Air pollution

A guide to global health diplomacy cannot prescind from acknowledging the now well-estab- lished role that subnational entities play in global governance. Among the many actors at this level, cities have arguably been some of the most proactive on the world stage for the better part of the past three decades. This box gives a brief overview of the recent rise of “city diplomacy”

and the current challenges in the intersection of such diplomacy with global health.

Cities have been in the spotlight across many global agendas, not just as an issue or as places, but more and more formally called upon by multilateral initiatives and frameworks as interna- tional actors in their own right. In turn, many local governments no longer defer to national governments when developing strategies and terms for international engagement on key issues.

Mayors, city councils, metropolitan commissioners and representatives of local authorities are reaching out directly to one another and more broadly to international actors, including corpora- tions, United Nations (UN) system agencies, and overseas nongovernmental organizations. There are now hundreds of formalized international cooperation mechanisms that have been estab- lished by cities (city networks), giving cities a voice in discussion on many global issues, such as the climate change agenda and the Paris Agreement or the Sustainable Development Goals (SDGs). This means that cities have been accorded a key role in responding to major transnation- al challenges. The COVID-19 crisis has further accentuated the front-line role of cities: as of September 2020, approximately 95% of COVID-19 infections had occurred in urban settings, with over 1500 cities affected worldwide. Accordingly, the UN Secretary-General has called for a clear- er understanding of how the pandemic, like other health challenges, is unfolding in an urban world. For their part, numerous cities and city networks have quickly activated their city diploma- cy connections to form COVID-19 task forces, repositories of policy actions and mechanisms for the exchange of best practices. Yet, city diplomacy should be understood in the context of a na- scent global urban governance, not simply as city-to-city exchange.

A brief history of city diplomacy is telling in that respect. The modern evolution of cities’ interna- tional engagement comprises at least three different “generations”. City diplomacy has gone from more culture-based city-to-city relationships to a complex mechanism and circuit for inter- national coalition-building and policy exchange, even in the wake of the considerable COVID-19-related impacts on international travel and cooperation. While the first modern gener- ation (early 20th century) of city diplomacy was based on formalized, bilateral “sister cities”, a second (mid to late 20th century) generation has scaled up these twinning networks to more formalized city network coalitions for advocacy and exchange, often backed by UN specialized Box 16: City diplomacy for global health

agencies. The mid-1990s were the heyday of efforts towards more formalized city health diploma- cy through the work of the European Healthy Cities Network under the aegis of the World Health Organization (WHO) and other regional efforts such as the Alliance for Healthy Cities (in the Western Pacific). Nowadays there are other similar, albeit more specialized, networks such as the WHO Age-Friendly Cities project.

The 21st century has, however, seen the emergence of a more complex realm of urban diplomacy, not least in health. This has led to even more specialized and often purpose-built networks that are closely intertwined with private and major philanthropic investments. City diplomacy is en- gaged directly in localizing major global agendas such as the 2030 Agenda on Sustainable De- velopment. In health this includes the launch of initiatives such as the Bloomberg Philanthro- pies-backed Partnership for Healthy Cities within WHO, or the localization of the health-related SDGs via the WHO Shanghai Consensus on Healthy Cities. Understanding city diplomacy from this angle allows greater room for manoeuvre beyond twinning and city-to-city cooperation, and gives a clearer idea of the intersections between cities and global governance.

Although potentially paradigm-changing, the COVID-19 crisis has not affected the impetus for city diplomacy. City governments still recognize the importance of engaging internationally but lack the necessary formal diplomatic training and resources for doing so to maximum effect.

Nevertheless, cities’ commitment to global agendas such as the SDGs (and not least their health related premises) remains strong, and international frameworks are increasingly influential in municipal affairs. Cities remain confident in their capacity to tackle global challenges. The crisis has also prompted attention for global health beyond the health sector: thus, health and well being are now covered by city diplomacy efforts originally focused on other sectors (for example, the environment in the case of the C40 Cities Climate Leadership Group, or migration in the case of the Mayors Migration Council).

Nevertheless, the role of city diplomacy in global health remains relatively limited compared with its role in other areas such as migration, climate or resilience. Cities and urban issues continue to occupy very modest positions on the global health agenda. Apart from the self-organized initia- tive of city networks, cities are at present still very much on the sidelines of official multilateralism.

WHO, for instance, still does not have a major unit for cities and has relegated the topic of urban health to relatively few, often regional, conversations. More broadly, as in many other global policy areas, capacity-building and investment remain critical at the local level, where there are significant constraints on budgets and training opportunities for “city diplomats”. Recognition and institutionalization of an urban voice are still a key challenge.