Cities as Platforms for Population Health: Past, Present, and Future

Centennial Issue
Population Health

Policy Points:

  • Cities have long driven innovation in public health in response to shifting trends in the burden of disease for populations. Today, the challenges facing municipal health departments include the persistent prevalence of chronic disease and deeply entrenched health inequities, as well as the evolving threats posed by climate change, political gridlock, and surging behavioral health needs.
  • Surmounting these challenges will require generational investment in local public health infrastructure, drawn both from new governmental allocation and from innovative financing mechanisms that allow public health agencies to capture more of the value they create for society.
  • Additional funding must be paired with the local development of public health data systems and the implementation of evidence based strategies, including community health workers and the colocalization of clinical services and social resources as part of broader efforts to bridge the gap between public health and health care.
  • Above all, advancing urban health demands transformational public policy to tackle inequality and reduce poverty, to address racism as a public health crisis, and to decarbonize infrastructure. One strategy to help achieve these ambitious goals is for cities to organize into coalitions that harness their collective power as a force to improve population health globally.

Most of the world’s population lives in cities. More than 56% of people lived in urban areas in 2020, while only 29% did in 1950. This proportion is significantly higher in Europe and North America, where 75% and 84% of the population, respectively, is urban.1 By 2050, nearly 70% of people globally will live in cities.2

The health of urban populations is dramatically influenced by the urban context, including its social, economic, environmental, and political conditions, in both positive and negative ways.3,4 Socially, the geographic concentration and colocation of people facilitate the formation of health-promoting social networks, while poor sanitation and high crime rates in population-dense areas feed the spread of communicable disease and physical injury. Economically, cities produce 80% of global gross domestic product, offering attractive employment prospects and elevating living standards but distributing both opportunities and gains from production unevenly, which drives urban poverty and growing inequality. Environmentally, robust transportation makes the workplaces and amenities of cities more accessible but contributes to air and noise pollution and rising carbon emissions, exacerbating associated health risks and climate change. Politically, opportunities for participatory democracy and community-level self-determination are often constrained by systematic disenfranchisement of marginalized populations and municipal corruption. The interplay of these complex factors occurs in the background of evolving challenges in health and medicine, ranging from aging populations and growing health care expenditures to novel
pathogens and global pandemics.


  1. Buchholz K. How has the world’s urban population changed from 1950 to today? World Economic Forum. Published November 4,2020. Accessed April 7, 2022.
  2. The World Bank. Urban development. Published April 20, 2020.Accessed April 7, 2022.
  3. Vlahov D, Gibble E, Freudenberg N, Galea S. Cities and health: history, approaches, and key questions. Acad Med. 2004;79(12):1133-1138.
  4. Vlahov D, Galea S. Urbanization, urbanicity, and health. J Urban Health. 2002;79(4 Suppl 1):S1-S12.

Gondi S, Chokshi D.A. Cities as Platforms for Population Health: Past, Present, and Future. Milbank Q. 2023;101(S1): 242-282.