Urbanization and the Future of Population Health

Centennial Issue
Population Health

Policy Points:

  • Cities, which are where the majority of the world’s population lives today, directly and indirectly shape human health and well-being.
  • Urban health research, policy, and practice are increasingly using a systems science approach to address the upstream and downstream drivers of health in cities, which include social and environmental factors, features of the built environment, conditions of living, and health care resources.
  • To guide future scholarship and policy, we propose an urban health agenda for 2050 focused on revitalizing the sanitation movement, integrating data, scaling best practices, adopting the Health in All Policies approach, and addressing intraurban health inequities.

Cities are the spaces in which people live, work, and play, and they are also environments that shape the health, culture, and organization of populations in the 21st century. The UN forecasts that more than two thirds of the world’s population will be living in cities by 2050.1 Levels of urbanization today vary across the globe, from 43.5% in Africa to 83.6% in Northern America. The largest and fastest growing cities today are located in Asia and Africa.2 Consequently, city dwelling is and will be the norm for current and future generations worldwide, with significant impacts for human society, culture, and health. The relationship between cities and health has evolved substantially over the past century. First, cities are no longer a detriment to population health. Historically, urban areas were characterized by poverty and segregation and exhibited greater health risks because of poorer sanitation and increased exposure to occupational and environmental hazards.3

However, public health reforms during the 20th century initiated a reversal of the traditional gap in mortality and morbidity between urban and nonurban populations. Indeed, in many countries across the world, the so-called “urban health penalty” gave rise to a new “urban health advantage.”4 Of course, city living does not lend itself to a universal experience of health, with the literature highlighting the existence of substantial intraurban health inequities. Yet on balance, urbanization today is associated with clear gains in health and well-being. For example, the 15% of the US population that lives in rural areas is at greater risk of death from chronic diseases and unintentional injury than the population that lives in cities.5


1. United Nations. 68% of the world population projected to live in urban areas by 2050, says UN. May 16, 2018. Accessed March 19, 2022. https://www.un.org/development/desa/en/news/population/
2. United Nations Department of Economic and Social Affairs. Data query: urban and rural populations. 2018. Accessed March 19,2022. https://population.un.org/wup/DataQuery/
3. McDonald R, Beatley T. Cities as inhumane: the urban health penalty. In: Biophilic Cities for an Urban Century. Palgrave Pivot; 2020:23-29. Accessed March 19, 2022. https://link.springer.com/chapter/10.1007/978-3-030-51665-9_3
4. Vlahov D, Galea S, Freudenberg N. The urban health “advantage.” J Urban Health. 2005;82(1):1-4. https://doi.org/10.1093/jurban/jti001
5. Centers for Disease Control and Prevention. About rural health. August 2, 2017. Accessed March 19, 2022. https://www.cdc.gov/ruralhealth/about.html

Kadakia K. T., Galea S. Urbanization and the Future of Population Health. Milbank Q. 2023;101(S1): 153-175.