There are times in history that are pivotal moments. Now in 2015-2016 is one of those times. While much attention was seen in 2007-2008 where for the first time in history half of the world’s population was urban, that figure included the fact that most of the developed world had already been highly urbanized for some time, lifting the global average. However, most all of the world’s population growth is in low- and middle-income countries (LMICs). It has been projected that 2015-2016, more than half of the population in LMICs will be urban. More important, the pace of growth in LMICs far outstrips that of the developed world and exceeds the ability of LMIC urban areas to accommodate such increases. Much of the LMIC’s growth will be into urban slums through both migration and natural growth. The term slum has been considered insensitive and has been replaced with other terms such as informal settlements, but for our purposes here the term slums conveys more poignantly the urgency of drawing attention to the plight of these areas that represent concentrated disadvantage.

With this crossover when the LMICs are becoming more than half urban, now is the time where we must draw increased attention to the threats to population health especially for vulnerable populations in areas of concentrated disadvantage. For decades, international agencies and foundations have focused their development projects in rural areas. The rational has included that rural areas contain the worst poverty and health outcomes, that development in rural areas might help to stem the pace of migration to cities, and that rural areas are more manageable than urban areas to see gains. However, once data were disaggregated from urban versus rural to look at smaller geographic units, it became apparent that urban slums had similar if not worse health outcomes than rural areas. Also, despite efforts to provide resources and programs in rural areas, the pace of migration to urban areas has continued and in some areas has increased. This migration to urban areas reflects the draw that urban areas provide for more opportunity to accumulate wealth whether through formal or informal economies. Rural areas have benefited from remittances from urban migrants to their families remaining in those rural areas. The lack of resources and ability to absorb the migration and natural population growth has been met with increased overcrowding usually in expanding rings of settlements around urban centers and commonly in unsafe terrain. Provision of resources is complicated with overwhelming need, limited funds and complex relationships. Building infrastructure and providing services to keep pace with population growth is a challenge.

Without resources and services, without economic opportunity, and without political voice, the health of slum residents is threatened. The ability to stem infectious diseases, to reduce chronic disease risk through nutritious diets and safe pedestrian byways with controlled traffic and public safety, and to offer preventive health services and quality housing requires investment in people, infrastructure and opportunity through political voice.

Addressing urban health challenges needs to take stock of characteristics that define such areas. Size, density, diversity, and complexity are what define urban areas. These characteristics come with advantages and disadvantages. Large size in cities means that we can efficiently reach large numbers of people for interventions yet larger size can also mean incomplete coverage for services. Density provides proximity and association to develop critical mass for economic and political gain, yet density can lead to population overcrowding and dispersal. Diversity can mean bringing together specialized talents, yet can also mean social exclusion and culture clashes. Complexity can bring together interlocking services yet can have competing sectorial divisions. An ideal in urban areas to address these characteristics of cities is to promote universal health and social service coverage, build density versus overcrowding, build inclusive opportunities, and attain good urban governance.

We continue to learn much about how to move toward urban health. Studies across disciplines build knowledge on competing risks and suggest then evaluate programmatic and policy interventions. While each urban area has a unique array of characteristics and dynamics, evidence is building for best practices. One compelling approach started in Brazil is Participatory Budgeting. This movement involves a sincere value to address inequity within the population, a commitment to have leadership with intersectional engagement across municipal government agencies, and action to achieve broad inclusion, active participation of an entire population with evidence of clear accountability. Even with a small portion of a municipal budget, the impact of this movement is evidenced with increased planned infrastructure for factors that build and preserve health including safe housing, water and sewage, transportation, settings for recreation, and a sense of worth through political participation. Data on health outcomes remain sparse but the few crude indicators available suggest improved life expectancy and reduced infant and under five mortality. This movement has spread worldwide from LMICs to the developed world with one of the most recent examples being areas within New York City where early data show participation in targeted neighborhoods is higher for participatory budgeting than in general elections.

The image of “urban” is increasing growth of megacities with larger slum populations, yet the real picture is different. Megacities represent only a very small proportion of urban populations. A far greater number of cities consist of less than one million people each. If the pattern of migration and natural population growth continues in these cities as may be projected for the next thirty years, we have the opportunity to look forward and plan now to make these urban areas into healthy cities. The first step is recognition of this trend. This must be followed with a commitment to address the needs in a way that reflects the unique circumstances and dynamics of each urban area. We have the opportunity, we need the evidence, and we need to act to achieve the goal of urban health. The United Nation’s Millennium Development Goals to be achieved by 2015 paid scant attention to the challenges of urban health. The opportunity to address these challenges with the next iteration of the Sustainable Development Goals needs to be explicit. We are at an important moment in history.

Publication Dates

History