The urban syndemic of COVID-19: insights, reflections and implications

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ABSTRACT

This editorial introduces the origin, purpose and scope of a Special Issue on COVID-19. It brings together 43 contributions from across the globe that examine the way in which COVID-19 has challenged the way we think about urban design, spatial planning and city governance. The editorial draws out a number of key messages from this body of work, highlighting how the impact of COVID-19 has been most devastating when combined with the existing vulnerabilities and chronic ill-health experienced in pre-pandemic cities. Following The Lancet, we, therefore, characterise this as a syndemic rather than pandemic, due to the way it interacts with existing urban NCDs. This provides further resolve to address long-standing urban health inequalities and challenges, while seeking more holistic ways of addressing these, for example through the Sustainable Development Goals. The editorial explains the role of our partners in the Special Issue (ISUH, Design Council and BOVA Network), draws out some of the themes from the collected papers, and finally highlights an agenda for future contributions to Cities & Health that will allow us to better understand and respond to the aftermath of the COVID-19 syndemic.

KEYWORDS:

• Healthy urban planning
• COVID-19
• urban health
• pandemic
• syndemic

The COVID-19 pandemic and the production of urban health knowledge

Cities & Health was launched in 2017 in response to the increasing focus of cities as key drivers of population and planetary health and health equity. Its purpose is to provide a forum to share and shape an emergent transdisciplinary research and practice agenda (OECD 2020) and focuses on how we can improve health and well-being through changes to urban design, spatial planning and city governance. It aims to stimulate a better understanding of the urban environment from a health perspective, as viewed by practitioners and researchers and wider community-members, and to develop novel interventions to improve the health of towns and cities. We view this journal as a key platform for the production and co-production of knowledge related to health and well-being in cities and has an ambition to inform policy, funding and implementation agendas. Ideally, this should happen in a timely and cyclical manner, with room for reflection and comment. This requires challenging orthodoxy, spanning disciplinary boundaries and engaging with a variety of communities of practice (e.g. epistemic\practitioner).

While recognising that most global city environments remain precariously challenged by infectious diseases fuelled by overcrowding, poor sanitation and water supply, we were also motivated by the rise of non-communicable disease (NCD), and the way in which dominant forms of urbanism threatened planetary ecosystems. However, while the threat of a global pandemic has a constant presence in public health, it has been largely absent from recent debates on shaping our cities for health and well-being. Indeed, a review of the first four volumes of Cities & Health indicates little discussion of infectious diseases. It seems a little obvious to point out how the shock of COVID-19 changed this. The virus is likely to have an enduring influence on cities for at least a generation and it serves as a harbinger of other similar global risks to health. It is highly likely that health of our conurbations will be regularly tested by other epidemics in the future, as it has been in the past.¹

As an emerging authoritative platform for debates on urban health, we felt that Cities & Health had a duty to provide space for reflection and to support cities and urban settlements throughout the world in responding to these new circumstances. The collection of papers included in this Special Issue is our first initiative in this endeavour and we anticipate that this will have a regular presence in the pages of the Journal for years to come. It is clear that the future trajectory of the pandemic and potential epidemics that may follow will have their own dynamic and localised impacts, and the Journal will seek to reflect these nuances as the situation evolves. However, we see this particular batch of papers as a specific time-capsule, or more evocatively, as messages in bottles cast out when the consequences of the COVID-19 pandemic first came crashing into the world’s urban settlements. The papers included here were written in the second quarter of 2020; a time of great anxiety, at the height of what is now called the ‘first wave’ and when many of the authors were in countries experiencing initial response to the pandemic, often with ambiguous and poorly defined regulatory measures, including severe ‘lockdown’ conditions.

When we issued a call for papers for this Special Issue, we did so with three key factors in mind; i) COVID-19 appeared to be a predominantly urban disease; cities across the world were leading in rapid and far-reaching responses to COVID-19; ii) city-dwellers suddenly faced dramatic new challenges many of which were shaped by the novel conditions of the urban environment in which they were now confined; and iii) the disease, and responses to it, appeared to be compounded by pre-existing vulnerabilities and inequalities. The academics and practitioners that responded to the call were coping with the rather intense experience of COVID-19, observing the resilience of cities to cope with rapid change, and reflecting on the more enduring lessons for addressing urban health and health equity. As the pandemic has progressed, it has become more clear that COVID-19 is as much syndemic as pandemic, as acute COVID-19 interacts with a range of NCDs (Horton 2020). Syndemics (‘synergistic pan/epidemic’) are characterised by the presence of two or more diseases or health conditions clustering in a specific population; and which adversely interact with each other, negatively affecting the mutual course of each disease trajectory, enhancing vulnerability, and accentuated by experienced inequities (Sharma 2017). This is not just a matter of comorbidity; Singer et al. (2017), note that a key factor in syndemics is the interaction of social, economic and environmental factors that increase the risk of clustering and vulnerability. As we learn more about the prevalence, risk and impacts of COVID-19 it is becoming more apparent that some of its worst effects have been in high-density cities, particularly with significant levels of poverty and poor sanitary conditions (e.g. UN-Habitat 2020), so it appears to be a predominantly urban syndemic. Understanding the nature of the crisis in these terms has critical implications for how it is managed in the long term. Although promising vaccines, which prevent severe disease, are being rolled out; it is not yet known whether they can reduce transmission, nor how long immunity will last. Similarly, for most in the world, there are only very limited treatments (such as anti-inflammatory drugs, immune plasma or monoclonal antibodies), these are still experimental and by no means widely available. We may face a situation of permanent containment, or regular re-emergence of the disease, both of which have very profound consequences for urban life and health. We are also only now learning about potential long-term effects of the disease arising from those unfortunate enough to be infected (Del Rio et al. 2020) and it is essential that we avoid COVID-19 becoming yet another driver of increased inequality and unsustainability (Simon et al. 2021). However, understanding this as a syndemic suggests that we should give even higher priority to tackling the causes of urban deprivation and patterns of unsustainable development that have been shown to underpin many of the most common NCDs. As noted by Ravetz (2020), this then gives rise to the possibility of framing the crisis as an opportunity for transformation using a co-evolutionary response that combines traditional epidemiological and medical approaches (treatment and tackling transmission paths) with a more radical response to fundamental urban conditions, drawing on ‘collective social intelligence’ that can emerge from collaborative efforts and the synergies of data sharing, expertise and new institutional design.

This is clearly a crisis that demands a response from Cities & Health which reflects its niche of an international, shared researcher/practitioner nexus fusing public health, spatial planning, urban design and city governance. There has been a rapid accumulation of commentaries and research on urban perspectives of COVID-19 across the mainstream media and in a number of academic blogs, and it is clear that there is intense pressure to share an expert opinion (for example, see Bell and Green 2020, Da Silva 2020). However, we also feel that it is vital to retain our established standards of peer review, meaning we would not provide knowledge at the pace of journalistic outlets. We have also been aware that the reconfiguration of work and domestic life under COVID-19 has resulted in differential pressures on different sectors, demographic groups and those of different socio-economic classes. One symptom of this is that conditions of lockdown and ‘working at home’ have had very varying consequences: some lucky folk, both engaged scholars and reflective practitioners, seemed to have been able to harness these conditions to improve their productivity or deepen their enquiries, while it has heavily impacted on others particularly those with caring responsibilities. We have tried to ensure that we were able to capture the widest possible range of voices from our community of practice, this collection of diverse and short reflections on COVID-19 and cities is our response.

As our starting point for understanding how Cities & Health could best frame the urban challenges and outlook under COVID-19, we referred back to the Leading Editorial in our first issue (Grant et al. 2017) which set out what the Editorial Board saw as being the evolving context for urban health. Virtually all the dimensions noted in that Editorial can be seen to have a direct link to the COVID-19 syndemic crisis. For example, from what we know, the emergence of the virus appears to be linked to increasing human interaction with nature, such as through new socio-ecological niches created by accelerating deforestation (Morens and Fauci 2020) and the expansion of a (relatively) new habitat, the urban environment, on a massive scale. Pathways of infection such as globalised urban networks and the immunological interactions between COVID-19 and obesity, illustrate the interaction between communicable and NCDs, which directly touch the key issues raised in our earlier Editorial. Above all, this pandemic has shone a spotlight on the poorest of the poor who suffer most from the disease, and demonstrates once again the pressing need to view spatial planning through a health lens (WHO/UN-Habitat 2020) to improve access to services, for transport design and better residential environments in poor communities. This, and the changing experience of cities during the crisis, has also meant that post-COVID-19 visions of the ‘new normal’ or how to ‘build back better’ tend to invoke many of the elements of established good practice in healthy urban planning that were acknowledged in our first Editorial: increase active travel, enhance the public realm, improve access to local services and secure more greenspace. It is important to stress that with the growth in human population, rapid communication and stressed environments; the likelihood of both new and emerging diseases (that is known diseases which are fast increasing in incidence or range) occurring is escalating (Morens and Fauci 2020). Despite pandemics having been predicted by specialists (Woolhouse 2002, Woolhouse et al. 2008), and indeed the impact of pandemics being top of the UK governments National Risk Register alongside large-scale Chemical, Biological, Radiological and Nuclear (CBRN) attacks² the rapid emergence of COVID-19 caught much of the world by surprise and while we are still learning about the characteristics of this particular virus, we should be reassured that the accumulated body of knowledge concerning how we make cities healthy (for which this Journal is now a recognised channel) has been actively and rapidly deployed during 2020. In countries in the Global North, these include formal measures such as reallocation of road space to cyclists and pedestrians, or securing universal access to urban greenspace and also unintended positive environmental impacts through behaviours such as reducing ‘non-essential’ consumption, shopping more locally and less use of private vehicles. There are also signs that some of the ‘emergency measures’ could become permanent features as enlightened city leaders recognised that hidden within the health crisis were policy windows (Kingdon 1984) that offered opportunities to unlock some stubborn and long-standing urban challenges. In the Global South, there remain major issues dealing with informal settlements in tropical towns and cities, improving housing in these less wealthy countries has the potential to yield significant health benefits (Tusting et al. 2019). We can therefore hope that the COVID-19 syndemic could be treated as a milestone in urban health, not just for its devastating impact on lives and livelihoods, but also as a profound indicator for why sustainable and healthy urban settlements are so fundamental to global society.

Previous Editorials in this journal have considered the type of knowledge, evidence and science that are needed to drive city health futures (Fudge and Fawkes 2017, Grant and Thompson 2018, Fudge et al. 2020). These call for an increased emphasis on trans-disciplinary research, more effective knowledge exchange between different silos of expertise and between those researching and those practising in urban policy (in essence forms of collective social intelligence highlighted by Ravetz 2020). The necessity of action during the COVID-19 crisis has highlighted the critical nature of effective collaboration across the researcher-practitioner-leader spectrum, and appears to have made a significant contribution to the elimination of transmission in New Zealand (Baker et al. 2020). Indeed, the closing paragraphs of our first editorial noted that ‘We will need to act with imperfect evidence but to track progress, adapt interventions and manage risk as to the preferred alternative to not acting at all’ (Grant et al. 2017, p. 6).

This Special Issue derives from the imperative to ‘act with imperfect knowledge’ and the need to ensure that when faced with urgent action we are able to draw on the best evidence available. We, therefore, wanted to focus on capturing the observations from the midst of the crisis, observations which may become lost in later waves of infection and recovery, yet could still be a source of valuable evidence for the future. While we understand that there will be many more insights generated from retrospectives of the pandemic, we are focussing here on the possibility of future learning from reflections made, often very rapidly, at what (then) appeared to be the height of the crisis.

In this way this collection of papers acts as a time capsule, not one to be sealed and excavated in decades to come, but one to be used as a key reference point in the dynamic process of making cities healthier and more equitable in line with the UN’s Sustainable Development Goals (SDG 1, 3, 10, 11 and 17, amongst others), as recently emphasised by António Guterres (UN, 2020). In order to operationalise this, we issued our call for submissions in late March 2020, allowing just a few weeks for the submission of Expressions of Interest in providing short commentaries of 500–1000 words. Although we initially anticipated publishing 10–20 commentaries, we were inundated by 220 Expressions of Interest, and we rapidly established a four-strong editorial team with complementary interests and experiences to handle the submissions. After an editorial selection involving two editors screening each submission, we invited 72 papers, with 51 eventually accepted for publication after an expedited review process involving at least two peer reviewers for each paper. The success of this process was underpinned by the involvement of three key partners (below) who helped disseminate the call and provided a cadre of peer reviewers willing to quickly comment on submissions. We witnessed many of the papers evolve rapidly and fruitfully in terms of their ideas and quality as a result of the insightful comments provided from reviewers during this process. Whilst these shorter think-pieces were being developed, a few authors also chose to submit papers focussing on COVID-19 into our open call with its more generic categories for longer commentaries, empirical and conceptual papers. These too have been included in this Special Issue.

Special issue partners

Three partners have co-operated with us for this special issue, each bringing a unique viewpoint; the International Society for Urban Health, the Design Council UK and the BOVA network (Building out vector-borne diseases in sub-Saharan Africa), whose perspective of this crisis is briefly outlined below:

International Society for Urban Health (ISUH)

This collection of commentaries on COVID-19 in cities at an early stage of the pandemic confirms the systemic nature of urban health and health equity. The experience shows a vital role for science in guiding public policies and for cities in tackling systemic health challenges like COVID-19.

Since the publication of the International Society for Urban Health’s vision (ISUH 2020), focussing on improving the built, social, economic, and physical urban environments to promote health, by means of its interdisciplinary collaborations, links between urban and global health have remained stronger and come under increased pressure. The COVID-19 pandemic has emerged along those links and has revealed the systemic nature of urban health, by exacerbating and broadening existing social and economic inequalities in cities. The COVID-19 pandemic has also made ISUH’s leadership role very clear and highlighted the need for increased efforts to cross-disciplinary boundaries and collective investments for health on this urban planet. By collaborating with this COVID-19 Special Issue, ISUH acknowledges that cities are vulnerable to health crisis and at the same time, underlines the vital role that cities can play in responding to health challenges like COVID-19. Cities & Health has then been visionary in its attempt to generate a better understanding of urban health. Though the 26 selected published papers are the most relevant to ISUH interests, we are concerned that mental health issues have drawn little attention. As the ongoing COVID-19 pandemic inflicts loss, uncertainty, instability, and a general decline in mental health and wellbeing across populations all over the world, we believe that mental health should not be such a neglected area of urban health. Indeed, as the syndemic evolves, its indirect consequences for mental health and child development are becoming increasingly evident and raise concerns for the future.

How cities, citizens, and governments respond to the syndemic and the effectiveness of local measures in reducing vulnerability and inequalities in cities need to continue to be rigorously scrutinized. Questions about the return on investments and impacts on equity will increasingly be asked. These questions inform ISUH’s strategy update, where we are exploring what other roles society and its members can play in proactively engaging in the construction of more equitable, resilient and healthy urban environments. ISUH’s next international e-conference on 6–8 July 2021 will focus on learning from the response to COVID-19 to help stocktaking one year beyond the start of the pandemic.

The continuing proactive engagement of scholars and practitioners in documenting and critically analysing experience in cities is essential. Journals like Cities & Health and societies like as ISUH have a major responsibility to articulate critical questions, distil learning and amplify resulting messages.

Design Council

The Design Council is an independent charity and the UK government’s advisor on design. It states its vision as a world where the role and value of design is recognised as a fundamental creator of value, enabling happier, healthier and safer lives for all. Its remit covers design of processes, products and places. It supports research, programmes and projects that offer strategic design advice to the built, natural environment and social innovation sectors. It has consistently demonstrated the need for transdisciplinary and place-based approaches for successful healthy city design and has made the irrefutable link to better health, economic and environmental outcomes as a result of good design. In 2020, COVID-19 shone a light on and validated what the Design Council and other healthy city advocates have known for decades. Areas of deprivation with poor health outcomes, bad housing and a lack of access to green and open spaces are where COVID-19, NCD’s and climate issues strike hardest.

The Council’s work in 2020, including Homes 2030 (DC 2020a), High Streets Task Force (DC 2020b), surveys on housing quality (DC 2020c), and ongoing research to reduce NCDs in the built environment through place interventions, aims to provide evidence to support policy and a system change to city design (DC 2020d). This Special Issue highlights the impact of urban green spaces, nature-based solutions, and active travel, on supporting and developing resilient communities in our modern stressed cities.

As COVID-19 continues to have consequences into 2021 and beyond, the Design Council will continue to work with partners to highlight and amplify the need for a truly diverse, transdisciplinary place-based approach to development, meaningful collaboration, co creation and engagement.

Building out vector-borne diseases in sub-Saharan Africa (BOVA) Network

The BOVA Network is a coalition of health researchers and practitioners from the built environment; established to develop the potential of improvements to houses and surroundings, as a means of protecting people from mosquito-transmitted diseases. We share Cities & Health’s aspiration to engender transdisciplinary research and practice. Although our primary focus has been on diseases such as malaria and dengue, our recommendations for preventing these infections call for buildings (including homes, schools and workplaces) which are healthier in every respect: better ventilated, less crowded, secure and comfortable, screened from mosquitoes, with a reliable, clean water supply, improved sanitation and free of accumulated waste (Lindsay et al. 2020).

Working across sectors is essential to delivering our recommendations. The COVID-19 syndemic has highlighted the key role of city leaders who have the requisite local knowledge and can bring together government, the private sector and communities. If our cities are to become healthier and resilient to future threats, city leaders must be fully supported; with evidence-based advice as well as the financial wherewithal.

Ultimately, our mission is to improve housing quality in Low-to-Middle Income Countries (Tusting et al. 2019, 2020) and help make our communities resilient against the considerable threat from infectious diseases.

The dynamics of emergent issues and themes

The contributions published in this Special Issue encompass the priorities of each of these partners, and provide rich insights into the consequences and challenges that have emerged from the COVID-19 crisis. The range and interrelated nature of the issues covered in the papers make it difficult to highlight dominant themes, primarily because COVID-19, and the responses to it, appear to have affected almost all aspects of urban life. Nevertheless, there are some clear messages that emerge from this collection of papers.

At a broad level, we should focus our attention on the dynamics of urban health lying outside the health system and linear infectious disease models. It reminds us of the need to act on the best available data, and not perfect data, in cities which are open systems, laboratory-honed truths and methods can lack relevance. The term action research is often used. Researchers need to work closely with cities and communities to help evaluate interventions as in vivo experiments, with room and agreements to adjust and iterate these experiments in light of emerging knowledge.

We need to coordinate actions and conversations across silos. This may mean joining global and local action and it can mean working across geographic boundaries linking up cities with similar urban forms, demographics or policy stances. It may mean working across sectors, health together with economics, transport or social policy. We also need to be profoundly aware of the consequences of pre-existing physical and health inequalities, and the frames use to make sense of these, which are embedded in deeply held social and cultural ‘norms’ around ethnicity and poverty, which are often reproduced in mainstream media and where the rise of populist politics has had a particular dangerous impact. We need to use the opportunity of this syndemic to reassert the ideas that increasing inequalities are not in the interest of anyone in society (Wilkinson and Pickett 2010); that such wicked problems are best addressed in as holistic way as possible (i.e. linking health initiatives with housing, food, transport policies); and that the most effective policies are entrenched in both democratic accountability and scientific evidence.

The papers that we are publishing in this Special Issue begin to join some of the dots in this complex and evolving puzzle of COVID-19. They range from policy statements (Gatzweiler et al. 2021) to research directions (Lennon 2021); spanning disciplines from psychology and mental health (McCunn 2021, Sinha et al. 2021) to gerontology (Biglieri et al. 2021, Hartt 2021): ranging across topics from climate breakdown (Newell and Dale 2021) and air quality (De Vito et al. 2021, Brittain et al. 2021) to food (Carey et al. 2021, Cummins et al. 2021); and from planning of informal settlements (Patel and Shah 2021, Tampe 2021) to the role of the domestic balcony in architecture (Grigoriadou 2021).

We are publishing papers that talk about the consequences of the syndemic on public space (Wray et al. 2021, Honey-Rosés et al. 2021, Kordshakeri and Fazeli 2021), particularly the provision of urban green space, (Hanzl 2021) and the value of more specialist spaces such as allotments (Niala 2021) and places for exercise (Payne 2021), which became highly valued under conditions of lockdown. Some of these papers touch on issues of biodiversity (Rastandeh and Jarchow 2021), zoonotic diseases (Vanhove et al. 2021) and infectious transmission (Adlakha and Sallis 2021, Kataria and Jackson Morris 2021).

Many papers raise issues of vulnerability and fragility of people and of systems (Berkowitz et al. 2021, Black et al. 2021) and consequences arising from inequalities (Cave et al. 2021, Diez Roux et al. 2021, Cole et al. 2021, Lawanson et al. 2021). Resilience is another theme that several authors examine (Rippon et al. 2021, Jenkins 2021, Obonyo and Mutunga 2021).

Similarly, several authors have highlighted the important consequences the syndemic has had on aspects of urban mobility (Nurse and Dunning 2021, Koehl 2021, Gutiérrez et al. 2021), especially the potential to stimulate major modal shifts towards active travel (Adlakha and Sallis 2021, McDougall et al. 2021). The syndemic also raises questions over the resilience of urban food systems (Carey et al. 2021, Cummins et al. 2021, Abwe and Daniel 2021), and in the long term may have implications for the wider food retail sector. Given its major role on quality of life, a number of papers consider the impact COVID-19 could have on the housing sector (Jones and Grigsby-Toussaint 2021), particularly in the context of the Global South where slum-dwellers are already facing major health challenges (Patel and Shah 2021, Tampe 2021, Smit 2021, Cobbinah et al. 2021, Wilkinson et al. 2021). In many Low and Middle Income Countries (LMIC), especially in sub-Saharan Africa, there is grave concern that attention will be directed away from the prevention and control of other serious diseases such as malaria and dengue. In this issue, Tampe (2021) draws attention to the lack of resources to maintain HIV and TB control programmes in slums while French et al. (2021) highlight some of the far reaching questions the pandemic poses for how we improve informal settlements. In LMICs the number of deaths directly attributable to COVID-19 could eventually be dwarfed by deaths due to indirect effects of the pandemic. It has been estimated that disruptions to health services and poor nutrition could, over 6 months, lead to 1,157,000 additional child deaths and 56,700 additional maternal deaths in these poorer countries (Roberton et al. 2020). Indeed, many of the contributions reflect on how different geographic and cultural settings have influenced peoples’ experiences of the pandemic (Jefferies et al. 2021, Cave et al. 2021, Diez Roux et al. 2021), while others highlight the differential impact of COVID-19 on different sections of the community including children (Kyriazis et al. 2021, Russell and Stenning 2021), women (Dadzie et al. 2021, Ebron 2021) and those of different racial or ethnic identities (Berkowitz et al. 2021, Whittaker et al. 2020), or those with pre-existing vulnerabilities, such as loneliness (Hartt 2021) and other aspects of mental health (Sinha et al. 2021).

Given the context in which these papers were invited and sourced, few offer strong empirical evidence that one would normally expect from peer-reviewed research, and this was never our purpose. They do, nevertheless, provide a jumping-off point for a series of important insights from the experiences and expertise of a diverse set of observers. Some papers raise important questions over questions of governance and global or city health policy (Natarajan 2021 or de Leeuw 2021) and differences of scale around which urban health and syndemic responses should be framed (i.e. from individual experience of the urban environment, Gillis 2021, Hartt 2021) to far-reaching ways on which we conceive of the urban system (Boyd 2021, Jenkins 2021). We hope that the value of this Special Issue rests on it being able to stimulate a phronetic social science approach (as advocated by Flyvbjerg 2012) helping to develop solutions to urban health challenges, based on the experiences of urban citizens. It is our intention that this collection of papers will be the start of an ongoing exploration of more far-reaching impacts of what COVID-19 (and our responses) have revealed about how to address urban health.

Future Agenda

Our initial reading of the contributions to this Special Issue, and to other channels, indicates that it is possible to draw out a number of key avenues of inquiry that future contributors to the Journal could usefully make in response to the COVID-19 syndemic and its aftermath, namely;

• Health across the urban system: In keeping with the framing of this crisis as a syndemic, it is important to think more broadly of cities as dynamic systems where health is affected by actions and structural conditions beyond the health system and infectious diseases model (e.g. Barton and Grant 2006), where inequalities exacerbate community and individual vulnerability to acute health challenges. It has taken Governments a long time to recognise that the impact of both COVID-19 illness and the adverse outcomes from restrictions has compounded existing societal inequities. Although many countries dedicated substantial resources to health protection and treatment, protecting the economy, building health service capacity and multiple interventions in the urban environment to support physical distancing, these have tended to lack the targeting towards those most in need. This also calls for a re-evaluation of the long-standing principle of Health in All Policies (HiAP) and we still have a lot to learn from an evaluation of the effectiveness of policies, projects and practices that integrate health across any urban system, or at least tackle health through other policy domains.

• Re-framing how we understand urban health: Following from this, the COVID-19 crisis has vividly demonstrated the need to broaden our understanding of good health and well-being. Good health is not only about access to local health services for treatment to patch up ill health, but infiltrates almost every aspect of society. It reminds us of the need to establish prevention and promotion of good health and wellbeing at the heart of public health. Many pre-COVID-19 public health concerns have risen to prominence during this crisis, cutting across agendas in the Global North and Global South, including overcrowding, how the poor can support themselves when self-isolating, the consequences of long-term isolation and loneliness; the importance of physical activity; the resilience that comes with good mental health; the need for access to greenspace; and the uplifting effect of social solidarity. We are interested in future research that explores such phenomena, particularly how the COVID-19 syndemic may have reframed society’s ability to tackle such issues, or examples of where the crisis has been used to open ‘policy windows’ for innovative action.

• Prioritising health inequalities and vulnerabilities: It is also clear that COVID-19 has very substantial variation of risk depending on a wider range of factors, including age, gender, ethnicity, underlying conditions and factors related to environmental exposure (such as housing conditions or nature of the workplace). This is underpinned not just by health inequalities, but also by wider inequalities across society (Marmot 2020), so that Cities & Health continues to encourage research that explores the effects of inequalities and how, in the context of COVID-19, it can be shown whether tackling the most vulnerable in societies can lead to better urban outcomes for all.

• Learning from crisis adaptation: The urgency of the urban responses to the COVID-19 syndemic has shown that there is an ability to rapidly change policy and reallocate resources once health becomes the highest urban priority, though regrettably in a notable small minority of countries the response has been very weak. Successful strategies have highlighted that it is possible to rapidly pool resources, knowledge and action across institutional and disciplinary boundaries, and shown benefits of being able to rapidly adapt to circumstances through practice-orientated processes of learning and knowledge exchange. We, therefore, welcome future contributions that explore the conditions and processes through which rapid adaptation can take place, and the longer term learning this can have for urban and health governance.

• Scales of innovation and intervention: The COVID-19 crisis has also shown how good public health requires both agency and supportive structures at every scale of the urban system. We have seen how it has brought together communities through actions of social solidarity, and the value of having access to good local services and green environments at the neighbourhood scale. It has also shown strengths and weaknesses in much broader metropolitan strategic infrastructure including food, housing and mobility systems. We are interested in the scale of innovation, where the most critical interventions can be made for securing urban health and crucially, how actions at different scales can be integrated and coordinated.

• Lessons for urban governance: Finally, it is very clear that the COVID-19 syndemic has asked very difficult questions of many aspects of urban governance including leadership, public engagement, policy-coordination, knowledge and resource allocation. Many of these issues are matters for longer-term reflection once the crisis has been averted, but it is clear that the experience could provide profound insights into how we can better organise and support urban governance so that it places citizen health as its overriding priority, and we welcome papers that can help shape this important debate.

Final words

COVID-19 has been a major shock to urban systems throughout the world. It has resulted in very high levels of suffering and death, but its health impacts go far beyond these direct effects; it has had profound consequences for the mental health of urban dwellers catalysed by the stress, loneliness and uncertainty around the aftermath of the forthcoming economic decline. It is clear that unless the syndemic is controlled worldwide COVID-19 will persist for years to come. Crowded urban environments of poor quality are found in counties of all income levels, as either market-led development or through informality and lack of an effective planning system. These can provide hotbeds of infection. Therefore, cities and their citizens must be the focus for both control and subsequent prevention. Furthermore, it is essential to recognise the interconnectedness between cities themselves (at both global and country level) and between cities and the wider environment. The ‘One Health’ approach (WHO 2017) recognises the interconnection between people, animals, plants, and their shared environments; and the importance of working across sectors to achieve better public health. This approach is endorsed in several of the papers presented here.

Cities can be highly resilient places capable of recovering from the most devastating impacts of war, natural disaster, and other events that may threaten their very existence. This resilience is not just based on the powerful forces of economic and social aggregation that have driven urban activity over millennia, but also the ability to reflect and learn from the risks and opportunities that can arise from such events. Cities can be and have been at the forefront of what has come to be the cliché of ‘building back better’. It is therefore of utmost importance that we take time to reflect on what cities have experienced, the vulnerabilities of urban living that this has exposed, and however dramatic and shocking the pandemic has been, we need to remain focused on the key urban health challenges that we faced in the pre-COVID-19 world, and that remain with us. Therefore, we should reset our sights on what we need in order to secure city futures that promote planetary, neighbourhood and individual health. At a UN summit held in 2015, all 193 United Nations Member States agreed to adopt the 2030 Agenda for Sustainable Development (United Nations 2020). Underpinning the agenda are the 17 Sustainable Development Goals (SDGs). They set out clear targets for achieving the goals and the means by which progress towards those targets will be measured year on year. In addition to focussing political attention and will, the SDGs provide a framework within which to understand complex problems and provide pointers on how best to set about tackling them. Goal 3 ‘Good Health and Well-being’ is of most immediate relevance in our current situation, but the papers presented in this Special Issue emphasise the pressing need to engage with all 17 SDGs both to mitigate the fallout from COVID-19 and avoid future crises.

The main dimensions of an urban strategy remain largely unchanged from our COVID-19 experience; we need to practice city planning and urban design as preventative medicine; we need to tackle the conditions of the most vulnerable urban dwellers; and we need to evolve approaches to governance and learning that will most effectively engage with the research, practice and leadership for transforming urban health to secure healthy, resilient cities and citizens.

Disclosure statement

No potential conflict of interest was reported by the authors.

Additional information

Notes on contributors

Geraint Ellis

The authors of this article all are members of the Cities & Health Editorial group or are from a organization that has partnered with the journal on this Special Issue: Geraint Ellis and Waleska Teixeira Caiaffa are members of the Editorial Board of Cities & Health; Marcus Grant is Editor-in-Chief and Caroline Brown is Senior Editor of the Journal; Fiona C. Shenton and Steven W. Lindsay are from the BOVA (Building-Out Vector-borne diseases) Network; Carlos Dora and Hénock Blaise Nguendo-Yongsi are from the International Society of Urban Health (ISUH); and Sue Morgan is from the UK's Design Council.

Notes

1. As noted by Girolamo Francastoro in (1546): ‘There will come yet other new and unusual ailments, as time brings them in its course… And this disease of which I speak, this syphilis too will pass away and die out, but later it will be born again and be seen by our decedents – just as in bygone ages we must believe it was observed by our ancestors …’.

2. https://www.gov.uk/government/publications/national-risk-register-2020.