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Rethinking Urban Health

With rapid urbanization has come a wide range of new health problems, particularly in low- and middle-income countries, and in low-income communities within the world's advanced economies. For policymakers, the challenge calls not just for more resources but for an entirely new approach to urban development.

CAMBRIDGE – In 1945, in the rural South African village of Polela, a community-based approach to improving health was implemented. In what became known as the Polela model, the prevailing health-care strategy was adapted to account for social, economic, and environmental data from community members. For example, monitoring of household crop failures and malnutrition in preschoolers allowed health authorities to anticipate vulnerabilities to health and well-being and intervene early to prevent ill-health.

For many years, the Polela model’s central ideas spread and were adopted by other communities around the world. But health care has since shifted back toward a narrower approach focused on biomedical interventions. We have recognized the importance of the environmental factors in health ever since the nineteenth century, when improvements in waste management and housing conditions helped to rein in cholera and tuberculosis in England, increasing life expectancy in the process. Yet with the rush of urbanization in recent decades, we have been neglecting these lessons, as well as our custodianship of the planet, with adverse consequences for public health.

Today’s cities have developed in ways that are ecologically disruptive and ultimately unsustainable. They are increasingly overcrowded, forcing the poor to live in low-quality housing with little access to health information, communication, and care. They are also chronically vulnerable to stresses on water, land, and food systems. And repeated shocks from natural disasters, climate change, and sociopolitical unrest – not to mention the legacies of colonialism and apartheid – will likely cause inequalities in health access and outcomes to widen further.