Half of the world’s population now lives in cities. By 2050, two-thirds of the planet will be urban dwellers, and 90% of the shift will happen in Africa and Asia. This trend means that focusing on urban development that benefits health is more important than ever.

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People have long migrated to cities in search of opportunities to improve their lives. But rising urbanisation is putting many cities under pressure to ensure that people’s needs are met and their well-being protected.

Urban life can present many challenges for public health. Cities that do not have effective systems for clean water, sanitation, and waste management, can see spikes in infectious disease such as cholera and diarrhoea. Cities also face a high burden of non-communicable diseases linked to social, environmental and behavioural risk factors associated with urban living, such as air pollution, poor diet and a lack of physical activity. Road safety and violence are constant concerns, as are mental health issues.

The challenge of ensuring a healthy diet

Around the world, millions of people struggle to eat a healthy,balanced diet every day. For many, extreme poverty, food scarcity, or living in a zone affected by climate change or conflict can mean they have very little food, or no food at all; every day, more than 820 million people go hungry.

Eating healthy meals can seem like a challenge in cities, many fast- food chains serving food and beverages that are high in fats, salt, and sugar. People in urban areas may often work very long hours, which can prevent them from investing time in buying fresh food for home cooking and eating well. Providing easy access to food that is not only healthy but affordable will be crucial in improving the diets of people who live in towns and cities.

Ignorance, lack of access to nutritious food or living in an environment that encourages obesity, safety issues preventing physical activity, high number of fast-food outlets, might mean they eat too much food with excessive fat, sugar or salt, compromising their health. Even for people living in cities, where food supplies can be higher compared to rural areas, ensuring a balanced, healthy diet can be a significant challenge.

Cities often have many outlets selling food and drink that are high in fat, salt and sugar, and the marketing of these foods, especially when targeted to children encourages people to consume it. Often, fast food and sugary drinks are cheaper, more convenient and more available to buy compared to fresh, locally-produced and nutritious food and safe, clean water. People with low incomes may have very long working days and travel long distances to their workplace, leaving no time to prepare fresh meals every day. Education, literacy and an understanding of nutrition can also influence whether or not people eat well.

Making the healthier choice the easier choice is a smart strategy to ensure people have a more balanced diet. For example, ensuring that fresh, locally-produced food such as fruits, vegetables, nuts and legumes are cheaper and as convenient as processed, packaged ready-to-use meals that are too high in fats, salt, and sugar. The city of Montevideo in Uruguay is helping citizens reduce their salt consumption by decreeing that every restaurant menu must offer at least 10% of items with no added salt.

Regulating marketing, especially to children, and having simple, easy-to-read and easy-to-understand food labels will help the urban consumer to make the right food choice. Quezon City in the Philippines is working to prohibit the sale and promotion of sugary drinks near schools. Encouraging urban agriculture and community or school gardens can also support local food production, reduce ‘food miles’, and allow people to be active participants in their health and diets.

Innovative approaches to reducing urban violence through urban planning and social mixing

Medellin has during a long time been known as one of the most dangerous city of the world and is an unlikely city in which to see a massive drop in violence. Yet the strategic urban redevelopment of Medellin did exactly that. In 2002, before its transformation, Medellin’s homicide rate was 185 per 100,000 population, accounting for nearly a third of all deaths in the city; by 2008, it had fallen to 30 per 100,000 of the population – one sixth of the previous homicide rate.

Violence, including shootings and stabbings, is a leading killer of people aged 15-44 years. Tens of millions are injured every year by non-fatal violence, including sexual assault, and it can lead to behaviour that is risky for health. Poverty, inadequate social protection, family dysfunction and poor parenting, mental health problems, and ease of access to alcohol, illicit drugs and guns can all contribute to increased levels of violence.

Urban violence is not confined to Medellin, of course. Around the world, every minute of every day, a person dies by homicide, many more are injured, and still more suffer from violence that leaves few physical consequences but is deeply damaging at cognitive and emotional levels. For instance, victims may experience anxiety, self-blame and a heightened fear of further violence. Violence occurs in rural and urban settings but is often more visible in cities given the high population density within them.

“Beyond deaths and injuries, exposure to non-fatal violence can put people at greater risk of smoking, alcohol and drug abuse, unsafe sex, mental health disorders, and social problems such as crime and unemployment,” said Dr Alexander Butchart, WHO Coordinator for the Prevention of Violence. “This increases their risk for non-communicable diseases such as cancers, cardiovascular disorders and diabetes, as well as HIV and sexually transmitted infections.”

In Medellin, the poorest slums sat at the top of steep hills, with the rest of the city and its facilities, at the bottom. The geography of the place made it impossible to traverse the city easily. Parts of the city were so prone to gunfire and other violence that few ventured in unless they had to, and those who lived there were trapped in their environment.

In 2004, innovative urban planners and violence prevention experts built a cable car system to bridge rich and poor areas of the city, which had the effect of connecting disparate worlds, enabling them to interact as neighbours. Yet violence has multiple causes and corresponding solutions at the individual, family, community, and societal levels. In Medellin the solutions were also multi- faceted, and alongside the cable car system, involved provision in the most disadvantaged areas of “library parks,” buildings for schools and recreational activities, and centres for addressing family problems.

Encouraging physical activity for better health

Physical activity helps prevent heart disease, stroke, diabetes, and some cancers, and also helps prevent obesity and improves mental health and well-being. Yet living in cities can make it challenging to be physically active, either through an over-reliance on cars, fear of crime, or a lack of public open and green spaces to exercise in.

The importance of physical activity in ensuring good health has long been demonstrated, yet around the world 1 in 4 adults, and as many as 3 in 4 adolescents, are not active enough. The least active in many countries include girls, women, older people, underprivileged groups, as well as people with disabilities and those living with chronic diseases. Levels of physical inactivity are as high as 2 out of 3 adults in some countries.

Ideally, the ability to be physically active would be prioritised during urban planning so that people can easily integrate exercise into their lives, e.g. cycling to work or walking around the city centre and having easy access to green spaces. Within specific sectors planning and design for physical activity are also important. For example, schools should provide environments for children to be active during and after the school day, and employers should provide opportunities for their staff to be active during the working day.

In 2018, WHO produced its first ever Global Action Plan on Physical Activity, which sets the goal of reducing physical inactivity by 15% by 2030 through four key policy action areas: creating active society through better knowledge and understanding of the multiple benefits of regular physical activity; active environments through policy that support physical activity by providing safe and accessible spaces in which to be active; active people through policy actions to increase provision of opportunities for people of all ages and abilities to be active; and active systems which includes policy actions to strength research, governance, data systems and financing mechanisms to support the implementation of physical activity.

The WHO European Healthy Cities Network has made designing urban places that improve health and well-being one of its priorities. By 2030, 80% of the European population are predicted to live in cities, and will have to contend with air pollution, overcrowding and congestion, heavy road traffic, and other factors that can make it challenging to be physically active. A report by the WHO Regional Office for Europe and the Gehl Institute, on how people interact with their environments, emphasises the importance of “identifying ‘win-win’ scenarios where solutions address multiple challenges simultaneously. For example, affordable housing redevelopments may also provide thoughtfully-designed, safe green spaces for gathering and active recreation.”

Creating age-friendly cities

Age-friendly cities are key to enabling people to live longer and healthier lives while fostering more productive societies. Age- friendly cities anticipate and respond flexibly to changing needs in older age for accessible housing, urban spaces, public transport, health and social support.

The world is rapidly ageing and the number of older people (aged 60 or over) is growing faster than all other age groups. Numbers of older people is expected to rise from 962 million to more than double (2.1 billion) by 2050 and to more than triple (3.1 billion) by 2100.

Most of today’s adults and children will be ageing in cities. Adapting city structures to the needs of a growing older population is preparation to meet the challenges of demographic change. Ageing can come with many opportunities such as time to explore new interests, travel, and spend time with friends and family. However, older people can face specific age-related issues, including difficulties in moving around, hearing, seeing and remembering, challenges with current housing, and isolation as social networks become fragmented (such as if their partner dies or children move away).

When not adapted to the needs of all ages, cities can be difficult environments in which to grow older. To allow older people to make their way to a health centre, the supermarket or just to participate in community life, each sector within a city (housing, urban planning, transport) needs to be working and integrated. One break in the chain, e.g. inaccessible housing, an unsafe road, poor public transportation, can make it difficult for older people to get out and about, and may restrict them to their house.

The rise of global cities networks in international agencies such as WHO indicates a strong international commitment to making the world more age-friendly. Through the WHO Global Network for Age-friendly Cities and Communities, a significant amount of work is being done worldwide to adapt cities to better respond to ageing populations, and to include older people in planning urban development. For many cities, housing and transport are two areas of focus in terms of responding to the changing needs of people as they age. Urban housing has not adequately focused on enabling older people who may be faced with declines in physical or mental capacity to stay in their own homes – which is what most people want.

Many older people are unable to or prefer not to drive, and thus accessible public transport is essential to enable them to continue to do what they value – see friends and family, remain independent, and so on. It is equally important that older people continue to have a good reason to go out and participate. Cultural offers and entertainment that cater to the interests of older people, opportunities for volunteering or civic engagement contribute to a fulfilling and enjoyable older age.

Tackling mental health in cities

Poverty, unemployment, overcrowding, noise pollution, poor infrastructure and lack of green spaces are just some of the obstacles urban residents face. All these challenges can create or intensify mental illness and leave people feeling overwhelmed and isolated. But cities can help people overcome these challenges through programmes and planning targeted at making urban spaces more conducive to good mental health.

Skyscrapers are not the only things casting shadows on people living in cities. Many people migrate to cities because of unemployment, divorce, loss of family members, violence, or mental and physical health problems. The very reasons that people move to cities can also be risk factors for mental health issues.

With more than half of the world’s population now living in cities, overcrowding can be a big issue in cities. Combined with noise pollution and even the way we travel, these cramped and over- stimulating conditions can lead to chronic stress and social isolation. It may seem counterintuitive but sometimes being surrounded by people can fuel feelings of loneliness. Social cohesion and community creation in urban environments can be much harder than in rural settings.

In addition, poverty and inequality are often more concentrated in cities. People may have difficulty finding employment and more than one third of people in cities live in urban slums or on the streets. Facing financial and social disadvantage can amplify mental health issues increasing the risk of becoming depressed or developing other mental health illnesses. Housing projects, job creation, employment programmes and strong primary health care services can all contribute to reducing the burden of poverty and housing insecurity.

Most cities also have a distinct lack of green spaces and access to nature. Access to natural environments and outdoor spaces is vitally important for good mental health, promoting social connection and physical activity and reducing stress, anxiety and depression.

However, there are also positive effects on mental health from living in urban environments. Mental health services are often more accessible, and many cities are harnessing technology to reach people with mental health issues. One example of this positive trend is ‘Step-by-Step’, a mental health app that WHO is developing to help people with depression.Having an organisation (within a larger organization) specifically focused around empowering girls and women allows the Kansas City Sports Commission to bring unique programming and marketing opportunities to the table. Partner organisations benefit from the enhanced advocacy at no additional cost.Having such inspiring keynote speakers as Billie Jean King or Ibtihaj Muhammad is a great asset when it comes to inspiring a young generation of women and using sport as a learning tool.Businesses large and small support WIN for KC both financially and with employee volunteers. By engaging community leaders WIN for KC is able to share the importance of their mission and connect directly with businesses that have a passion for encouraging women leaders. Businesses are learning the importance of girls and women participating in sports as it encourages leadership.

World Health Organization (WHO)