Geography of urban health

 Concern for ensuring good health in cities is nothing new. However, the diseases taking most years off our lives today (from cancer to cardiovascular accidents) are very unlike those of a century ago, and oblige us to consider the health impacts of environmental, climate and lifestyle factors. We must place health and wellbeing at the heart of urban development and reclaim urban geography as the best option for advancing the wellbeing of most of the planet's population. 

While it may seem recent, the dilemma of how to ensure good levels of health in cities is nothing new. It is merely an evolution of the logic that in the mid-19th century led Ildefons Cerdà to ask how the city could be made into a healthier space. Focussed on the local level, his idea was to achieve a human urbanism that would provide well-being and promote greater equality. Studying the living conditions of people within a walled city led him to seek answers to the three main problems with the ancient city of Barcelona: density, mobility and mortality. During the years of unbridled industrialisation, a sense of urgency derived from the fact that workers’ life expectancy barely reached 30 years. Epidemics raged, as infectious diseases like tuberculosis, cholera, typhoid and dysentery spread along narrow streets in dense cities. The concern in those days was not the health of the planet – the world was not yet globalised, or at least was not perceived as such. But, like today, changes to the environment of urban life were required, including wider streets in which air could circulate and interior green spaces for it to regenerate. In combination they could help prevent the spread of infectious diseases, creating healthy spaces in the midst of industrial expansion. 

Today’s need for a cleaner climate is the same, except the same strategy no longer suffices. In terms of disease we have come a long way. The shadow of the worst pandemic for a hundred years still causes anguish because of its impact in terms of closed cities, confinement and restrictions, but the landscape has changed. Developed countries have undergone an epidemiological transition. We now live much longer lives and, COVID-19 apart, infectious diseases, like those that decimated populations in the past via epidemics and plagues are now less of a threat than chronic diseases like cancer, heart and respiratory failure and diabetes, many of which are induced by environmental and climate factors, as well as by lifestyle habits including mobility and diet.  

By 2050, the United Nations have projected that two-thirds of the world's population will live in cities. In less than a decade, cities will be home to almost a third of the world's jobs and account for over half of consumer spending (MGI, 2016). More than a dozen cities will have populations in excess of 20 million. This rapid and uncontrolled urbanisation is straining the determinants of health in many people's lives. Traffic, factories and construction poison the air, water supplies can be polluted, substandard housing is harmful to health, and even the food supply and quality – especially processed food – can be compromised as a result of mass concentrations of people. In lower income countries, especially in Africa, this urban sprawl will generate even more inequity. Nearly a billion people live in slums, created as mass reception areas without urban planning or adequate health provisions (Khan, 2023). The United Nations projects that 60% of these urban dwellers are under the age of 18, meaning that many inhabitants of these slums, which often arose as a result of rural–urban migration, will fall victim to the infectious diseases with the highest mortality rates, such as pneumonia and diarrhoea, and which particularly affect children under the age of five, whose immune systems have yet to fully develop. 

But the phenomenon is not limited to countries with lower economic capacity, and while logically the greatest vulnerability is always found at the extremes, the race to lead the ranking of healthiest cities has also become a concern for political decision-makers in countries with more advanced economies. Leading cities, those that produce the best living and working conditions, cannot ignore factors that impact health like smoke, caused in part by traffic, but also by supply, production and construction, and which causes or worsens respiratory diseases like asthma, cardiovascular disease and cancer. Others, such as noise, impact anxiety, stress and insomnia and can hinder children’s cognitive development.  

How to build a healthy city 

Studies by the Barcelona Institute for Global Health (ISGlobal) estimate that good transport and urban mobility planning could prevent at least 20% of premature deaths in cities in developed countries. The question is therefore how to build a healthy city. Collaboration between the planning, transport, environment and health sectors is essential to address the challenges of urbanisation. We must put health and wellbeing at the heart of urban development and the problems we face, such as high levels of air pollution and noise, the effects of global warming, the shortage of green spaces and sedentary behaviour. But we must also work on changing people’s behaviours, interests and habits, accustomed as they are to a model of urban life that generates health risks and reduces longevity and quality of life. It is difficult to cross the line between acceptance and rejection without information campaigns, inclusive decision-making processes and, above all, clear action plans that, while making clear that the changes are not minor, can be adequately defined in the time needed to tackle the transition. 

Part of this work involves public building and urban planning initiatives. The city of the future must be green. Green spaces, including urban parks, gardens, tree-lined streets and forests, provide multiple health benefits to adults, including stress reduction, longer life, and better general and mental health. Among children, they are linked to improved attention spans and emotional and behavioural development. The relationship between good health and blue spaces like fountains, lakes, rivers and seas remains a relatively new field of research. Being associated with increased levels of physical activity they could be beneficial for mental health, especially for stress reduction and self-perceived well-being. Climate change has created a need for urban design to prioritise the prevention of rising temperatures in cities by improving building insulation, reducing emissions from heating and cooling systems in homes and offices, and incorporating more heat-absorbing urban materials, including increased vegetation.

As well as regulation and public policies to adapt standards to private enterprise, promoting mobility is another significant factor. According to a report by IS Global, sedentary lifestyles are a global public health problem, comprising the fourth greatest risk factor for mortality worldwide and the cause of one in four cases of breast and colon cancer. Cities should be designed to encourage physical activity through active transport, using urban design to facilitate walking and cycling. Half of all car journeys in cities are under 5 km – a distance that can be covered by active transport, which would result in significant public health benefits due to increased physical activity and reduced levels of air and noise pollution. There is a social and not just individual need to raise levels of physical activity, and this must be integrated into city design. For this to be equitable, it is estimated that 25% of total space must be allocated to connected green and blue areas distributed throughout the municipality.  

The absence of a single global government means that addressing climate change requires international agreements to be reached; but cities already have governments that can regulate and plan. Time is limited but the potential impact is enormous, both in terms of lives saved and years of higher quality of life, as well as saving resources for health systems. The race to build healthier environments will define many cities’ futures. The best-prepared cities will also be the most competitive, attract the most knowledge and generate the most added value. Living in a city does not have to be detrimental to health, quite the contrary. For those who trust the science, sufficient evidence already exists on the abyss towards which we are heading and the impact on our lives of continuing with trends and habits that belong in other ages without facing up to the major changes our urban environment requires. For those still unconvinced about the dangers, suffice to visit any hospital and see how the diseases that cut short our lives these days, from cancer to cardiovascular accidents, have much more to do with environmental factors than the illnesses killing people just a century ago. Here, urban geography can claim to be the best means of advancing the well-being of the majority of the world’s people. 

References

Khan, Amina. “Cities of missed opportunities: improving the lives of people in poverty”. ODI blog (2023). 

MGI-McKinsey Global Institute. Urban world: the global consumers to watch. McKinsey Global Institute, 2016.

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