Contextualizing Health: Accounting for the Urban Environment

By Jakab, Zsuzsanna | Harvard International Review, Summer 2012 | Go to article overview

Contextualizing Health: Accounting for the Urban Environment

Jakab, Zsuzsanna, Harvard International Review

Dr. Margaret Chan, Director General of the World Health Organization, begins her foreword to the 2010 WHO/HABITAT report Hidden Cities:

"It is well known by now that half of humanity lives in urban areas - and the proportion is growing. Cities, with their concentration of culture, infrastructure, and institutions have long driven the progress of civilization and have been the focus of opportunity and prosperity."

However, cities are also the nexus of negative economic, environmental, and economic forces jeopardizing the lives and poor health of many inhabitants. The aim of Hidden Cities is to unmask these deprivations, less visible in Europe than elsewhere, often hidden beneath glittering facades and marginalized in prosperous economies. It is our responsibility to overcome the great health inequalities which still prevail between and within the nations of Europe.

The first part of this article highlights some specific challenges facing urban communities in Europe. The second part summarizes how urban institutions and citizens of Europe are meeting these challenges, which is absolutely relevant to the work of the European Region of the WHO. Improving health and reducing health inequities has been the constant first priority of the Region, from the first of our targets for Health for All, published in 1984, through to Health 2020, the new European Strategy for Health. Health 2020 adopts a whole systems approach, acknowledging both the central role of national governments in the provision of health services, as well as the role of local government and its partners in influencing the wider determinants of health.


Part One: Challenges

Urbanization is an irresistible social phenomenon and has been a dominant global demographic trend over the last two centuries. The level of world urbanization today is unprecedented. Cities are currently home to half the world's population, and it is estimated that over the next 30 years, most of the more than two billion person increase in the global population will occur in urban areas. Today, some 400 cities contain one million people or more, and about 70 percent are in the developing world. By 2017, the developing world is likely to be more urban than rural in character.

In the modern era, the European Region was the first of the WHO regions to urbanize, with industrialization inducing exponential population growth in the nineteenth and twentieth centuries. Now, our population of 900 million in 53 countries has stabilized overall, and we are not subject to the intense pressure of population growth experienced by other regions. Nevertheless, Figure 1 shows a divergence in the trajectories of urban populations in groups of European countries. In southern and eastern Europe, migration from rural settlements has been a major reason for population growth in cities. Since 1989 migration flows from eastern to western countries have increased, and some cities have accommodated high numbers of refugees and migrants.

The fragmentation of urban populations, alongside social and economic development, can create a number of serious management issues affecting individual and social life. There is pressure stemming from physical infrastructure, environmental degradation, traffic congestion and pollution, housing shortages, overcrowding, and other stress-related phenomena. These trends have heavily burdened social, health and welfare services in the host cities as well as the housing and employment markets, particularly during times of economic recession, when public authorities have reduced expenditure on housing and urban infrastructure and cutting allowances for welfare, health and community care.



Besides migration, the other salient demographic in Europe is an aging population. The age "pyramid" has become an age "mushroom." In earlier eras of European development, and now in most developing cities in Global South, high fertility rates expanded the base of the age pyramid and limited life expectancy reduced die apex. …

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