of new ones, e.g. AIDS); 2) rising inequalities among social groups; 3) an increase in the homeless population; 4) barriers in access to quality medical services for ethnic minorities and/or the poor; 5) water and air pollution; and 6) terrorism (e.g. the world trade center bombing in New York) and bio-terrorism (e.g. the release of toxic sarin gas in Tokyo's subway system).

       New York City probably has the greatest local authority and responsibility for managing its public health infrastructure and public health system. London, Paris and Tokyo are capital cities in strong unitary states that have more power to intervene in the life of their capital. Nonetheless, health protection in all four cities involves important links between local, regional, and central or federal authorities. New York City stands out in contrast to London, Paris and Tokyo because it has the largest share of children under the poverty level. It is also notable for trying to integrate its public health surveillance system and develop community health profiles. London has just established a new Greater London Authority which may rethink policies and institutions for improving the health of Londoners. The Paris experience can illustrate the critical role of local authorities in assuming safety net responsibilities that have eluded its centralized state and national health insurance system. With a slew of new public health agencies (for AIDS, food safety, public health surveillance, infectious disease..) however, the central government will continue to play a critical role. Tokyo is the city with the most even income distribution and interesting forms of social cohesion. Since it is the healthiest city of these four giants, by traditional health indicators, and a WHO-sponsored 'healthy city,' it will serve as a useful standard of comparison for the other cases.

       The specific issues and questions my investigation will address are summarized below and organized around themes for tentative book chapters.

A. Dimensions and Significance of the Problems Addressed

Chapter 1. The Rise of Megacities: A Challenge for Global Health
       The growth of global integration and international travel makes the health of the U.S. population increasingly dependent on management of health risks all over the world. 3These risks include control of emerging and drug-resistant infectious diseases, contaminated foods, toxic substances, biological and chemical terrorism and rising social inequalities. No health systems are more vulnerable to such risks than those serving the residents of megacities with populations exceeding 8 million inhabitants. 4Yet the literature in urban planning, geography, ecology, economics, anthropology and sociology, on these vulnerable giants, has largely skirted issues related to public health infrastructure, health systems and health.
       The UN projects that 61 percent of humanity will live in cities by 2025. 5There are now at least 20 megacities; in 2015, there will be 33. 6The fastest growing megacities are located in developing nations. Such cities are like "huge human sponges, soaking up 61 million new people each yearÉ." 7Air travel and other routes of transportation have magnified their influence and vulnerability. What new threats do exploding megacities in developing countries pose to global health? What are the key issues related to public health and health systems, which are routinely ignored in the growing literature on megacities? How can this study of four world cities in wealthy nations serve to improve public health infrastructure in megacities, global health, and consequently U.S. health policy?

Chapter 2. The City as a Unit of Analysis: Conceptual and Methodological Issues
       Despite seminal empirical research on small-area variations in health care utilization, the field of health policy and management, in the U.S., and elsewhere, typically neglects the city as a unit of analysis. 8 While institutions responsible for disease surveillance and control -- at the international, national, subnational and local levels -- collect epidemiologic data by geographic location, U.S. health policy is made without systematic collection of information for monitoring health status, public health infrastructure and the performance of health systems, in cities."9
       I shall try to answer three questions: 1) How can use of the city as a unit of analysis advance the comparative study of health care systems? 2) How can inter-city comparisons of quantitative health information, e.g. indicators of premature mortality and morbidity, provide a better understanding of similarities and differences between them? 3) How can intra-city comparisons of quantitative health information be used to assist with setting health priorities and assessing public health programs?

Chapter 3. Public Health in World Cities: A Common Framework for Case Studies
       Four questions will guide the research for each case study: 1) How have the organization of public health infrastructure and the health system evolved over the late 19th and 20th centuries? 2) How are these systems currently organized: the nature of existing intelligence and control mechanisms for epidemiologic surveillance; the main organizational relationships between city health authorities, health care providers and the nonprofit sector in public health; and the relationship between local, subnational and national-level responsibilities in public health? 3) How do each of the cities rank along a spectrum of health indicators? 4) How have each of the cities responded in similar or different ways to common problems and conditions?

B. Arrangements for Health Protection in Four World Cities

Chapter 4. New York City: A Strategic Local Role in Health
       New York City (NYC), unique in comparison to other big cities in the United States10 has twice the national average rate of uninsured Americans, children living below poverty and recent immigrants. The New York Department of Health (DOH) was established in the 1860s in response to a cholera epidemic. Although much has changed about New York City and the DOH, its mission to protect New Yorkers against infectious disease remains strong in light of the recent AIDS and TB epidemics. Recognizing the need to improve public health infrastructure at the local level, the CDC recently awarded grant funding to the DOH to improve the City's public health surveillance activities, including the capacity to develop community health profiles of NYC neighborhoods. 11
       I shall examine the DOH plan to integrate its public health surveillance programs, especially the nature of its collaboration and organizational relationships with the New York State DOH, the CDC and other local agencies at the City level: the public municipal health and hospitals corporation (HHC), the City's Office of Emergency Management, the emergency medical service, fire departments and police. How can relationships between DOH and the provider community be improved? How will the increasing capacity to develop community health profiles for NYC populations and neighborhoods affect the development of safety net services for the poor?
Chapter 5. London: Strategies to Improve the Health of Londoners and Achieve "Healthy City" Status
       Recent legislation calling for a new Greater London Authority with a Mayor and Assembly to be elected in the year 2000 is a significant change for city-wide governance of Greater London. The Association of London Government is already working to secure London "Healthy City" Status from the World Health Organization. The Chair of this Association, Lord Harris of Haringey notes that "The Mayor will have the largest direct mandate of any politician in Europe with the exception of the President of France. This will be a powerful mandate for change." 12 The Mayor's mandate includes the development of a public health agenda for "promoting improvements in the health of persons in Greater London." 13This will involve the transport strategy, the London Development Agency strategy, the London Bio-diversity Action Plan, the Municipal Waste Management strategy, the London Air Quality strategy, and the London Ambient Noise strategy.
       I shall investigate the kinds of collaborative arrangements emerging between local authorities (e.g. the Mayor's office) and NHS officials responsible for the London Region; the kinds of partnerships developing between London's voluntary sector and government health agencies; and how London authorities are conducting public health monitoring and epidemiologic surveillance activities. Also, given the growing gap, in London, between a well-off majority and a poor minority, and the fact that nearly a quarter of the capital's people are ethnic minorities, 14what policy interventions, programs, and monitoring activities are being developed to make Londoners more healthy?
Chapter 6. Paris: A Strategic Local Health Role in a Centralized State
       Paris authorities have taken strong measures, since the Middle Ages, to protect their citizens from health risks, including bubonic plague. Following the French Revolution, local responsibility for public health was explicitly defined. Despite its national commitment to the public hygiene movement in the 19th century, and its identity with centralization and a strong state, until recently the central government has played a limited role in public health. At the time of the cholera epidemic (1837) and the outbreak of Spanish influenza (1918-1919), the Paris Health Council, was largely responsible for addressing the public response. Since World War II, three public agencies have shared responsibility for the public health of Parisians: the public hospital system, Assistance Publique, the Directorate for Sanitary Action and the Bureau of Social Aid.
       Following the crisis over contaminated blood in the 1990s, concern about AIDS, and drug resistant TB, new awareness about the dangers of food poisoning, a many new national agencies were established to safeguard public health. At the same time, the City of Paris's Division of Health and Social Affairs, the Assistance Publique and the voluntary sector have forged new alliances to protect public health and confront the rise of social inequalities, homelessness, delinquency among youth and social exclusion. What is the extent of collaboration among national and local levels in this new context? What data are routinely collected for public health surveillance and health promotion? How are safety net services delivered in the context of national health insurance?
Chapter 7. Tokyo: A Healthy City with Emerging Problems
       Tokyo suffered the devastation of the Great Kanto Earthquake, in 1923, and significant population evacuation, damage and near famine during World War II. In the early 1990s, Tokyo was the richest city in the world. It may no longer be the richest; but it is the largest metropolitan area of the four world cities I will study. It is the only one that has an active WHO-sponsored healthy cities movement and research team. 15Tokyo's Metropolitan Government (within which the Bureau of Public Health is located) is one of Japan's 47 Prefectures of which the central part (roughly 8 million population) consists of 23 wards. Each of the wards is a semi-independent municipality, with its own elected mayor and council; each is responsible for making its own city health plan. 16 Just as Japan is No. 1, in comparison to OECD nations, with respect to infant mortality and life expectancy, Tokyo, in comparison to New York, London and Paris, has the lowest infant mortality rates and the longest life expectancy at birth.
       Despite these impressive achievements, Tokyo must now face new public health problems - congestion and road traffic noise, the risks of more subway terrorism, AIDS, homelessness,17 water and air pollution, mental disorders, iatrogenic disease due to enormous consumption of drugs; and more. Will neighborhoods within Tokyo's wards maintain their past ability to promote solidarity and social cohesion in a relatively homogeneous society? Are social inequalities in Tokyo far less pronounced than in New York, London and Paris? How well does Tokyo Metropolitan Government finance and organize its public health infrastructure? What information is routinely collected for disease surveillance? What is the nature of collaboration between public authorities, the voluntary sector and the provider community?

C. Lessons for U.S. Health Policy

Chapter 8. Comparative Evaluation of Public Health Infrastructure, Health Systems and Health
       Why did each city health system evolve in the way it did? How can intra-city comparisons of health inequalities serve to characterize each city in making inter-city comparisons? How can comparison of the case studies trigger cross-national learning? What hypotheses for further research might explain significant differences or similarities, among health outcomes between cities?
Chapter 9. Implications for Megacities and US Health Policy
       What can we learn from best practices to public health infrastructure in New York, London, Paris and Tokyo? What lessons do the experience of these world cities yield for one another, for megacities in developing countries and for other large U.S. cities? How, based on the application of the common framework to the four cases, could this approach be adapted and applied to other megacities? Finally, what are the implications for U.S. health policy?

2. Conceptual Foundations and Approach


       My inquiry is guided by a combination of four related approaches: 1) Comparative, cross-national analyses of health systems; 2) Historical analyses of public health; 3) Multi-disciplinary studies on megacities; and 4) Indicators for comparing public health infrastructure, health systems and health outcomes.
Comparative, cross-national analyses of health systems
       My previous research in this field is on health planning and policies in France, Britain, Canada, Japan and the U.S. I aimed to shed light on the organization and financing of national health systems and the formation and implementation of national health policies. There is an immense literature on cross-national comparisons of health systems and health and social policies in OECD nations. 18 For example, health data for OECD member states are routinely published. 19
        The problem with these studies, however, is that their focus on national aggregates masks important variations within nations, between urban and rural areas, and between large and small cities. In contrast to nation states, comparison of smaller and more similarly situated units, e.g., world cities, share more common characteristics and problems; they therefore provide notable advantages for cross-national learning. Local authorities are typically able to move faster than their national governments, and learning from best practices across cities is often easier to implement through city-to-city exchanges. 20I therefore revert to my training in city and regional planning and focus on the city as the unit of analysis.
Historical analyses of public health:
       The literature on the history of public health ranges from the heroic - the triumph of knowledge over ignorance - to the new anti-heroic, inspired by Foucault, which emphasizes the encroachment of state bureaucracy over individual autonomy. 21 I will take account of both traditions. As with comparative analyses of health systems, this tradition has largely examined the evolution of public health in relation to the growth of the nation state. It is an important approach for public health has made the city more habitable through environmental hygiene (sewerage systems, garbage disposal) and moral reform. However, the main body of research on public health and the dominant scholarship on cities has typically ignored issues of public health and urban health care systems.
       There are some case histories on the evolution of public health and health care reform efforts in specific cities.22 My own work has covered some of these issues with respect to the history of public hospitals in New York and Paris. There are also significant histories and archives on selected aspects of public health in New York, London, Paris and Tokyo. Such documents, and many more which I must still identify, will form an important base on which to compare the evolution of public health infrastructure, and its present organization, among these world cities.
Multi-disciplinary studies on megacities
       Cities and megacities are typically studied from perspectives ranging from architecture, urban design, the environment, urban planning, economics, sociology, anthropology, management, and ecology. Thus, an important approach to my inquiry on health and megacities will be to synthesize a wide range of disciplinary and professional perspectives as they relate to the organization of public health infrastructure, the health system and health in megacities.
       The main reason for focusing this research on world (or global) cities in wealthier nations is that there already exists reliable data and significant scholarship on their economic and social characteristics, urban core and surrounding metropolitan areas. 23 There is even a recent comparative study of London, Paris, New York and Tokyo commissioned by the U.K.'s Department of the Environment and the Government Office for London. 24 Although these world cities function as headquarters for transnational corporations, international financial centers, and more generally, international nodes of 'command and control' over the economy, there are still formidable methodological problems in collecting comparable data about them. 25With the rise of privatization and deregulation in the global economy, and the generally declining role of the nation state, Saskia Sassen argues that global cities will increasingly become city states rivaling national and sub-national political units. 26Despite the surge of interest in these entities, however, comparative studies of pubic health infrastructure, health systems and health, among world cities, are notably absent from all of this literature.
       The World Health Organization (WHO) launched a movement known as "Healthy Cities," which has promoted the social and economic determinants of health through demonstration projects and innovative programs in cities throughout the world. 27 The Healthy Cities network has sensitized local authorities to the health implications of different urban policies and developed a list of indicators in 32 health-related areas. 28 With the exception of very preliminary comparisons, however, this movement has not made significant contributions to research. 29 Moreover, there have been no systematic comparisons of public health infrastructure, health systems and health among WHO's healthy cities network.30

Indicators for Comparing Public Health Infrastructure, Health Systems and Outcomes
       My inquiry is guided by the important literature on social indicators and ways of measuring "quality of life" and health outcomes, including preventable mortality and morbidity. 31 In comparing these measures across the four world cities, I rely on the following previous work: 1) Quality of life in the world's 100 largest cities (Population Action International) 32; 2) Health systems and outcomes across 24 industrialized nations (OECD)33; 3) City profiles, health systems and outcomes across Europe (WHO)34; 4) Youth, disadvantaged groups and the elderly in capital cities of Europe (Project Megapoles)35; and 5) Community health profiles for New York's neighborhoods (HOP)36 .
       These approaches suggest five dimensions along which to compile indicators based on comparable data from multiple sources and jurisdictions:
  • Outcomes: aggregate indicators of population health and illness, e.g. premature mortality and morbidity, and disaggregated measures for specific population subgroups;
  • Inputs: public health workforce; primary care providers
  • Outputs: disease prevention services: surveillance, inspections, maternal and child care, health education and primary care for socially excluded groups.
  • Population characteristics: socio-economic and demographic factors;
  • Urban characteristics: crime and injury, use of drugs and alcohol, measures of "social cohesion" and involvement in civil society.


    •        I will not explore the relationships among these dimensions by testing individual-level data with causal models. These dimensions are meant only to provide a common framework within which to conduct intra-city comparisons (within each city) for each case study and inter-city comparisons of New York, London, Paris and Tokyo (Chapter 8).


3. Research Strategy and Challenges Facing the Project


       This investigation is a qualitative comparative case-study analysis that combines historical and policy-analytic research with descriptive statistics and open-ended interviews. Each case study will emphasize the distinctive characteristics of its world city, highlighted in the chapter titles of the book outline (p.3-9). Each will also follow a common framework guided by the questions noted under chapter 3 (p.5) and the conceptual foundations discussed in the preceding section. This approach is descriptive in the sense of compiling information on the evolution and current organization of each city's public health system; indicators of health outcomes; images of current problems with surveillance and control systems; and local capabilities for response to health crises. It is analytical in the sense of applying a common framework to four cases and searching for common denominators, differences and lessons. The research is ambitious, but not more complex than my first book, The Health Planning Predicament: France, Quebec, England and the United States 37. Since then, I have prepared for this study with my book on Public Hospital Systems in New York and Paris38.
       To obtain answers to the specific questions raised in Section #2 (pp.3-9), I will rely on three main investigative procedures: 1) literature review and synthesis; 2) compilation of comparable quantitative information; and 3) primary data collection through interviews. Details on these methods and the challenges facing this project are provided below:
Literature Review and Synthesis
       I shall review and synthesize existing literature, across social science disciplines, epidemiology, public health, urban planning and health policy, on: 1) health and megacities, in general; 2) public health infrastructure, health systems and health in New York, London, Paris and Tokyo. I shall also compare, among these world cities, existing historical research and archival documents (from city departments of health and other relevant organizations). My focus, here, is on the evolution of public health infrastructure and health systems since the mid-nineteenth century. I will place special emphasis on developments since World War II because they are critical for understanding existing institutional arrangements for public health infrastructure and local health system organization.
       In addition, I shall compare (for New York, London, Paris and Tokyo) public documents on local public health surveillance, information systems for monitoring outbreaks of communicable disease, and indicators for monitoring community health among high-risk groups, including preventable mortality and morbidity.
       This review and synthesis of secondary data sources represents an original contribution of the study. To my knowledge, no literature review, let alone synthesis, has been conducted on these topics.
Compilation of Comparable Quantitative Information
       Examination of quantitative information is an important addition to the qualitative case study approach of this research. Drawing on the five dimensions for indicators (Section 2, p.13), I will focus on those indicators for which comparable data are available and accessible, and present intra-city and inter-city comparisons over three points in time (circa 1980, circa 1990, and most recently available:1995-97). The Appendix provides some possible examples of indicators. Such information has never been compared with attention to differences reflecting institutional, historical and cultural factors. It will: 1) highlight similarities and differences among, and within the four cities; 2) help to assess the success or failure of public health infrastructure and health system outreach activities; and 3) identify those cities where quality or range of information provide models or guidelines for public health surveillance.
        In presenting both intra-city and inter-city comparisons, I will rely on tables, charts and maps based on GIS software (MapInfo or ArcView). I already have the mapping data for New York, Paris and Tokyo.
       The data required for the compilation of this information are all in the public domain. Sources range from the decennial population census, in each country, to vital statistics (birth and death registries), hospital admission data and special surveys on selected public health issues, and employment data.
Primary Data Collection Through Interviews
       I will conduct approximately 10-15 open-ended interviews with city health officials and knowledgeable experts, in the fields of public health, demography, epidemiology and health policy, from each city. These interviews (roughly one hour) will serve to: 1) elicit speculation on the factors that give rise to differences in infrastructural development and health indices in public health; and 2) explore the consequences for importing aspects public health infrastructure across cities. Also, the interviews will assist me to: 1) learn more about the actual operation of public health infrastructure, including the level and qualifications of the work force directly involved, the information systems for public health surveillance, and the kinds of organizational links between public health agencies, health care providers and the nonprofit sector and; 2) keep up-to-date on new developments or innovations in the public health infrastructure of each city; 3) obtain agency documents and check for possible inconsistencies in data or ambiguous definitions of indicators within each city; and 4) receive informed reactions to the disparities between cities, revealed by the compilation of comparable quantitative information.
        I will begin the interview phase of the study in New York, my home base, to assess current problems and challenges with regard to the City's efforts to renovate its public health infrastructure. This will assist me in raising pertinent questions in London, Paris and Tokyo.
       The interviews will be taped and transcribed for my review. Some interviews might require follow-up if I discover patterns in the responses across cities, which merit further attention. For any information crucial to the research, the subjects will be given an opportunity to check for accuracy or add information.
Conceptual, Methodological and Logistical Challenges
        This project faces three challenges: 1) The first stems from its exploratory nature. Little is known about the relative strengths and weaknesses of the systems for health protection in New York, London, Paris and Tokyo; and the conceptual foundations for comparative, cross-national study of such systems, using the city as a unit of analysis, are inadequate.2) The second concerns data availability and quality. For example, in assessing preventable morbidity, population-based hospital admissions data, by ward and by cause, are not yet available for Tokyo. The available hospital admissions data, by cause, in Paris and Tokyo are based on ICD-10 classifications, whereas the data for New York City and London are based on ICD-9. Also, it is apparent that some indicators are inconsistently defined across nations and cities. Thus, Japanese definitions of infant mortality result in slight underestimates in comparison to U.S., French and U.K. definitions. Also, city definitions that flow from the organization of services tend to vary, e.g. homelessness. 3) The third challenge involves logistical support in Paris, London and Tokyo under circumstances where no funds are requested for travel.
       I already have a strong research infrastructure that can help me to meet some of these challenges as I have spent the past year, on sabbatical leave from NYU, organizing a research project on health and social services for older persons in Paris, London and Tokyo. This work is funded by the International Longevity Center (ILC) -USA, Ltd., which has sister organizations in Paris (ILC-France), London (ILC-UK) and Tokyo (ILC-Japan). I have worked closely with the directors of each ILC -- Dr. Robert Butler, Dr. Francoise Forette, Lady Sally Greengross and Shigeo Morioka -- and their staff, and have assured collaboration in two ways:
       1) First, they will assist me in identifying leading experts and/or local government officials for an advisory board that I would appoint at the outset of the project. The board would consist of two advisors from each city, with whom I would work individually by telephone, e-mail, and/or correspondence, on conceptual and methodological issues, as they arise. My advisors would also help select city health officials and knowledgeable experts for me to interview.
        2) Second, they will assist me in obtaining local documents and data; and in following up on interviews.
I am confident that the third logistical challenge can be overcome because I do not require funding for the interviews in Paris and London. I am invited to Paris, on average, twice a year for lectures and conferences on health policy and management; it would be easy to arrange for a short stay in London. As for Tokyo, I recently received a grant from the Japan Foundation's Center for Global Partnership, for a two-year grant to fund the Tokyo component of the ILC-USA-sponsored study on health and social services for older persons in four world cities. 39

4. Timeline


        This will be a three-year project beginning on February 1st, 2000. I will appoint the advisory committee within the first 3 months and will ask each member to review and comment on my work throughout the entire project period.
Spring, 2000: Literature review on conceptual foundations and on New York City. Preparation of paper synthesizing major ideas, gaps, assumptions, inconsistencies and directions for research (chaps.1,2).

Summer, 2000: Interviews in New York City. Develop interview guide, arrange meetings, draft chapter 4.

Fall, 2000: Tokyo case: literature review and synthesis. Preparation of background paper.

Spring, 2001: Interviews in Tokyo. Develop interview guide, schedule meetings over 10-day period and draft chapter 7.

Summer, 2001: Paris case: Literature review and synthesis. Preparation of background paper.

Fall, 2001: Interviews in Paris. Develop interview guide, schedule meetings over 10-day period and draft chapter 6.

Spring, 2002: London case: Literature review and synthesis. Preparation of background paper.

Summer, 2002: Interviews in London: Develop interview guide, schedule meetings over 10 day period and draft chapter 5.

Fall, 2002: Write draft of chapters 8 and 9.



5. Contributions and Applications of Research


        I will summarize the study's findings in a book for policymakers, policy analysts and clinicians; and in articles for professional journals and Op Ed columns.
        By introducing the city as a unit of analysis in comparative health systems research, the research will improve the conceptual foundation on which health policymakers monitor, compare and eventually learn from the experience of world cities with their health systems and population's health. In addition, the project would end a methodological shortcoming in the field of health policy and management -- the tendency to overlook some key spatial dimensions of health systems and health status.
        On a more pragmatic level, by comparing best practices with regard to public health infrastructure in New York, Paris, London and Tokyo, the research will provide insights for improving U.S. health policy by contributing ideas for monitoring global health and managing megacity health systems worldwide.
        In addition, this project will provide a comparative framework and database, which could serve as basis on which to organize workshops with public officials, senior staff and experts in each city, to inquire about best practices, get their views on initial findings, and solicit suggestions for further investigation. For example, in collaboration with the Wagner School's new Center for Excellence in New York City Governance, I plan to organize a conference for health officials and their staff from each of the four world cities to review the study's findings and discuss opportunities for mutual learning. New York City health officials could learn from best practices in other world cities, even explore how the lessons could be transposed to other large U.S. cities?
       Finally, as I "clean" the database for comparing public health infrastructure, health systems and health across the four cities, ILC-USA has agreed to add it to their "server" for their world cities project (WCP) on health and social services for the elderly, and to the WCP section of ILC-USA's Internet web site. This would make the database widely available for officials from world cities, researchers, health policy analysts, and other interested users. Eventually, such a database might be of sufficient interest to world cities so that the process of maintaining and updating it would become self-financing -- perhaps by an association of world cities, yet to be formed.

APPENDIX: EXAMPLE OF POSSIBLE INDICATORS
    Health Outcomes
  1. Life Expectancy at Birth; at 1; at 65
  2. Infant Mortality Rate per 1,000 Live Births
  3. Low Birth Weight Babies (<2.5 Kg)
  4. Standardized Mortality Rates
  5. Standardized Mortality Rates by Cause
  6. Suicides per 100,000 Population
  7. Communicable Disease Incidence (e.g. HIV/AIDS, TB)
  8. Prevalence of Selected Chronic Conditions, e.g. asthma, diabetes, stroke, arthritis
  9. Prevalence of Lead Poisoning of Children
  10. Tooth decay in 5 year old children

    Inputs: Personnel and Facilities
  1. Public Health Workforce by Skill Levels per 1000 population
    -Public Health Physicians
    -Public Health Nurses
    -Epidemiologists
    -Health Educators
  2. Primary Care Physicians per 1000 population
  3. Specialty Distribution of Practicing Physicians
  4. Intra-City Distribution of Primary Care Physicians
  5. Primary Care Facilities/Physicians

    Outputs
  1. Immunization and Vaccination Coverage Rates
  2. Number of Health Department Inspections per 1000 restaurants
  3. Average Number of Prenatal Care Visits per Term Pregnancy
  4. Number of Visits to the Emergency Room per 1000 Population
  5. Percent of Emergency Room Visits Resulting in Inpatient Hospital Admissions
  6. Hospital Admissions among Geographic Areas Within Each City
    7. -for ambulatory care sensitive conditions by age cohort

    Population Characteristics
  1. Age Distribution
  2. Percentage of Foreign-Born Population
  3. Percentage of Live Births to Teen-Age Mothers <18 Years; <20 Years
  4. Poverty Status of Population by Geographic Area
  5. Per Capita Income
  6. Percent of Single-Parent Households
  7. Fertility Rates
  8. Educational Attainment
  9. Occupational Status

    Urban Characteristics
  1. Population Density
  2. Number of Reported Homicides, Rapes and Other Crimes per 100,000 Population
  3. Measures of Air Pollution
  4. Percent of all Acute Hospital Admissions in "Urban Core" from Population Residing in Urban Core
  5. Housing Conditions - Number of homeless
  6. Transport Patterns -car use, cycles, accidents

1By "public health infrastructure," I mean the capacity of local officials to perform the core functions of public health: a) assessment, "The regular, systematic collection, assembly, analysis, and dissemination of information on the health of the community;" b) policy development, "The development of Éhealth policies (on the basis of) scientific knowledgeÉ;" c) assurance, "The assurance to constituents that Énecessary (services)É are providedÉ" The capacity of local officials to perform these functions will depend, in part, on the size and quality of their workforce; their information systems for epidemiological surveillance; and the organizational links they can forge to implement regulations and deliver public health services. See Roper, W., Baker, E., et al., "Strengthening the Public Health System," Public Health Reports (107)6, 1992.
2J. Gottmann, J. "World Cities and their Present Problems." In Wynne, G. Survival Strategies: Paris and New York. New Brunswick, NJ: Transaction Books, 1979.
3Institute of Medicine, America's Vital Interest in Global Health. Washington D.C., 1998.
4The United Nations, in its publications on World Urbanization Prospects, classifies cities with population over 8 million as "megacities." One has only to recall the recent epidemic of pneumonic plague that struck Seurat, India, in 1994, or the Ebola epidemic, in Kikwit, Zaire, in 1995, to understand that such centers serve as "staging areas for waves of impoverished people that are drawn thereÉ the next stop is a megacity ÉSao Paulo, Calcutta, Bombay, Istanbul, Bangkok, Tehran, Jakarta, Cairo, Mexico City, Karachi; and the likeÉ All paths ultimately lead these people to the U.S., Canada and Western Europe." (L. Garrett, "The Return of Infectious Disease," Foreign Affairs (75)3, 1998) For example, when the outbreak of plague was reported in India, and Ebola in Kikwit, the New York City Department of Health joined with the federal CDC to set up a program to protect New Yorkers from potential importation of these deadly diseases. Although neither the plague, nor the virus appeared in New York City, such threats helped persuade the City's Health Commissioner that the Department's response mechanisms and core public health functions need to be strengthened. (See M. Hamburg, "Pathogens in New York City," J. of Urban Health (75)3, 1998.
5UN projections cited by E. Linden, "The Exploding Cities of the Developing World," Foreign Affairs (75)1, 1996.
6UN, Department of Economic and Social Information and Policy Analysis, 1995.
7R. Horton, "The Infected Metropolis," The Lancet (347), January 20, 1998.
8I refer to the work of John Wennberg and his collaborators. The work of Wallace, D. and Wallace, R. on patterns of infectious disease transmission within and across large metropolitan regions is an important exception to this tendency: A Plague on Your Houses. London and New York, Verso, 1998.
9This is so not only for megacities around the world, but also for big cities in the United States. Chicago's Department of Health has attempted to fill this gap by releasing three versions of comparative health data on 46 of the largest cities in the U.S. This is not the same, however, as what might be accomplished by a "national system for compiling important indicators of morbidity and mortality at the city level (N. Benbow, Y. Wang and S. Whitman, Big Cities Health Inventory, 1997: The Health of Urban USA. Chicago, Department of Health, 1998., p.10).
10Bellush, J. and Netzer, D., eds. Urban Politics New York Style. Armonk, Sharpe, Inc., 1990.
11New York City Department of Health Implementation Plan for Integrated Surveillance, Internal Document, May 1998.
12Health and the Mayor of London, King's Fund: www.kingsfund.org.uk/execsum/hatlm.htm
13Ibid
14Capital Divided. London: London Research Centre, 1997.
15Takano, T. Steps Toward Healthy City Tokyo. Promotion Committee for Healthy City Tokyo, Dept. of Public Health and Environmental Science, Tokyo Medical and Dental U., May 1991; Takano, T., Ishidate, K., Nagasaki, M., Formulation and Development of a Research Basis for Healthy Cities. Dept. of Public Health and Environmental Science, Tokyo Medical and Dental U. 1995; Takeuchi, S., Takano, T. Nakamura, K. "Health and Its Determining Factors in the Tokyo Megacity," Health Policy (33) 1995.
16Takeuchi, S., Takano, T. and Nakamura, K., "Health and Its Determining Factors in the Tokyo Megacity," Health Policy (33)1, 1995.
17Takano, T. et al. "Disease Patterns of the Homeless in Tokyo," J. of Urban Health(76)1, 1999.
18For a review of this literature and bibliography see Rodwin, V.,"Comparative Analysis of Health Systems: An International Perspective."In Kovner, A. and Jonas, S. eds., Health Care Delivery. New York: Springer, 1999.
19OECD Health Data is a CD ROM available from the Paris or Washington office of the Organization for Economic Cooperation and Development. The most recent version (1998) uses a broad definition of "health" and includes a wide range of social and economic indicators.
20For example, in the 1980s, cities in the U.S. and Canada passed ordinances banning ozone-depleting chlorofluorocarbons, well before the 1996 deadline for eliminating them was set by an international treaty (Molly O'Meara, Worldwatch Institute).
21G. Rosen, From Medical Police to Social Medicine. New York: Science History Publications, 1974; M. Foucault, The Birth of the Clinic. London: Tavistock, 1971.
22See e.g. J.W. Leavitt, The Healthiest City. Princeton: Princeton U. Press, 1982; R. Alford, Health Care Politics. Chicago: U. of Chicago Press, 1975.
23See, e.g. Hall, P. The World Cities, London: Weidenfeld and Nicholson, 1966; Sassen, S. The Global City: New York, London, Tokyo. Princeton: Princeton U. Press, 1991; Sassen, S. Cities in the World Economy, Thousand Oaks, CA: Pine Forge Press, 1994; Sassen, S., "Global Financial Centers," Foreign Affairs (78)1, 1999.
24Four World Cities. London: Llewelyn-Davies, June 1996.
25Short, J, Kim, M. ad Wells, H., "The Dirty Little Secret of World Cities Research: Data Problems in Comparative Analysis," International J. of Urban and Regional Research (20)4, 1996.
26Globalization and its Discontents. New York, New Press, 1998.
27See, e.g. Aicher, J. Designing Healthy Cities: Prescriptions, Principles and Practice, Malabar, Fla: Krieger Pub. Co., 1998; Ashton, J. Healthy Cities. Bristol, PA: Open University Press, 1992; Duhl, L., Hancock, T. A Guide to Assessing Healthy Cities, WHO Healthy Cities Project Office, Copenhagen, 1988.
28Garcia, P. and McCarthy, M. Measuring Health. A Step in the Development of City Health Profiles. Copenhagen: WHO Regional Office for Europe.
29 WHO's Collaborating Center for Research on Healthy Cities, in the Netherlands, is conducting an evaluation of what has been accomplished in selected "Healthy Cities."( See internet site: http://www.rulimburg.nl-who-city/aswww.html).The new Kobe Center directed by Dr. Kawagushi is working on comparisons of selected Asian cities (Based on a conversation with Dr. Yasuhiro Suzuki, Executive Director, Social Change and Mental Health, WHO). Also see Doyle, Y., Brunning, D., et al Healthy Cities Indicators: Analysis of Data from Cities Across Europe. Copenhagen: WHO Regional Office for Europe, 1996.
30See internet site: http://www.rulimburg.nl-who-city/aswww.html
31See, e.g. Innes, J. Knowledge and Public Policy: The Search for Meaningful Indicators.New Brunswick: Transaction, Second Edition, 1990.
32Life in the World's 100 Largest Metropolitan Areas. Washington D. C., Population Action International, 1990.
33OECD Health Data. CD Rom. Paris: 1998.
34WHO, Healthy Cities, proposes 32 indicators (See, e.g. Garcia, P. and McCarthy, M. Measuring Health,.op. cit) Also see Health For All Database. Copenhagen: WHO Regional Office.
35Bardsley, M., Project Megapoles, Health Indicators Project, Preliminary Report for Validation. London: Directorate of Public Health, East London & The City Health Authority.
36Garfield, R., Greene, D. Abramson, D. and Burkhardt, S. eds. Washington Heights/Inwood: The Health of a Community II. New York: Columbia University, Health of the Public (HOP) Program, 1998.
37Berkeley: UC Press, 1984. I developed a framework for analyzing health planning efforts and applied it to the experience of France, Quebec, England and the U.S.
38(with D. Brecher, R. Baxter and D. Jolly) New York: NYU Press, 1992.
39"Health and Social Services for the Elderly in New York, Tokyo and Paris: Intellectual Exchange," (with Dr. Robert Butler and Dr. Marianne Fahs)Ref. # 98 ACR 8622N. This would cover travel and expenses to Tokyo in
 



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