Estair Van Wagner
Globalization means that if someone in China sneezes, someone in Toronto may one day catch a cold. Or something worse - if, in Guangdong province, 80 million people live cheek by jowl with chickens, pigs and ducks, so, in effect, do we all. Global village indeed.
Editorial Comment, Globe and Mail, March 29, 2003
The rapid global spread of SARS between cities in Canada and Asia in 2003 exposed the unanticipated vulnerability of global urban centers, linked to each other through networked and complex flows of people, capital, and commodities across the globe, to the spread of emerging infectious diseases. While SARS claimed lives and wreaked havoc on economies and health systems globally, sites of contemporary globalization and urbanization were unexpectedly exposed as environments in which infectious diseases can thrive and prosper. Whether we consider the SARS case, the anticipated avian influenza pandemic, or the re-emergence of tuberculosis in recent years, the need to understand how and why infectious diseases are emerging (and re-emerging) and spreading is clear and increasingly urgent.
Assertions of a "human victory" over the forces of illness and disease, and notions of geographical containment, are being disproved with increasing frequency and force (Garrett 1996). After SARS, we are coming to terms with the realization that the networked relationships of cities in contemporary globalization are more than the pathways of global capital and human mobility - they are also the pathways of rapid and undetected viral transmission. While the emergence and spread of infectious diseases is more than an academic problem to which clever theoretical solutions can be applied, building a theoretical framework through which we can understand the relationship(s) between globalization, urbanization, and emerging infectious diseases is fundamental to the development of informed and ultimately successful practical responses to future, and potentially more devastating, outbreaks of infectious disease. The focus of this chapter is to explore how the evolving body of research known as the literature on "global cities" (Sassen 2000, 2002; Brenner and Keil 2006) or "world cities" (Friedmann and Wolff 1982; Friedmann 1986; Knox and Taylor 1995; Taylor 2004) can assist us in this project of simultaneously elucidating the fluid pathways of urban connectivity and analyzing the role of spatially fixed sites in contemporary globalization.
Global cities research offers important insights into the trajectory of SARS, which David Fidler has referred to as the "first post-Westphalian pathogen" (2003, p. 486). Building on Ali and Keil's (2006) analysis of SARS, I propose that we must combine insights from both more traditional global cities perspective of relationships between nodes in a hierarchical network (Sassen 2000, 2002; Knox and Taylor 1995; Taylor 2004) as well recent topological approaches (Amin and Thrift 2002; Smith 2003b). While I contend that global cities research can make an important contribution to our understanding of emerging infectious disease in the global city, I also point to a number of ways in which approaches to understanding urbanization and contemporary globalization are challenged by the gaps, problems, and questions exposed by the experience of SARS.
Contemporary Globalization and Urbanization: The Renewed Potential for Disease
A deepening of global connectivity, in which aspects of our lives traditionally understood to occur primarily at the local or national level are increasingly embedded in broader global processes (Appadurai 1996; Hall 1991a,b), is occurring simultaneously as more and more of us are living in cities. Already over 50 percent of the global population are urban dwellers, with UN projections showing that 67 percent of the world's population will be by 2030 (UN-HABITAT 2006). A number of significant features of both global cities and of contemporary neoliberal globalization indicate a renewed potential for the emergence and re-emergence of infectious diseases: the speed and ease of global travel; flows of international migration; rapid and uneven urbanization; increasing population density; ecological changes ranging from global climate change to dam building; war and displacement; poverty; malnutrition; inadequate access to basic infrastructure and services; and the breakdown of public health and medical systems and aging populations (Lines et al. 1994; Louria 2000).
As Jonathan Mayer (2000) suggests, truly understanding disease causality in an era of intensification of both urbanization and globalization requires moving beyond the biomedical model of causation. He calls on us to examine how relationships of political and economic power define all levels of human-environment interaction, shaping our social, physical, and spatial reality. The impact of human interactions with our environment and each other is clearly visible in the globalized urban environment as populations expand and migration to urban centers increasingly overwhelms infrastructure and services of cities, particularly those of the global South.
While cities have often been associated with the development of public health systems and advanced medical care, they have also been sites of some of the most devastating epidemics, due to poverty, inequality, and lack of infrastructure. The case of SARS and its rapid and undetected spread between global cities illustrates how the globalized urban environment may be a particularly hospitable environment for emerging infectious diseases. Recent outbreaks of emerging infectious disease appear to be strongly related to features of contemporary urbanization (Vlahov and Galea 2003), as a brief overview of the experience of Toronto in the 2003 SARS crisis will demonstrate.
Toronto and SARS: Global Citiness as Vulnerability
Toronto is Canada's global city, through which the national economy is articulated into the global economic system (Todd 1995; Sassen 2000; Kipfer and Keil 2002). Taking it as an example, it becomes clear that many of its global city qualities are the very relations that made it most vulnerable to the SARS outbreak. Toronto is home to the busiest airport in the country with 30,000-40,000 passengers taking off to international destinations every day (St. John et al. 2003). As no two airports in the world are more than 36 hours apart (Gould 1999, p. 203), airports become "interchanges" in disease transmission and spread (Ali and Keil 2006), with the time between Toronto and any other city likely much less than the incubation period of any emerging infectious disease. The time-space of air travel contrasts with that of the body (Dodge and Kitchin 2004) and of viruses such as SARS, which has an incubation period of between two and ten days, during which a traveler could be across the world with no signs of illness (WHO 2003a).
A destination for large-scale international immigration and home to a number of different diasporic communities, Toronto is often called one of the most "multicultural" cities in the world (Driedger 2003; Ali and Keil 2006). This indicates a connectivity extending beyond economics to cultural and social links with global reach involving relationships across geographical distance facilitated by communication technologies, but also face-to-face contact and physical travel, which becomes critically important in understanding the spread of infectious disease (Urry 2004; Ali and Keil 2006).
Toronto's vulnerability cannot be understood only in relation to the movement of the virus through individual people. There are a number of other subtle and long-term ways in which "global citiness" shaped Toronto's experience with SARS, particularly in regards to public health and health governance. While federal funding and legislation provides an overall framework for health care in Canada, provinces have authority in regards to where and how money is spent. However, despite this provincial jurisdiction, health care is administrated and experienced primarily at the local level. Hospitals are subject to standards set by the province that funds them, but they are locally controlled by community level boards that are only loosely coordinated and the approach to care is marked by discontinuity between institutions (Armstrong and Armstrong 2003). Also, arguably the most important branch of the health system for the prevention of infectious diseases, public health in Canada falls to the level of government with the least power, resources, and autonomy at its disposal. As a statutory `creature' of the province, the municipal government of Toronto had very limited ability to deal with the SARS outbreak, given that the scale of prevention had as much to do with the global as it did with the local. As Warren Magnusson points out, for a local government to "... deal with questions of public health, it would have to project its authority far beyond its immediate boundaries. In a sense, it would have to follow its particular connections throughout the world" (1996, p. 291). During SARS, the problematic nature of an uncoordinated and geographically fixed approach to health governance and administration were made blatantly clear:
We were not prepared for SARS, nor did we have a system wide critical care communication strategy in place. From a critical care perspective, the most important limitation in the response to SARS was the absence of a coordinated leadership and communication infrastructure. (Booth and Stewart 2005, p. S58)
In recent decades, the drive to build globally "competitive" cities has become a dominant force in Toronto's urban restructuring (Kipfer and Keil 2002). Pressure for Canadian cities to be efficient and management oriented has been accompanied by the downloading of significant costs and responsibility from federal and provincial governments, who at the same time have decreased funding to municipalities. Shifts toward neoliberal public administration models such as New Public Management (NPM), coupled with the decreased capacity of the local government to satisfy the needs and desires of the public, has resulted in the increasing privatization and contracting out of public services. Guided by the imperative of attracting transnational business and elites, local governments are shifting their focus from redistribution to the creation of wealth (Porter 1995). As Rodwin and Gusmano's (2002) research on health governance and infrastructure has revealed, rising inequality between social groups and barriers in access to health care, particularly for the poor and ethnic minorities, are "onerous health risks" faced by global cities (2002, p. 449).
In Canadian cities these risks have been exacerbated by neoliberal restructuring that continues to dismantle Canada's universal public healthcare system and push social services into the private sector. Like entrepreneurial models of urban governance emerging in Canada, health reform has been driven by the private sector, emphasizing speed and efficiency (defined in market terms), leading to an increased reliance on outpatient services. This kind of assembly line medicine makes the diagnosis of a disease such as SARS, with subtle and non-specific symptoms, increasingly difficult and unlikely. As well, basic sanitation services have been drastically cut in recent years and hospitals increasingly rely on contracting-out for cleaning and laundry services, eliminating full-time and unionized staff as a way to cut costs. Hospital environments, and particularly emergency rooms, are increasingly dirty, making them highly vulnerable to the spread of infectious diseases such as SARS. Neoliberal discourses of efficiency minimize these aspects of health care, focusing on treatment instead of prevention (Armstrong and Armstrong 2003; Keil and Ali 2007).
Re-Reading Global Cities: "The Dialectic of Mobility and Fixity" Understanding the complexity of emerging infectious diseases in the age of global cities calls for more than a straightforward collaboration between medical or epidemiological research and global cities perspectives. Building an appropriately complex and flexible theoretical framework requires more than adding a "health" or "disease" perspective to our understanding of global cities, or including an "urban" perspective in the study of health and disease. Rather, it calls for an innovative reading of global cities research; one that questions fundamental assumptions about how and why global city networks are formed and produced, and for what purposes we should attempt to understand them. We can, and should, simultaneously consider what the emergence and development of a "global cities network" means for emerging infectious diseases, and what emerging infectious diseases mean for a global cities network.
The relationship between cities and infectious diseases challenges us to consider both the fixed nature of spaces in which diseases are experienced and health is governed and the fluid mobility of microbes that thrive in the connectivity of globalized urban environments. As Ali and Keil (2006) have noted, "[I]t is the dialectic of mobility and fixity that is truly characteristic of the urban condition under globalised circumstances." Following from this, I suggest that an appropriate theoretical framework accounts for the ways in which cities are fixed nodes in networks bound by specific contexts - historical, social, and political developments within socio-spatial structures of local, national, and regional scales that are further embedded in the global economic system. At the same time, this context demands a conception of time and space through which we can see the city as fluid and hybrid, constantly in the process of change and transformation, populated by a multiplicity of actors, themselves constantly emergent.
"Global Cities," "World Cities": Situating the Urban in Globalization
Since the early 1980s, scholars have linked their treatment of the urban to explorations of the relationship between global forces and cities (Brenner and Keil 2006). "Global cities" research has highlighted the role of the cities as critical sites in contemporary globalization, breaking with traditional approaches to economic and political analysis that have tended to ignore the local actors, emphasizing the role of the nation-state (Keil 1998a). Important contributions by scholars such as John Friedmann, Saskia Sassen, Michael Peter Smith, Michael Timberlake, and Manuel Castells have helped to define the relationship between globalization and urbanization as a critical agenda for urban scholars (Brenner and Keil 2006).
Global cities, hierarchy, and vulnerability
A significant amount of global cities research has focused on the way in which specific cities have emerged in the post-Fordist era as central nodes in a global urban network, functioning as the capitals of finance and advanced producer services, and as the headquarters of transnational corporations (TNCs), which produce the global economy (Friedmann and Wolff 1982; Zukin 1991; Friedmann 1986; Sassen 2002). Efforts to map the hierarchical organization of cities within contemporary global capitalism have tended to focus on a select group of "global" cities that act as "command and control" centers in the various geographical regions of the global economy (Friedmann 1986; Sassen 2000, 2002; Taylor 2004). In The Global City (2002), Saskia Sassen used New York, London, and Tokyo to illustrate the emergence of a global urban system in which a few "core" cities, supported by a larger network of "peripheral" cities, articulate the global economy.
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Excerpted from Networked Disease Copyright © 2008 by S. Harris Ali. Excerpted by permission.
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