Networked Disease

Emerging Infections in the Global City

S. Harris Ali, Roger Keil, S. Harris Ali, Roger Keil

• Publisher: Wiley-Blackwell
• Year: 2011
• ISBN:
  9781444399110
• Edition: 1
• Topic: Medicine
• Subtopic: Epidemiology

A collection of writings by leading experts and newer researchers on the SARS outbreak and its relation to infectious disease management in progressively global and urban societies.

• Presents original contributions by scholars from seven countries on four continents
• Connects newer thinking on global cities, networks, and governance in a post-national era of public health regulations and neo-liberalization of state services
• Provides an important contribution to the global public debate on the challenges of emerging infectious disease in cities
• Examines the impact of globalization on future infectious disease threats on international and local politics and culture
• Focuses on the ways pathogens interact with economic, political and social factors, ultimately presenting a threat to human development and global cities
• Employs an interdisciplinary approach to the SARS epidemic, clearly demonstrating the value of social scientific perspectives on the study of modern disease in a globalized world

Part I

Infectious Disease and Globalized Urbanization

Introduction

S. Harris Ali and Roger Keil

It has been noted that, for the first time in history, more than half of the world’s population is now living in urban areas (United Nations Population Fund 2007). This outcome – the result of intensified urbanization – has coincided with a second large-scale development, namely globalization. Globalization has been conceptualized in various ways, but most definitions include the following elements as identified by Held et al. (2002): extensivity – a widening reach of social activity and power; intensity – an increase in the number of interconnections between places of the world as patterns and flows begin to transcend particular localities; velocity – an overall increase in the speed with which ideas, goods, information, capital, and people travel; and impact propensity – the fact that the impact of distant events is magnified at the local level, while at the same time, localized events have magnified impacts on distant locales.

The repercussions of the dialectical interaction of these two master processes of urbanization and globalization are both numerous and wide-ranging, but perhaps one of the most vivid manifestations of the urban–global dialectic is the emergence of the "global city." The research group on Global and World Cities (GaWC) defines a global city in terms of various indicators such as: population size (typically several million); an active influence and participation in international events and world affairs; the presence of an international airport that serves as a hub for international carriers; the existence of an advanced transportation and communications/information infrastructure; a strong presence of international communities and cultures; a vibrant sports and cultural scene, with world-renowned cultural institutions and festivals; and the presence of influential international financial, legal, and corporate firms and headquarters, as well as the tendency for translocal economic forces to have more weight than local policies in shaping urban economies (GaWC 2004). Through the performance of their institutional structures and processes, global cities articulate the local economy with the world economy by providing a space for capital accumulation while serving as nodes for global communication and population migration, thus resulting in sites of intense economic and social interaction (Friedmann 1986).

Global cities around the world are linked through flows of various sorts – capital, people, commodities, transportation vehicles (planes, ships, cars, trains, trucks, etc.), as well as information and communications (Friedmann 1986; Sassen 1991, 2000; Knox and Taylor 1995; Smith and Timberlake 2002; Taylor 2004; Brenner and Keil 2006). A natural consequence of these linked flows is that global cities serve as nodes of connection within an emergent network; that is, the global cities network. It is important to note that because the flows that essentially constitute both the global city and the global cities network are always in motion – they are, in essence, in a constant state of flux – for this reason global cities should no longer be thought of as static, bounded entities (Thrift 1996, 2000b). Consonant with this reasoning, one of the central objectives of this book is to draw attention to the networked, yet fluid, nature of global cities and the networks to which they belong, in order to emphasize the role that these characteristics have not only for the contemporary spread of infectious disease, but for understanding the social and political reactions to disease spread under the conditions of intensified urbanization and globalization – that is, under the influence of the urban-global dialectic.

The changes generated by the urban-global dialectic provide windows of opportunity for altering the microbial traffic of pathogens by changing the social and biophysical conditions required for disease emergence and spread. Thus, the noted virologist Richard Krause (1993, p. vii) remarks that: “Microbes thrive in these ‘undercurrents of opportunity’ that arise through social economic change, changes in human behaviour, and catastrophic events … They may fan a minor outbreak into a widespread epidemic" (cited by Davis 2005, p. 55). Second, analysts have noted that we may be heading toward a single global disease ecology (McNeill, 1976; Barrett et al. 1998), wherein previously localized and bounded disease ecologies have undergone a process of convergence due to factors such as the revolutionary changes in transportation technology (Cossar 1994), and the increasing permeability of geopolitical boundaries (Farmer 1996) – factors that are integral elements of the urban-global dialectic that undergirds the global cities network. Consequently, any event can have unexpected, disproportionate, and emergent effects that are often distant in time and space from when and where they originally occurred (Smith 2003, p. 566). The case of SARS, as we shall discuss at various points throughout this volume, illustrates this point well. The spread of SARS can be viewed as a "borderless" phenomenon, as evidenced by the fact that the virus spread across nations and regions but within the global cities network. The SARS virus represented another flow type that connected global cities. The spread of SARS in this manner therefore underscores the fact that today infectious diseases cannot simply be considered as a public health issue that is exclusively confined to the developing world or pegged to a particular level of scale (whether it be the local, regional, or national).

The two chapters in this part introduce us to various aspects and implications of the themes outlined above. Building on the previous work of Ali and Keil (2006), Estair Van Wagner explores how we can begin to move toward the development of a theoretical framework that will help us grapple with the problem of simultaneously elucidating the fluid pathways of urban connectivity while analyzing the role of spatially fixed sites in the spread of new and emerging diseases such as SARS. The theoretical precepts involved in the work concerning the spread of infectious diseases within the urbanglobal dialectic introduce practical challenges for policy-makers within the global city. Victor Rodwin draws out and discusses some of these challenges in terms of how health and disease, public health infrastructure, and the health system may be compared among New York, London, Paris, and Tokyo. He highlights the convergent health risks and contrasting views of urban health in the literature and calls attention to the notable neglect of poor and vulnerable populations within high-risk areas of global cities.

1

Toward a Dialectical Understanding of Networked Disease in the Global City: Vulnerability, Connectivity, Topologies

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.¹ 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).

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 fnequality 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 entr...

Table of contents

• Cover
• Series page
• Title page
• Copyright
• List of Figures
• List of Tables
• Notes on Contributors
• Series Editors’ Preface
• Preface
• Introduction: Networked Disease
• Part I: Infectious Disease and Globalized Urbanization
• Part II: SARS and Health Governance in the Global City: Toronto, Hong Kong, and Singapore
• Part III: The Cultural Construction of Disease in the Global City
• Part IV: Re-Emerging Infectious Disease, Urban Public Health, and Global Biosecurity
• Part V: Networked Disease: Theoretical Approaches
• Concluding Remarks
• Bibliography
• Index