For most of human history, the link between cities and disease was deadly obvious. In 430 B.C.E, the Plague of Athens presaged the city-state’s downfall. Centuries later, when the bubonic plague spread from London to the Caspian Sea, it decimated Europe’s population. In the twentieth century, Spanish flu ravaged cities around the world, claiming millions of lives. In each outbreak, high population density, scientific misunderstanding of disease, and lack of public-health infrastructure turned cities into breeding grounds for pestilence.
Cities survived, a testament to the incredible social, cultural, and economic benefits that emerge from urbanization. And the link between cities and disease began to fade in the American mind. Although SARS, MERS, and Ebola all emerged in the past two decades, the epidemics were always concentrated in distant nations. Until March 2020, Americans could blissfully believe that their country had severed the link between cities and sickness.
The COVID-19 pandemic exposed how woefully unprepared American cities were for a health disaster. It also revealed the specific shortcomings of modern civic life—income inequality, massive disparities in healthcare and education, and small businesses hamstrung by bureaucracy—which created the conditions that allowed the pandemic to thrive. All undermined the ability of America’s cities to respond effectively to the pandemic.
Glimp professor of economics Edward Glaeser and Eckstein professor of applied economics David Cutler have both thought deeply about how inequalities in the United States destroyed the resiliency of communities fighting COVID-19. The pair argue in a new book, Survival of the City, that cities are worth fighting for, and that the benefits of urban life—the cultural, economic, intellectual, and social possibilities—far outweigh the costs. But a central theme is that a city is only as healthy as its weakest members. Unless swift action is taken to reduce inequality, especially in healthcare and education, Cutler and Glaeser write, the future of some American cities is in jeopardy—and they may not survive the next pandemic.
“I remain fundamentally optimistic about the city,” Glaeser, whose 2011 book was titled Triumph of the City: How Our Greatest Invention Makes Us Richer, Smarter, Greener, Healthier, and Happier said in an interview. (To hear Glaeser discuss the benefits of urban growth, listen to Harvard Magazine’s “Ask a Harvard Professor” podcast: “Edward Glaeser: Should We All Be Living in Cities?”) “But I do think the future depends on whether this pandemic continues for several more years, or if we have another pandemic in the next decade that’s deadlier than this one. That’s a dark vision for cities and it’s worthwhile to invest a great deal to make sure that vision doesn’t come about.”
An obvious candidate for improvement is the healthcare system, a subject in which Cutler is expert. The United States spends more on healthcare than any other developed country, yet consistently ranks near the bottom of its peers in terms of the quality of care received by its citizens (see “The World’s Costliest Healthcare,” May-June 2020, page 44). The problem, he says, is that the U.S. health system is essentially running on autopilot, structured so that the federal government absorbs much of the cost, while letting the market decide how that money is spent. As a result, Americans see more specialist providers than generalists, receive more acute than preventative care, and spend more on administration costs than on healthcare itself.
The incentives intrinsic to the American healthcare system dramatically increase the cost of care, Cutler continues, while delivering only marginal health benefits. As a remedy, he and Glaeser advocate for improved public-health infrastructure focused on preventing people from getting sick in the first place, rather than on treating them once they are already ill. “We failed in testing, we failed in isolation, we failed to provide personal protective equipment, we failed in allocating scarce ICU capacity, we failed to supply ventilators, and so on,” says Cutler. “We want more public health and less medical care, but we’re not set up to do that.”
While healthcare in the United States is generally thought of as a federal issue, implementing effective public-health programs occurs at the local level. The key, says Cutler, is that policymakers in America’s cities need to administer programs that focus on improving the health of their most at-risk citizens. Underserved communities often suffer the most during health crises such as pandemics, increasing risk to the city as a whole. “Cities have to think about the health behaviors of the least healthy populations, not just because they care about them as individuals, but because they care about the whole city,” says Cutler. “We’re only as healthy as the least healthy among us.”
Making cities pandemic-proof, Cutler and Glaeser argue, will require improved education, lower costs of living, higher wages, and reformed small-business regulation that lowers the barriers to entrepreneurship. All have a role to play in making cities not just resilient to pandemics, but places where their citizens can thrive. “You can’t solve everything at the city level, but there are crucial things that the government does locally,” says Glaeser. “It’s hard to think of more vital things than schools, safety, and social mobility to make a city stronger.”
Failure to reduce inequality along these dimensions could have dire consequences, Cutler and Glaeser warn. Cutler’s nightmare is a future where the rich and middle class wall themselves into closed communities beyond the city. This would be disastrous economically and socially, he says. Avoiding this outcome won’t take a miracle, but it will require city leaders to act. “There are times in government where what you need are big, bold ideas and there are times where what you need is great implementation,” he says. “I don’t think we need big bold ideas for these things. We know what to do. We just need competence in carrying [them] out.”
