The emergence of a modern paradigm for urban health

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Cities offer important opportunities to improve health and wellbeing while also presenting significant challenges. As our understanding of, and evidence, for the importance of determinants of health beyond health care have grown, the need for urban health policies and actions that transcend disciplinary and sectoral boundaries and involve multiple stakeholders in urban decision-making has become clearer. Current urban health practice builds on decades of conceptual and operational work. This paper traces the evolution of the urban health paradigm through research, policy and practice in recent decades. We suggest that, despite the proven utility of urban health as a paradigm and its conceptual and practical evolution for effective urban health governance, significant challenges remain, especially related to implementing the systems approaches needed to improve health and wellbeing amidst the complexity of urban dynamics." } { "@context": "http://schema.org", "@type": "BreadcrumbList", "itemListElement": [ { "@type": "ListItem", "position": "1", "item": { "@id": "https://f1000research.com/", "name": "Home" } }, { "@type": "ListItem", "position": "2", "item": { "@id": "https://f1000research.com/browse/articles", "name": "Browse" } }, { "@type": "ListItem", "position": "3", "item": { "@id": "https://f1000research.com/articles/13-987/v2", "name": "The emergence of a modern paradigm for urban health" } } ] } Home Browse The emergence of a modern paradigm for urban health ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Grant M, de Leeuw E, Teixeira Caiaffa W et al. The emergence of a modern paradigm for urban health [version 2; peer review: 2 approved, 2 approved with reservations, 1 not approved] . F1000Research 2025, 13 :987 ( https://doi.org/10.12688/f1000research.154294.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. Close Copy Citation Details Export Export Citation Sciwheel EndNote Ref. Manager Bibtex ProCite Sente EXPORT Select a format first Track Share ▬ ✚ Review Revised The emergence of a modern paradigm for urban health [version 2; peer review: 2 approved, 2 approved with reservations, 1 not approved] Marcus Grant https://orcid.org/0000-0002-7838-8725 1 , Evelyne de Leeuw https://orcid.org/0000-0003-3434-1439 2 , Waleska Teixeira Caiaffa 3 , Jo Ivey Boufford 4 , Carlos Dora 5 , Susan Parnell 6 Marcus Grant https://orcid.org/0000-0002-7838-8725 1 , Evelyne de Leeuw https://orcid.org/0000-0003-3434-1439 2 , [...] Waleska Teixeira Caiaffa 3 , Jo Ivey Boufford 4 , Carlos Dora 5 , Susan Parnell 6 PUBLISHED 06 Oct 2025 Author details Author details 1 Environmental Stewardship for Health, Bristol, UK 2 University of Montreal, Montreal, Canada 3 Universidade Federal de Minas Gerais, Belo Horizonte, Brazil 4 New York Academy of Medicine, New York, New York, USA 5 International Society for Urban Health, New York, USA 6 University of Cape Town, Cape Town, South Africa Marcus Grant Roles: Conceptualization, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing Evelyne de Leeuw Roles: Conceptualization, Writing – Review & Editing Waleska Teixeira Caiaffa Roles: Writing – Review & Editing Jo Ivey Boufford Roles: Writing – Review & Editing Carlos Dora Roles: Writing – Review & Editing Susan Parnell Roles: Writing – Review & Editing OPEN PEER REVIEW DETAILS REVIEWER STATUS This article is included in the Making the Case for Urban Health: Defining Value and Relevance to Contemporary Challenges collection. Abstract The importance of urban health in achieving population and planetary health goals is increasingly recognized. Cities offer important opportunities to improve health and wellbeing while also presenting significant challenges. As our understanding of, and evidence, for the importance of determinants of health beyond health care have grown, the need for urban health policies and actions that transcend disciplinary and sectoral boundaries and involve multiple stakeholders in urban decision-making has become clearer. Current urban health practice builds on decades of conceptual and operational work. This paper traces the evolution of the urban health paradigm through research, policy and practice in recent decades. We suggest that, despite the proven utility of urban health as a paradigm and its conceptual and practical evolution for effective urban health governance, significant challenges remain, especially related to implementing the systems approaches needed to improve health and wellbeing amidst the complexity of urban dynamics. READ ALL READ LESS Keywords Urban health, health policy, Health in All Policies, determinants of health, Corresponding Author(s) Marcus Grant ( [email protected] ) Close Corresponding author: Marcus Grant Competing interests: No competing interests were disclosed. Grant information: The author(s) declared that no grants were involved in supporting this work. Copyright: © 2025 Grant M et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. How to cite: Grant M, de Leeuw E, Teixeira Caiaffa W et al. The emergence of a modern paradigm for urban health [version 2; peer review: 2 approved, 2 approved with reservations, 1 not approved] . F1000Research 2025, 13 :987 ( https://doi.org/10.12688/f1000research.154294.2 ) First published: 02 Sep 2024, 13 :987 ( https://doi.org/10.12688/f1000research.154294.1 ) Latest published: 06 Oct 2025, 13 :987 ( https://doi.org/10.12688/f1000research.154294.2 ) Revised Amendments from Version 1 In response to the many valuable comments from four reviewers, we have fleshed out material and filled in gaps across the whole text. Especially in relation to: the development and literature over the more recent 20 years; the commercial, economic and political determinants of health (new sub-section 3.5), the role of social movements and sociology and social epidemiology. We have in several places cited and included material about political economy and health, governance and health equity, and expanded the section on COVID-19, and particularly as it relates to health equity. We have clarified the role and nature of private sector health services and digital technologies in relation to urban health. The sustainable development goals section has been developed, as has the planetary health material (new sub-section 3.7). We have also now included more of the foundation work on well-being by international agencies, such as the recent Geneva Charter for Well-being (WHO, 2021). Importantly, in the conclusion, we have better developed the forward thinking and future trends for urban health. In response to the many valuable comments from four reviewers, we have fleshed out material and filled in gaps across the whole text. Especially in relation to: the development and literature over the more recent 20 years; the commercial, economic and political determinants of health (new sub-section 3.5), the role of social movements and sociology and social epidemiology. We have in several places cited and included material about political economy and health, governance and health equity, and expanded the section on COVID-19, and particularly as it relates to health equity. We have clarified the role and nature of private sector health services and digital technologies in relation to urban health. The sustainable development goals section has been developed, as has the planetary health material (new sub-section 3.7). We have also now included more of the foundation work on well-being by international agencies, such as the recent Geneva Charter for Well-being (WHO, 2021). Importantly, in the conclusion, we have better developed the forward thinking and future trends for urban health. See the authors' detailed response to the review by Trevor Hancock See the authors' detailed response to the review by Priya Balasubramaniam See the authors' detailed response to the review by Nicholas Freudenberg See the authors' detailed response to the review by Aimee Afable READ REVIEWER RESPONSES 1. Key messages • A modern paradigm of urban health is evolving with an ever strengthening evidence base, deeper understanding of the wider determinants of health and wellbeing in towns and cities, and a recognition that effective action requires a multi-sectoral systems approach. • Access to the highest attainable standard of health has come to be recognised as a right of all urban dwellers. This goes beyond access to health care services, but demands roles for government at local and national levels, the private sector and civil society in co-creating healthier social, physical and economic environments. • Conceptually, urban health has shifted from a predominantly biomedical focus to an upstream and settings-based approach that recognizes the multi-sectoral, systemic nature of challenges to human and planetary health and the critical nature of decisions by many actors outside the medical sphere. • Contemporary approaches to urban health increasingly recognize health equity as a constant and universal core challenge for effective action to advance urban health and wellbeing. • Understanding how to tackle urban health has moved beyond merely addressing environmental ‘bads’, such as pollution and specific agents of disease, to prioritizing a systems approach that encompasses complexity and focusses upstream on the ‘causes of the causes’ of ill-health. Systemic action captures co-benefits across the sustainable development agenda whilst also making changes to upstream drivers of ill-health. • WHO has been a thought leader and active partner in developing the modern paradigm of urban health, contributing to international policy milestones with technical guidance and a global evidence-base, including case studies of effective action. Support for the new approach to urban health has spread rapidly across academia, encompassing both research and education, and including non-health disciplines. • Although all urban health action must be adapted for local conditions and stakeholders, many common ‘entry points’ can be found. • Political leadership, sponsorship, and support at both national and city levels, and often through city networks, is crucial for successful implementation of action for urban health and health equity. • Significant barriers remain including the needs to: engage the required actors; adopt effective models of governance, and careful match capacity with realistic goals. • As a host of global pressures bring into focus the vulnerability of human existence on this planet, the new urban health paradigm continues to evolve and move towards a more fundamental role in securing humanity’s future wellbeing. 2. Introduction and background The term ‘Urban Health’ is used to refer to many aspects of the health challenges in urban areas. Currently, for the WHO, urban health is a cross-cutting work stream focussing on improving health at city level. It has five main areas of work: normative work, including building the evidence base of what works to enhance urban health; building partnerships and networks to scale up implementation of effective interventions; developing synergies across different urban health initiatives; capacity building in addressing urban health; and global advocacy ( WHO, 2025 ). This paper seeks to inform the wide variety of those who may be working for better urban health and provide both a background to the development of the paradigm ‘Urban Health’. We hope it can also act as basis for assessing its current development and its future trajectory of the urban health paradigm. Those involved in urban health service delivery and health care may be disappointed that our scope is not broad enough to address their concerns for treatment and prevention for urban populations. However, they may take solace that the focus is very much non-clinical urban health measures that can be taken to support healthier populations, and so reduce the burden of disease and hence the numbers of people becoming patients and requiring care and/or treatment. Urban health has been defined as both: 1. The art and science of improving health and health equity in urban areas, including by securing the resilience and sustainability of health-supporting natural and human systems; more than the sum of its parts, it ensures that people, institutions, and environments interact to create healthy situations and that every person has the chance to thrive, now and into the future, and 2. A measure of the health of urban dwellers as continually created by their complex interactions with urban physical and social environments, and by the decisions and institutions at all scales that shape these interactions ( Siri et al., 2025 ). Urban health, is both a concept and a goal. In both guises it has grown in prominence in step with increasing urbanization and urban influence over the last century. As the total urban population has continued to expand through urbanisation and urban growth, ever more people have been exposed to urban environments, with direct consequences, both benefits and dis-benefits, for health and health equity. These trends have provided a critical impetus for the emergence of a widespread community of interest in urban health. Urbanization can be beneficial for health, but also creates many pressure points for urban populations when living conditions become intolerable or unjust. Grassroots movements for social change arise, often rooted in issues such as access to housing, employment, transportation, utilities, education and/or decision-making. These issues have direct or indirect implications on health outcomes. This paper does rehearse the social history of urban health, but in discussing ‘urban health’ as an emergent paradigm, and relevant governance and political factors, we need to recognize the ever present potential, and often actualized role, that movements for social change play in shaping urban policy through the attitudes and actions of other actors. So, the urban milieu also continues to evolve. The largest cities in the world today lie mainly in relatively poor countries, a departure from historical experience; in the past, the largest cities were typically found in the richest places. By 2030, the UN projects close to 400 one-million- residency cities in developing countries, compared to 250 in developed nations ( UN, 2000 ). As poor mega-cities continue to grow in size, with poverty contributing to high population growth, economic dynamics deny such cities the city-level wealth required to address emergent risks to health ( Jedwab & Vollrath, 2015 ). The reality, at an urban neighbourhood level, is that without more comprehensive planning and management of cities, the number of people in the global south living in shanty towns, informal settlements and slums, and facing corresponding health challenges, will continue to grow. At the same time demographic trends continually adjust the balance between those economically active, those with dependents and those requiring support, these too are an important factors for urban health ( Duminy et al., 2023 ). At global, national and local scales, through physical, social and economic dynamics, the urban is always in a state of constant flux. Both for expanding cities in the global south and the cash-strapped health systems of cities in the global North, the modern urban context requires fresh thinking about how best to maximise urban health and wellbeing. The recent wake-up call of global risk from pandemics helped focussed the world’s attention on urban health being more than the immediate bio-medical concerns of transmission, containment and treatment, but all too fleetingly. A spotlight was shone on many perennial spatial urban health concerns such as density, proximity, green space, crowding, transport, air quality, access with equity as a crosscutting issue ( Ellis et al., 2021 ). As a concept and a practice, through the accumulation of evidence from research and practice, the urban health paradigm has evolved substantially over the past century. Urban health challenges are now recognized to be profoundly influenced by systemic upstream determinants, which encompass structural, cultural, technical, political, economic and commercial determinants. Arguably critical to human health, is a better understanding of the systemic health conditions in and of cities. Cities have a crucial role to play in achieving the sustainable development goals by balancing the wellbeing of people and the health of the planet. Without knowledge of cities’ systemic health, cities cannot mobilize their capacity for resilience by adapting to climate change, to resource and demographic challenges or more fundamental systemic transformations. Further methodological and conceptual innovation is necessary for transforming the conventional science model towards transdisciplinarity ( Gatzweiler, F. et al., 2025 ). Urban health determinants provide a potent loci for broader societal ills: such as profligate patterns of resource use (and deep-seated resource inequalities) rooted in commercial drivers, vast power disparities and a lack of accountability, authoritarianism and other challenges to good democratic functioning. Incorporating health into urban planning policy is not straightforward ( Pineo et al., 2020 ). With a few notable exceptions, urban policy treats population health as one of many negotiable factors ( Le Gouais et al., 2023 ), if it addresses it at all. One result of ‘health-blind’ urban policy and public/private investment is that the physical form and structure of our towns and cities limits, and frequently precludes, many aspects of a healthier lifestyle. For example, the spatial form of most urban places, planned and designed during a period of abundant and carefree fossil fuel use, has locked many urban dwellers into situations where the patterns of daily life can be damaging to their health and those around them through the necessity of regular trips using a private car. In another pertinent example, even investment for new or refurbished public housing is predicated on narrowly defined ‘value for money’, the long term health of resident will be limited to avoiding well-known proximal risks such as damp and toxins; the wider determinants of health are not part of the equation. And in mainstream private housing, capital investment seeks to minimize financial risk and maximize short-term returns on investment; other than compliance with building regulations, future resident and/or community health is rarely on the balance books. Not a new phenomenon, but brought to the fore through recent shifts in geo-global politics, it is evident how challenges to democracy pose serious threats to the health of populations and health equity in cities, as they also do at a country level. To what extent do we actually need healthy societies to beget urban health, asks Buse et al. (2023) . Geopolitical conflicts are joined by climate breakdown and risks from cross-species pathogens, together exerting a profound influence on health risks in urban areas. These risks can be amplified by migration dynamics and the migrant health outcomes they trigger, with more work needed to understand such impacts ( Immordino et al., 2024 ). In short, the nature of the urban health challenge has both enduring and new dimensions. Interest in, and understanding of, urban health has spread over time and across many domains, with the links between health and sustainability re-articulated in the 1990s ( Hancock, 1996 ). One measure of its more recent prominence was the inclusion, for the first time ever, of a subnational goal for global action on sustainable cities and communities (Goal 11) in the 2030 Agenda, the Sustainable Development Goals (SDGs) ( Dora et al., 2015 ). Although health is not mentioned overtly in SDG11, many of its components are, in fact, determinants of health (see Figure 1 ). SDG11 includes policy areas, all-to-often not included within the portfolio of public health action, such as transport, urban planning, urban food, neighbourhood design, local resilience, energy infrastructure, flood management and biodiversity and climate. Decision-making in each of these, and many other, sectors can have a profound influence, either positive or negative, on the conditions needed to promote health and health equity, yet there is an absence of a global-level urban science advisory system to support integrated policy-making at the scales required ( Espey et al., 2024 ). With its emphasis on evidence-informed decision-making, urban health has the ability to become a unifying platform that can catalyse bridges across important but seemingly disparate urban policy areas ( Ramirez-Rubio et al., 2019 ). We hope that this paper, in outlining the many factors colliding to force evolution in the paradigm of urban health can help foster integrated action to serve the goals of health and sustainable development more broadly. 3. Conceptual developments in health and their translation to the urban context We can trace the history of thinking about urban health back to some of the earliest human settlements, however urban health as an issue of professional concern related challenges to health surfaced during urban expansion associated with the Industrial Revolution ( de Leeuw, 2017 ). Here, we review the contemporary conceptual and institutional framework for urban health that emerged from broad legal and global institutional developments of the mid-to-late 20 th century until the emergence of the 2030 Agenda for Sustainable Development and subsequent drivers. 3.1 The legal recognition of health as a human right The WHO Constitution (1948) marked the first international and legal articulation of a universal right to health. It advocated for ‘… the highest attainable standard of health as a fundamental right of every human being,’ a right that was subsequently embedded in many other international declarations. Developed in a succession of UN documents and commentaries, the right to health is highly nuanced and does not equate merely to provision of state health care services. In fact, the evolution of the modern concept of urban health has drawn on a wider definition of health, as embodied in the WHO constitution, which states that: ‘Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.’ This readily definition acknowledges that aspects of good health, whether at the level of the individual or populations, transcend a narrow medical perspective. For example, the UN Committee on Economic, Social, and Cultural Rights (2000) interprets the right to health as an inclusive right extending not only to timely and appropriate health care but also to the underlying determinants of health, including access to potable water and adequate sanitation, an adequate supply of safe food, nutrition and housing, and healthy occupational and environmental conditions, among other things. This wider framing places urban planning, management and development squarely at the centre of current and future efforts to secure health and wellbeing. Yet, the actualization of this concept of urban health is rarely found in urban policy. 3.2 Urban health beyond the health sector; from treatment to prevention and wellbeing One consequence of the framing of human health as broader than solely ‘ the absence of disease or infirmity ’ is that securing good health requires action beyond the health sector. The World Health Organization consolidated the grounds for non-medical approaches to health in the Alma Ata Declaration ( WHO, 1978 ), which states that ‘the attainment of the highest possible level of health is a most important world-wide social goal whose realisation requires the action of many other social and economic sectors in addition to the health sector ’. Significant too, in the conceptual advance of supporting the need for urban health activity ‘beyond health care’ is a ‘settings’ or place-based approach. In terms of urban spatial planning, much has been written about the close historic relationships (at the advent of formal city planning) between three interests: sociologist traditions looking for betterment of the working classes, public health seeking to minimize health risk, and the aims and techniques of those involved with urban policy, town layout and spatial design. However, the once potent and close interplay between these three elements weakened following the post-war period as these disciplines evolved on separate trajectories. In 1984, the WHO ‘Beyond Health Care’ conference launched a foundational document that helped the re-emergence of an urban health settings approach, the WHO Ottawa Charter ( WHO, 1986 ). This charter recognised that ‘ Health is created and lived by people within the settings of their everyday life; where they learn, work, play and love.’ In legitimizing this approach, the Ottawa Charter provided a framework that challenged the all-to-dominant perception of healthcare systems as the sole (or primary) means for creating and sustaining health. Moreover, the charter stated that health was a ‘resource for everyday life’, not simply an objective. The Ottawa Charter called for several ‘areas for action’. Among those particularly innovative at the time, and arguably even now, called for a shift in the urban health paradigm, was the call for nations ‘to create supportive environments’. There was a stipulation that protection of natural and built environments and conservation of natural resources must be addressed in health promotion strategies. Notably, other areas of emphasis included; strengthening community action, building ‘Healthy Public Policy’, and recognizing that the responsibility for enabling, mediating, and advocating for health promotion lay with a variety of stakeholders including those outside the health sector. The second WHO Health Promotion Conference on Healthy Public Policy, in Adelaide 1998, resulted in the Adelaide Statement. This sought to move towards a shared governance for health and wellbeing, stating that government objectives are best achieved when all sectors include health and wellbeing as a key component of policy development ( WHO, 2010b ). Coalescence of the ‘Healthy Public Policy’ concept can also be found in Promoting Health through Public Policy ( Milio, 1980 and 1986 ), supporting its key role in the Ottawa Charter. Healthy Public Policy advocates using the goal of positive health outcomes across all public policy areas. Its ambition is to create social, economic and environmental conditions for health at population level. As recent commentators note ‘Attention thus moves “upstream” to policies and institutions rather than “downstream” to behaviors or health services’ ( Harris and Wise, 2020 , p. 1). More recently, we have seen the rise of the ‘Health in All Policies’ (HiAP) framework. HiAP as a moniker neatly captures the concept of Healthy Public Policy, giving it better policy traction. HiAP is a developing approach to public policy that systematically accounts for the health implications of decisions in all sectors, seeks synergies, and avoids harmful health impacts to improve population health and health equity ( Puska & Ståhl, 2010 ). It emphasises the importance of inter-sectoral work and policy coherence. HiAP relies heavily on the use of scientific evidence and evaluation tools, such as health impact assessments, which come in a wide variety of forms and may include testing of policy or project proposals, health economic assessment, and broad stakeholder input to inform the integration of health into a range of actions. In broadening responsibility for health to non-health sectors there is an implied and sometimes explicit shift from curative to preventative approaches. For example, the Ottawa Charter articulates an ambition to ‘reorient health services’, stating that the health sector must move increasingly in the direction of health promotion, beyond clinical and treatment-based services. Some municipal administrations may now be rising to this task, as they begin to embrace HiAP and health impact appraisal approaches that rely on processes less familiar to health practitioners, such as those for options testing for place-making, housing policy or urban infrastructure investment proposals. COVID-19 provided a strong, but maybe short-lived, boost to the realisation that protecting health was not just the preserve of the health sector. Of course, there were plenty of lessons for national handling of pandemics ( Sachs et al., 2022 ; Ali et al., 2024 ). But there was also a focus, receiving less attention, on lessons for the wider determinants of health ( Ellis et al., 2021 ). To take just one example, in addition to a variety of restrictions on social mixing and physical mobility, in many countries urban public space was quicky adapted to permit use, whilst also reducing the potential for infection. Through these measures and others, it became evident to all that both urban health risk and safeguarding were not the preserve of the health sector, but were also impacted by elements baked into many aspects of society. Visually evident, in the public realm, governance and design of urban space came to the fore. To create safe public outdoor places, adaptation often re-allocated space; reassigning road space to favour pedestrians and cyclists. In terms of physical activity, air quality and road safety, some of the measures taken echoed what evidence-based public health had been saying for years, and they were popular, some led to permanent changes. Many hoped for a step change in understanding and actions for urban health as new ways of working became evident and new agendas arose ( Honey-Rosés et al., 2020 ). The potential for a new salutogenic approaches through collaborations between public health and built environment professions was touted ( Capolongo et al., 2020 ). However, with discourses and agendas forever on the move, the long-term impact of this powerful but short-lived ‘natural experiment’ and insightful period, that revealed new ways of ‘doing’ urban health, risks being lost ( Ellis & Grant, 2021 ). 3.3 The growing emphasis on health equity The 1978 Alma Ata Declaration also placed health equity firmly on the table, stating that: ‘ The existing gross inequality in the health status of the people, particularly between developed and developing countries as well as within countries, is politically, socially, and economically unacceptable and is, therefore, of common concern to all countries. ’ In 2005, WHO established the Commission on Social Determinants of Health to support countries and global health partners in addressing the social factors leading to ill health and health inequities. The Commission relied on several knowledge networks established to inform the report, including one for urban issues. The Commission’s 2008 report and subsequent updates focus on improving daily living conditions, tackling the inequitable distribution of power, money, and resources; and better measuring and understanding the problem and assessing the impact of action. Partly based on evidence and analysis within the Commission’s report and subsequent work, health equity has achieved greater and greater resonance in urban health thinking. It has become a vital strand weaving together a multitude of perspectives. The reach of health equity and its core focus on supporting health across a variety of population groups can be seen in the ever-relevant report from the World Health Organization, Centre for Health Development, and the United Nations Human Settlements Programme ‘Hidden Cities: Unmasking and Overcoming Health Inequities in Urban Settings’ ( WHO/UN, 2010 ). A fundamental building brick and platform for the foundational document of modern sustainable development ‘Transforming Our World: the 2030 Agenda for Sustainable Development’ ( UN, 2015 ); advocating that ‘ a rights-based approach to health requires that health policy and programmes prioritize the needs of those furthest behind first towards greater equity ’. On-the-ground research has also contributed to the policy shift toward a greater focus on health equity. For example, a series of field studies in the 1990s in Latin America and Africa changed the landscape for urban health by demonstrating the enormous disparities between the health status of urban populations living in the most deprived compared to the least deprived areas ( Stephens et al., 1994 ; Stephens, 1996 ; McGranahan et al., 1999 ). These types of studies helped move the focus from the urban poor as an isolated and at-risk sub- population to the broader issue of urban inequity in town and city governance. Moreover, the work of Pickett and Wilkinson in ‘ The Spirit Level ’ (2010) demonstrated how large income inequalities can lead to a breakdown in social cohesion, with both direct and indirect negative consequences for physical and mental health plus wider impacts across society. A more recent driver of health equity awareness, with a global in vivo demonstration of the links between social gradients and adverse health outcomes for disadvantaged population groups has been COVID-19 ( WHO, 2021b ). The pandemic disproportionally affected the poor, disadvantaged minorities and a range of vulnerable populations. This was largely due to its inequitable spread in areas of dense population, populations with limited temporary mitigation options, and whose work in critical service-level industries, such as food industries, deliveries services and social care, put them more at risk. These populations also tended to had a higher prevalence of pre-existing chronic conditions and poor access to high quality health care. It also became clear that collateral effects of the pandemic such as the global economic downturn, and social isolation and movement restriction measures, also were unequal in impact; affecting those in the lowest stratas of societies to a greater degree ( Shadmi et al., 2020 ). 3.4 Complexity and the ‘causes of the causes’ of ill-health Growing understanding of what is now seen as a ‘web of causality’, along with experience in examining the process and outcomes of interventions targeting the social and environmental determinants of health, have pushed the conceptual paradigm for urban health toward an embrace of complexity. The world is increasingly interconnected, complex. and uncertain, with significant implications for the way we generate, disseminate, and use knowledge. As such public health work needs a systems approach to address its complex evidence-base ( Rutter et al., 2017 ). Recognition of the role of urban complexity and the need for systemic approaches in research, policy development, and the design and practice of implementation is slowly spreading, from antecedents which span the last several decades. For example, in the 1990s, work on transport and environment identified issues for cross-sectoral cooperation for health in public policy ( Dora & Phillips, 2000 ). HiAP, too, implicitly recognizes the role of complexity in contemplating cross-sectoral synergies, untended consequences and co-benefits. From the early 2000s, the International Science Council (ISC) has promoted transdisciplinary science as a means of grasping and dealing with complexity when interacting with the major challenges facing humanity, including urban health. Moreover, the ISC programme on Urban Health and Wellbeing, founded in 2014, has focused strongly on systems thinking as a means for understanding and addressing urban health and wellbeing challenges ( Gatzweiler, 2020 ; Gatzweiler et al., 2017 , 2023 ). In parallel, the ongoing work of the Stockholm Resilience Centre (e.g. Rockström et al., 2009 ; Richardson et al., 2023 ) to define and raise awareness of planetary boundaries and their possible impacts on health has stimulated several systemic urban health research programmes. These include the Wellcome Trust’s Our Planet Our Health funding initiative and several national programmes for non-medical public health place-based research (e.g. Canada’s Healthy Cities CIHR funding, Australia’s HEAL NHMRC funding, UK’s NIHR’s Public Health Research programme and streams within the US’s NiH programmes). Through networks of researchers and stakeholders involved in projects funded by these programmes, we are starting to see the creation of a more widespread contemporary understanding of urban health. However, not all innovation promoting a greater focus on complexity has been initiated by health interests in the urban family: organizations that have brought attention to combined health and environmental issues in cities include city networks like Metropolis and Cities Alliance, civil society organizations like Slum Dwellers International, think tanks like IIED, and multilateral agencies like UN-Habitat, UNESCO, the OECD, and the World Bank. Intellectual work like Kate Raworth’s Doughnut Economics (2012) and other work on systems thinking ( Puppim et al., 2015 ) has focussed attention on the social origins of many environmental problems, helping to bridge the gaps between natural science assessments and potential applications in urban health, while signposting how integrated work on urban health needs to go beyond traditional urban policy. Arguably better awareness of the ‘web of causality has led to a wider understanding of the need to work on the upstream ‘causes of the causes’ of ill-health ( Braveman and Gottlieb, 2014 ). For example, how decision-taking in the built environment, housing, and construction sectors affects health ( Pineo, 2022 ; Le Gouais et al., 2023 ), and how approaches to financial risk, investment decisions and the embedded culture in the development industry can influence health ( Black et al., 2024 ). In parallel, a new emphasis is emerging on the Commercial ( Gilmore et al., 2023 ) and Political Determinants of Health ( Dawes and Gonzalez, 2023 ). 3.5 The Commercial Determinants of Health Gilmore et al. (2023) define the Commercial Determinants of Health as: ‘ the systems, practices and pathways through which commercial actors drive health and equity.’ (p1195). Within the main conceptual frameworks of the social determinants of health, the Commercial Determinants of Health does not appear to be explicitly or prominently included ( Maani et al., 2020 ). Shedding more light on this apparent gap, Buse et al. (2023) wanted better to understand ‘how a range of related concepts and fields inform approaches to “healthy societies”’(p7450). They undertook a thematic analysis of conceptual frameworks, since the Alma Ata Declaration ( WHO, 1978 ). Although screening over 200 political declarations, commissions and United Nations reports, peer-reviewed papers, commissioned evidence reviews and non-governmental organisation guidance notes, they concluded that the role of the commercial sector in influencing political and scientific processes received scant attention. While the activities of commercial entities can contribute positively to health, and in urban health we need to find ways to channel benefits, there is growing evidence that the products and practices of some commercial actors, are responsible for escalating levels of avoidable ill health, planetary damage and health inequity ( Gilmore et al., 2023 ). The Lancet Planetary Health (2023) , warned that poor planetary and populations health outcomes are perpetuated by “ vested interests seeking to preserve the status quo ”(p. e441) as such they run counter to the conditions needed to support healthy societies. Lobbying by companies and their associations for policy environments favourable to their own interests ( Buse et al., 2023 ) has been important in framing of the developing discourse on the Commercial Determinants of Health. It is system level issue. The system level is all-encompassing and includes major industry sectors, global trade, products, practices, services, working practices ( WHO, 2023b ) and even news media ( Even et al., 2024 ). Of course, these are all very relevant in the urban health sphere, as much any other. WHO has initiated a new programme of action, the Economic and Commercial Determinants of Health, which has four goals: to strengthen the evidence base; develop tools and capacity to address the commercial determinants; convene partnerships and dialogue; and raise awareness and advocacy ( WHO, 2023c ). Echoing the Ottawa Charter WHO state that ‘Commercial activities shape the physical and social environments in which people are born, grow, work, live and age – both positively and negatively’. However, when viewed through the lens of a settings approach there seems to be a profound oversight in the Commercial Determinants of Health discourse to date; the drivers of the spatial policy and spatial form in our towns and cities. Urban spatial form, a key determinant of planetary health, human health and health equity, is heavily influenced by commercial interests and private corporate investments. Urban spatial form sets the context for daily life and life choices – transport modes, access to work and commuting distances, distribution of green space, air quality, thermal comfort, food access, community safety, social interaction; and importantly, neighbourhood and housing quality and their characteristics. This devastating oversight is partly due to the continuing gulf between the public health and built environment professions, in particular their antipathetic ontologies and approaches to evidence ( Grant & Davis, 2019 ). However, the agenda is not only about commercial risk to health, there are also many glimpses of how commercially driven policy and finance can be geared towards healthier place-making. In terms of upstream drivers of place-making, approaches range from the philanthropic to the pragmatic. With longer-term or more broadly developed property investment portfolios, there are examples of social impact bonds, which can incentivise private sector participation in urban health initiatives and examples of neighbourhoods developed for healthier ageing. An example of the latter though linking health insurance interests with estate development investments, and so making the hard financial case to keep an ageing population in good health, through healthy place-making. In support their Fourteenth General Programme of Work, the WHO are currently preparing the first WHO Global Report on the Commercial Determinants of Health, which they say will be to protect public health and safeguard against conflicts of interest while leveraging the potential of the business community. 3.6 The political economy A reciprocal relationship between politics and economic interests can be found weaving through the developmental concepts outlined above. This interacts with, and to a large extend determines ‘widely accepted’ understandings of what is meant by urban health ( de Leeuw et al., 2021 ). A significant impact being that, in spite of a well-articulated academic discourse about challenges to urban health having a systemic basis, the dominant urban health paradigm is all too reductive. Kelly and Green (2019) argue that there is untapped empirical and theoretical potential within sociology, which could and should be harnessed for urban public health. However, if urban sociology and the political economy are ignored, or taken as a given and immutable context, although local solutions may be found – has anything changed in contextual understanding and the upstream drivers that led to the problem in the first place? This upstream context has the potential to re-create the problem again and again, at another time and/or in another place. A system’s approach looks both upstream, at drivers, and downstream, at outcomes ( Cavill et al., 2020 ). A complex intervention ( Skivington et al., 2021 ) is needed to address the political economy, whilst also obtaining practical health outcomes, and not veering into conceptual and theoretical realms. A productive avenue being explored in this context is the use of action research approaches. Especially important are those methodologies that can deal both with emergent issues as the research project proceeds; and are also grounded through a theory of change which recognises the importance of participatory generation of systemic solutions ( Nobles et al., 2022 ; Cavill et al., 2020 ; Felmingham et al., 2023 ). 3.7 Planetary Health As the urban health paradigm developed the capacity to encompass virtually all aspects of town and city activity, so too have several terms that look beyond the urban: – to the impact of human activity on the planet, and the impact of planetary systems on health. These have developed, changed and merged in various ways, and include: • ‘Ecological Public Health’ which integrates the material, biological, social, and cultural aspects of public health ( Lang & Rayner, 2012 ); • ‘One Planet Living’ ( Bioregional, 2018 ) and “One Planet Cities’ ( Hancock, 2018 ), advocating living within planetary resources as a holistic settings-based approach; • ‘One Health’, emerging in 2004 and attempting a ‘triptych’ to integrate the environment and health of our ecosystems, alongside human and animal health ( Destoumieux-Garzón et al., 2018 ); • ‘Planetary Health’ as a principle that asserts that we must conserve, sustain, and make resilient the planetary and human systems on which health depends by giving priority to the wellbeing of all ( Horton et al., 2014 ). As concepts, each with their own research adherents and particularities, they also have influenced ‘urban health’ as a concept. An example being the policy and practical foci on ecosystem services, and nature-based solutions. Important here too is the often overlooked importance of soils, and pointedly urban soils; in realms such as the human micro-biome, urban food growing, water retention and discharge, biodiversity and carbon sequestration. Maybe this can all be summed up by the emerging threat to health posed by what the UN calls “the triple planetary crisis” of climate change, biodiversity loss and pollution ( Anderson, 2020 ), all three of these are the result of human action, often due to the ever-growing demand for energy and resource consumption (including land), and the dispersal of ‘wastes’, from our towns and cities. In the nature of subsequent health outcomes, it is those who consume the least who are at risk of the greatest impacts. Maybe the best fit image here for planetary health is of the snake that consumes itself, tail first. The WHO has stepped into this multiple agenda with the ‘Geneva Charter for Wellbeing’, building on the legacy of nine global conferences on health promotion. This charter attempts to draw together many strands of health and wellbeing. It advocates for global commitments and expresses ‘the urgency of creating sustainable wellbeing societies, committed to achieving equitable health now and for future generations without breaching ecological limits’ ( WHO, 2021a ). 4. WHO support for applied urban health action WHO has been a primary thought leader in urban health and a driving force globally for the application of both sophisticated concepts and urban-based action, both through its own work and in collaboration with partners. This has included supporting initiatives for healthy cities and advocating for health promotion; conducting research and providing guidelines through the WHO Secretariat and Regional Offices and various specialized centres; joint work with UN-Habitat to amplify the links between health and urban planning; and the development of methodologies, tools, and data for urban health. This section highlights several important strands of this work. 4.1 Healthy Cities movement and other city networks One of the most important developments in the modern history of urban health is the WHO Healthy Cities movement. This built on novel undertakings in Canada in the 1980s, where the city of Toronto had declared its ambition to become a ‘Healthy City’. A main driver being the strong intent of developers of the Ottawa Charter to move from statements to demonstrable change. They wanted to establish settings-based networks to support a shift in focus, from specific ‘problems to be solved’ towards a wider systemic approach to urban health. The WHO European Regional Office supported the initiation of a small pilot programme, inviting European cities to commit to a set of values and approaches concordant with the Ottawa Charter, further developed in Promoting Health in the Urban Context ( Duhl & Hancock, 1988 ). This approach was accessible with a prescient action-based agenda, dozens of cities expressed their interest, not just the handful that WHO had expected. Interest and commitment quickly radiated to other regions, including Australia, New Zealand, and Japan, where networks of Healthy Cities emerged and were supported by city and national governments. Following that call to action in Toronto and inspired by the booming European network, provincial networks of Healthy Cities also emerged across Canada. Around the world, other local urban initiatives adopted the original Healthy Cities values in part or in whole. For example, Central and Latin American towns that had worked toward primary health care-focused ‘ Sistemas Locales Para la Salud ’ felt empowered to establish broader new networks for Healthy Cities and Communities (‘ Ciudades y Comunidades de Salud ’). Networks of healthy cities and towns also emerged in the North Africa Maghreb and southern African regions. In this rapid spread, the central message of the Alma Alta Declaration, that achieving health required the action of many other sectors in addition to health, finally found fertile ground. Each of these individual and networked entities emphasized different priorities as locally relevant. In some contexts, basic sanitary and environmental health concerns were prioritised, in others, processes of equitable urbanization or the health and wellbeing of slum dwellers. Although difficult to assess, one estimate puts the number of ‘Healthy Cities’ styled initiatives at more than 15,000 ( De Leeuw, 2017 ). However, comprehensive academic assessment and evaluation of healthy city initiatives is sparse. Due to the complexity of attempting to demonstrate causality, published analyses tend to dwell on qualitative aspects and description of process ( de Leeuw et al., 2015 ). What is apparent is the diversity of effort and the importance of certain key elements ( Harpham & Molyneux, 2001 ; Grant, 2015 ). Such elements include: the level of understanding and degree of political ‘sponsorship’, especially among city leaders; the empowerment of citizens and their understanding of how their quality of life is impacted by urban health challenges; and the existence of mechanisms whereby local health issues and concerns can influence local environments and urban policy. The emergence of the Healthy Cities movement drew greater attention to urban health in WHO global policy discourses. For example, in 1991, the World Health Assembly (the governing body of the World Health Organisation) adopted a resolution focused on health development in urban areas ( WHO, 1991 ). In response to growing urban populations combined with increases in exposure to health risks, it urged Member States to strengthen their capacity for healthy urban development. Specific actions included: implementation of policies to foster sustainable urban development and preserve health-supporting environments; assessment of the impacts of all urban policies on community and environmental health; and creation of structures and processes for inter-sectoral and community participation in urban policy development. The Healthy Cities movement represented one of the first global city networks; since then, many others have emerged with synergistic values and comparable packages of commitments. Such themed networks include WHO’s Age-Friendly Cities network, as well as Transition Towns, Child-Friendly Cities, Smart Cities, Sustainable Cities, Resilient Cities, and Slow Cities ( de Leeuw, Simos & Forbat, 2020 ). 4.2 WHO support for new thinking, and joint work with UN-Habitat, focussing on urban planning and spatial form The WHO designates external academic Collaborating Centres to support its work. In 1990, the Institute of Action Research for Community Health in Indiana was the first Global Collaborating Center in Healthy Cities. The WHO Collaborating Centre for Research on Healthy Cities in Maastricht was designated in 1992. However, it was not until 1995, that the WHO European Regional Office established a unit centred on spatial form with expertise in urban planning and place-making through evidence-based design. This was the Collaborating Centre for Healthy Cities and Urban Policy in Bristol, UK, a centre uniquely situated within a built environment faculty, rather than a health faculty. Its distinctive mission was to build bridges between the health and urban constituencies by involving planners, architects and urban designers, geographers and landscape architects in the health agenda. As such, its focus was to act as a European and national hub to embed a deeper understanding of urban form as a determinant of health into public health understanding and practice. As a result of this work, the governance, planning and design of the physical form of cities became a new focus for the WHO European Healthy Cities Network during the 2000s, with the emergence of the concept of ‘Healthy Urban Planning’ ( Barton & Tsourou, 2000 ). Urban planning went on to become a thematic priority during successive phases of the WHO Healthy Cities initiative. Developed at the Bristol WHO Collaborating Centre, European member cities started to pilot and promote the use of ‘The Health Map’ ( Figure 1 ) ( Barton & Grant, 2006 ; Dahlgren & Whitehead, 1991 ), this tool was developed to enable cross-sector understanding and collaborative working on the determinants of urban health for the built environment sectors. There are now four versions of the health map to suit different applications. Having been translated into over 30 languages, the Health Map has now been adopted by a wide range of actors at international, national and local level ( Grant, 2023 ). Figure 1. The Health Map: The determinants of health seen through the lenses of agency in spatial planning, urban design, place management and city governance. Also in 1995, WHO established the Centre for Health Development in Kobe, Japan (known as the Kobe Centre), a global research institution that quickly established a leadership role vis-à-vis the urban health agenda. An early symposium entitled ‘Urbanization: a global health challenge’ featured global experts in various sectors voicing support for inter-sectoral research in relation to complex health issues surrounding urbanization. The Kobe Centre was soon seen as a leader in promoting crosscutting research and new integrative approaches for analysing determinants of urban health (and for other pressing global health problems, like those of ageing societies). For example, in 2010, the Kobe Centre published the Urban Health Equity Assessment and Response Tool (Urban HEART), designed to help ministries of health and city-level health officials measure health inequities within and between cities. This tool has been applied in large metropolitan centres (populations over 1 million) in low- and middle-income countries around the world ( Pakeman & Collins, 2018 ). This activity at Kobe and Bristol laid the foundation for a stream of joint work on urban health involving UN lead agencies for health and for urban settlements ( WHO, 2010a ), much of this work focusing on the role of urban planning and spatial form. Also in 2010, and in light of the continuing shift toward an eco-social rather than a biomedical view of health, there were two global landmark reports on urbanisation and health. The Kobe Centre co-produced a report on urbanisation and health with UN-Habitat. ‘Hidden Cities: Unmasking and Overcoming Health Inequities in Urban Settings’ (WHO/UN, 2010a). This sought to increase attention on urban health challenges, especially health inequities, through building a robust evidence base for action. In the same year, the final report from the ‘Global Research Network on Urban Health Equity’ provided an in-depth review of improving urban health equity through action on the social and environmental determinants of health, including sections on urban planning and housing design ( GRNUHE, 2010 ). In 2016, the Kobe Centre and UN-Habitat co-produced a second major output, the ‘Global Report on Urban Health: Equitable healthier cities for Sustainable Development’ ( WHO & UN-Habitat, 2016 ). This presented yet further evidence that in cities, health improvement depends not only on the strength of health systems, but also on shaping urban environments. It reiterated, that local governments typically have responsibility over many critical functions that determine wellbeing and liveability in cities such as land use planning, building standards, water and sanitation systems, roads and transportation, and environmental protection. Their actions can thus exacerbate or reduce health inequities. The report asserted that good governance for urban health demands a deliberately integrated approach across many different actors. Also during 2016, the advent of the 3 rd vicennial United Nations Conference on Housing and Sustainable Urban Development (Habitat III) in Quito elevated the intensity of coordinated urban health activity between WHO and UN-Habitat. With a view to influencing the meeting’s outcomes, WHO published ‘Health as the Pulse of the New Urban Agenda’ ( WHO, 2016 ) in collaboration with independent global experts and the International Science Council programme on Urban Health and Wellbeing; other global science groups like Future Earth contributed thinking on the role of systems approaches in achieving urban sustainability ( Bai et al., 2016 ). These inputs fed decades of theory and lessons from practical experience in urban health into the Habitat III process and the New Urban Agenda, reflecting the ideas and insights of a diverse community of researchers and practitioners. More recent products arising from this collaboration include health input to UN-Habitat’s ‘International Guidance for Urban and Territorial Planning’, which features guidance on how to use spatial planning to achieve better health outcomes (‘Integrating Health in Urban and Territorial Planning: a sourcebook’) (UN/WHO, 2020) and a collection of case studies. Urban health, as a focus, continues to grow as a focus for both agencies. 4.3 Urban health work within WHO WHO has supported urban health through the work of its secretariat at global, regional, and country levels, providing technical guidance, supporting research, and advocating for action. This has included technical guidance related to specific sectors, including active and sustainable transport (e.g., Health Economic Assessment Tool (HEAT 1 ); Integrated Sustainable Transport and Health Assessment Tool (iSThaT 2 ), green space (e.g., Green Urban spaces and health tool (GreenUr 3 ), energy (e.g., Clean Household Energy Solutions Toolkit (CHEST), housing (e.g., WHO Housing and health guidelines 4 ), and several others. These instruments are widely used: for example, HEAT, which estimates health benefits from healthy transport interventions, has been used by hundreds of cities worldwide and was recently upgraded to include climate pollutants as well as health. There is also an extensive and growing compendium of WHO and other UN guidance on health and environment, with over 400 items. More broadly, WHO provides targeted technical support for urban health in areas ranging from air pollution, non-communicable diseases and injuries, emergency preparedness for COVID-19 and other disasters, vector control, and more. WHO has also developed set of implementation frameworks and tools for urban health. The urban health capacities assessment and response resource kit is on suite of online tools that supports multi-sectoral teams in assessing whether a proposed initiative is able to meet its goals in a complex urban environment ( WHO, 2024 ). It helps answer the critical question, are the right capacities in place to achieve objectives and influence urban health—whether directly or indirectly? It is a tool for collaboration tool not only to assess, but to highlight and garner implementation capacity. This is sits at the heart of a broader Urban Health Initiative (UHI), 5 which outlines a model process for integrating health into policymaking in the context of climate and air pollutants. Through such frameworks, it has also supported action research to estimate impacts of urban policies on a range of health impacts. For example, the UHI has applied Health Impact Assessment involving stakeholder and policy analyses to estimate expected co-benefits from sectoral policy alternatives to reduce air and climate pollutants in cities in low- and middle-income countries. As discussed above, WHO has been instrumental in establishing major networks for urban health including Healthy Cities and Age-friendly Cities, and in supporting others like the Bloomberg Partnership for Healthy Cities. Through these networks and its own engagement, it has sought to mobilize urban health action—for example, through the BreatheLife 6 campaign which targets the implementation of city- and individual-level solutions for air pollution in support of global development goals. In its 13 th General Programme of Work (2019-2023), WHO recognized the relevance of urban health to its programmes across the board, setting up a new cross-cutting urban health unit within the new Department of Social Determinants of Health (SDH). Important objectives of this unit include harnessing the momentum of global work on urban health and supporting countries and local communities to develop positive urbanization trajectories for health equity. This advisory recommendation recognizes a need to increase visibility, better align, coordinate, and build on existing urban health work across the organization. The urban health unit has worked to consolidate a number of strands of urban health work, including by better defining and articulating the scope and possibilities of urban health and of a more strategic approach, the current paper and others in the F1000 ‘Making the Case for Urban Health: Defining Value and Relevance to Contemporary Challenges’ collection are one element of that work. Another significant effort is the development of a global Urban Health Research Agenda for 2022-2032, this draws on an extensive scoping review, widespread consultation, and global and regional mapping of activities and stakeholders. More recently, the urban health unit launched a new repository on urban health, this is a live resource covering urban planning, housing, environmental issues, transport and mobility, nutrition, physical activity, COVID-19, and many others. This searchable system allows users to access WHO materials by health topic category, product type, geographical area, and year of publication/development. 7 Away from the Geneva headquarters, substantial work on urban health has also been undertaken in WHO’s regional and country offices. For example, in 2011, WHO’s Western Pacific Regional Office published Healthy urbanization: regional framework for scaling up and expanding healthy cities in the Western Pacific ( WHO, 2011 ), which called for a systems-wide approach to urban health, recognizing the need for strong support from national governments ( WHO, 2010 ). This action-oriented framework adopted the Kobe Centre’s definition for healthy urbanization as ‘ the process of enabling people to gain greater control over their health and their determinants through good urban governance that creates equal social opportunities for health for all’ ( WHO KOBE, 2008 ). With similar intent, the Pan American Health Organization recently launched a Healthy Municipalities, Cities, and Communities initiative to promote intersectorality, community participation, and an approach centred on health equity. The WHO’s European region, outlined above, has just celebrated 35 years of progress under its Healthy Cities Network initiative. 5. Urban health in academia, education and research Although urban health emerged as an important component of international public health practice during the mid-1980s, it was not until the 2000s that a widely accepted academic framework to guide research was developed ( Vlahov & Galea, 2003 ). Recognition that health services alone could not effectively tackle health problems led to an increasing policy emphasis on intersectoral action (‘joined-up government’) in higher-income countries, and in turn to research funding programmes that supported interdisciplinary research teams. Together with other trends this led to what was initially referred to as a ‘new public health’ and eventually to the formal discipline of ‘urban health’ ( Harpham & Molyneux, 2001 ). The concept was in place, but not reflected in research activity, a review about how the environment affects health and wellbeing, some 16 years after Vlahov and Galea, concluded that there was a lack of interdisciplinary approaches that highlighted the complexity of urban structures and dynamics, and their possible influence on urban health and wellbeing ( Krefis et al., 2018 ). Observing worrying trends of increasing ill-health, academics saw that supporting the health of urban populations demanded a re-think, with a particular focus on the role of public health research. For example, many urban areas were experiencing a shift from predominantly communicable diseases to a trend of rising non-communicable diseases. This shift took place most rapidly in countries with the highest levels of urbanisation ( PAHO, 1998 ; Harpham & Tanner, 1995 ). Some risk factors for non-communicable disease in these contexts involved individual behaviours; others were more directly associated with urban environments themselves ( Harpham & Molyneux, 2001 ). In low-income countries, studies in the 1990s demonstrated that despite major advances in reducing some communicable diseases in urban areas, communicable diseases continued to play a major role in urban mortality. In public health circles, the concepts of ‘burden of disease’ and ‘determinants of health’ became more prominent in the twin battle against twin issues – both rising communicable and also noncommunicable disease in lower-income countries. The term ‘urban penalty’ was proposed to account for an excess burden of disease associated with urban living ( Gould, 1998 ). Arguably, evolution of ‘urban health’ as a separate academic area of work was accelerated by the UN ‘World Urbanization Prospects’ (2000) report, which announced that over half of the world’s population lived in urban areas, with trends suggesting that by 2050 this would reach over two-thirds. The report led to increased global interest in urban health in both the academic and policy communities. However, scholarly interest in urban health is ‘distributed’ across multiple disciplines. To name just three ( Vlahov & Galea, 2003 ): urban planners bring to the field perspectives about city form and its potential impacts on health; urban sociologists study community interactions, inclusion and agency; epidemiologists document the burden of disease in urban areas and the factors associated with those diseases. However, as we have discussed, many other disciplines need to be in the ‘urban health’ tent including those with expertise in urban transport, urban ecologists, resource planning, housing, urban geographers, and importantly political scientists. In step with this development of urban health research, arose an emphasis on academic education, publishing and scholarly professional practice in the field. A significant ingredient in the rise of urban health as a discipline was the New York Academy of Medicine reorienting and retitling their in-house journal in 1998 to become the Journal of Urban Health, followed in 2002 by their establishment of the International Society for Urban Health. In 2003, the Academy hosted a meeting, co-sponsored by several global academic and public health institutions, that underscored the intellectual foundations for evidence-based urban health ( Vlahov & Galea, 2003 ). Citing the increasing health threats to growing urban populations, these authors asked rhetorically, but prophetically at the time: ‘Why should health professionals take a particular interest in urban living?’ (p1091). They noted that ‘Although public-health interventions have long had a role in the control of disease in cities, research about the features of modern urban areas and the facets of urban living that influence health has been sparse’ (p1091). By 2006, the Handbook of Urban Health had been published ( Galea & Vlahov, 2006 ), and with widening academic discourse and a growing evidence base, it was soon followed by many other books—for example, the notable ‘Urban Public Health: A Research Toolkit for Practice and Impact ( Lovasi et al., 2020 ). New journals, such as Transport & Health (established in 2014), Cities & Health (2017) and, the all too short lived, Infrastructure & Health (2022) also helped broaden the field. Academic educational programmes and policy-focused publications in urban health sit at a crossroads between research, policy, and practice. The goal of urban health in public policy is institutional transformation towards a healthy, equitable and sustainable future, and educational programmes at undergraduate and professional levels have an important part to play. Because many professions with profound impacts on health outcomes have no formal public health input in their training, a transdisciplinary and multi-professional approach to urban health education presents challenges but also significant opportunities ( Corburn et al., 2014 ). Indeed, the number of courses tackling urban health increases constantly, both on-line and in-person, at undergraduate and postgraduate levels, and in the context of professional development. Globally, the past 10 years saw the emergence of the first courses, research projects, funding programs, university departments, and academic institutes devoted to urban health in many disciplinary contexts; there is now a critical mass of these in most geographic regions. An analysis of these various traditions show, however, still a significant disconnect between disciplinary foundations ( Kim et al., 2022 ). 5.1 Urban health observatories Given the significant health implications of urban environments and urbanization, cities and other urban health actors need detailed information on health needs and outcomes linked to demographic, economic, cultural, physical, and environmental data ( WHO, 2023a ). Establishing effective mechanisms for monitoring urban health and health equity is essential ( Caiaffa et al., 2014 ). Robust data, used wisely, can help integrate actions across existing systems in both health and non-health sectors (e.g., urban planning, urban resource and infrastructure investment, city development, transport, trade, food systems, etc.). One approach to addressing the obstacles presented by the wide range of factors that influence health, and the dispersed and uncoordinated nature of relevant data ( Dias et al., 2015 ), is the ‘public health observatory’—or in urban settings, the ‘urban health observatory’. The idea of health observatories dates back to the late 19th and early 20th centuries. Early efforts included the establishment of local health boards and the collection of key statistics in cities like London, Liverpool and New York. This idea of health observatories gained momentum in the latter half of the 20th century, coinciding with advancements in epidemiology, data collection, and computing technologies. The focus on urban health observatories specifically, emerged in the late 20th and early 21st centuries, driven by increasing urbanization and the recognition that cities face unique health challenges (see Box 1 ). Key milestones in this development include: WHO support in 1998, through launching the Health Metrics Network to improve health information systems globally and the European Urban Health Observatory (EURO-URHO), established in the early 2000s. In 2006, UN-Habitat reported the existence of 119 local urban observatories, its Global Urban Observatory Unit oversees and coordinates approximately 374 today and focuses on monitoring urban conditions and trends, including health indicators, to support sustainable urban development. Urban Observatories are now commonly found in sector outside the health sector, with providing a potential for combined work within a broad urban health paradigm. Box 1. Urban health observatories. Urban health observatories act as focal points for urban data, collecting, monitoring, analyzing, and managing information on urban health and health equity. They monitor and assess health determinants and outcomes in the urban populations they serve, often focusing on social inequalities and urban health inequities. They generally operate within large urban areas facing issues related to unplanned urbanization, fluctuating populations, health inequities, and the need for sub-population, urban and sub-urban, and neighborhood-level health intelligence. Information and communications technologies play a crucial role in helping many observatories enhance decision-making and improve health outcomes. Many Urban health observatories establish partnerships with diverse stakeholders to understand the impact of wider determinants of urban health ( Castillo-Salgado, 2015 ). Early examples of Urban health observatories included those in Barcelona (established in 2000) and in Belo Horizonte (established in 2002). By 2010, urban health observatories had been established in every inhabited continent, countries hosting one (or more) included the UK, Spain, France, Canada, USA, Brazil, Chile, South Africa, Kenya, India, China and Australia. A decade ago, the Asia-Pacific Urban Observatory Network and Africa Centre for Disease Control and Prevention Health Observatory were also established. In many areas, including but not restricted to informal settlements, regularly collected, reliable data does not exist. However, a wealth of new data is now available from modern technologies like earth observation, mobile phone, and other spatial sources ( Thomson et al., 2019 ), among others. In recent years, the rise of big data, advanced analytics, and geographic information systems has further enhanced the capabilities of urban health observatories. Urban health observatories now integrate diverse data sources, including electronic health records, environmental data, and social determinants of health, to provide a comprehensive view of urban health. AI and agent based modeling will no doubt lead to new and emergent capacities. 5.2 Micro- data, meso-data and digital urban health At the other end of the scale from advances in Big Data, we must not ignore the continual evolution of micro-data, including remote sensing and socially sourced data ( Xing et al., 2024 ). Both collection of data, and delivery of analysis are advancing at local place-based and individual/community scales. On the positive side there may be the potential, through this micro-data for individuals to help balance gaps in healthcare access and exposure to health risk in urban areas, where both ‘unhealthy’ and ‘healthy’ infrastructure is unevenly distributed, often leading to health inequities. For example there are now mobile phone based apps being developed showing walking routes with good air quality, locating free water points, and how be more independent in the public realm through showing location of access to local toilet facilities. However, these developments may not align well with ‘Health for All’, vulnerable populations often lack the required technology, or the digital literacy required, to access such digital analysis. Digital access influences and is influenced by the social determinants of health in self-perpetuating cycles ( Acuto et al., 2025 ). Significant digital gaps exist also within and between cities and countries, contributing to marked urban health inequities. Institutionally, digital technologies are increasingly applied to improve the design, effectiveness, and efficiency of urban systems that affect health, including by increasing the quantity and quality of information available to decision-makers and improving the quality of communications and citizen engagement. Through these and other emerging digital technologies, public actors can shape urban areas to support the health of urban dwellers ( Siri et al., 2025 ). 6. Urban health in policy, practice and process In the preceding text, many elements that are supporting the emergence of a more coherent and distinct concept of urban health have been described. This section briefly outlines how applied action on urban health, in policy, practice and process has evolved. There is no doubt that experiential knowledge, which is essential to action on-the-ground, has been gleaned from implementation, accumulated in part through case studies of successful local projects and practices. At times, such work is initiated by urban health advocates, but given the numerous potential synergies and co-benefits with other urban agendas, lead actors can arise from many other sectors. For example, outside the built environment and transport sectors, driven by concerns about the rise in non-communicable diseases linked to poor diets, food is a significant sector for urban health. Most of the food produced globally is consumed in urban centres, and urban populations rely heavily on purchasing the foods they consume in place of growing, catching, or producing food themselves ( Lundberg et al., 2025 ). This sector embraces food access, quality, supply chains, local growing and cooking skills, and had a long history of both activism and policy for supporting health equity. With such an all-encompassing agenda as urban health at both a policy and a practical level (see again Figure 1 ), the concept, and identification, of ‘entry points’ is increasingly found in discourse. The recent WHO/UN-Habitat publication, ‘Integrating health in urban and territorial planning’ serves as a sourcebook for ‘entry points’ for urban heath, linking to over 50 global examples of entry points through third party resources, most outside the traditional public health sector ( UN/WHO 2020 ). Recent examples of integrative urban health policy and practice include a large number of individual town- or city-level initiatives that support population health, such as implementing 15/20 minute neighbourhoods, school streets, cycling towns/cities, urban food growing, or a plethora of low-emission zones for traffic, among others. This burgeoning of ways to support urban health mirrors the 12 key agendas listed in the ground-breaking Healthy Urban Planning (2000), published some twenty years earlier. In parallel, cities have become involved in a wide variety of networks, such as Local Governments for Sustainability, United Cities and Local Governments, Cities Alliance, C40 Cities, and Bloomberg Cities; each has different membership and fundamental goals, but all act in ways that are relevant to health and heath equity—several even have specific urban health thematic sub-networks. At national-level, a significant example of a systemic policy relevant to urban health is the Welsh Government’s Wellbeing of Future Generations Act ( Welsh Government, 2015 ). Here the sustainable development concept of futurity is translated to a national legal framework, binding together population and planetary health in ‘a law to improve social, economic, environmental and cultural wellbeing’. In developing countries, there has been a project-level shift in focus from ‘vulnerability’ to ‘resilience’ for urban health. In practice, this has seen greater local-level participation through collaborations with those embracing a community assets-focused and action-oriented agenda ( Harpham, 2009 ). At a global level, international Healthy Cities Health Impact Assessments meetings have, for instance, supported the inclusion of health within the Strategic Environment Assessment protocol of the Environment Impact Assessment convention ( Dora, 2019 ). Whereas prior work tended to be limited to documenting health damage from climate change and implementing measures for adaptation, a better understanding of health co-benefits from interventions to mitigate climate change ( WHO, 2012 ; Ganten et al., 2010 ) has introduced a Health in All Policies focus into climate impact policy. As digital technology gets more sophisticated, online platforms and tools are emerging to better support urban health policy and practice ( Acuto et al., 2025 ). In additional to the information and analysis tools developed through the WHO’s Urban Health Initiative (referred to previously), sophisticated platforms are emerging that allow the integrations of place, people and health and the testing of ‘what if’ scenarios at community level, such as the Healthy City Generator (see www.healthy-cities.com ) and a variety of Place Standard online developments (see www.ourplace.scot/Place-Standard-Climate ). Advances in digital environmental data collection for place-based and individual-based health determinants are continuous. Examples include air quality monitors fixed to baby’s buggies, thus recording real time lived exposure, and traffic noise and air quality monitors in school playgrounds. Experiential knowledge, arising from policy and practice, not always captured in the academic literature, is evolving and essential for long-term health outcomes. It has yielded a pragmatic emphasis on process and lessons learnt through implementation. It is not enough to know ‘what to do’, attention must also be given to ‘how to do it’; this highlights, among other things, the critical nature of governance and stakeholder participation ( Harris, 2022 ). Governance is has often been mentioned in this paper, but how might we define it for urban health? Formally Governance should be taken to be adaptive and refer to ‘the structures and processes by which people in societies make decisions and share power, creating the conditions for ordered rule and collective action, or institutions of social coordination’ ( Schultz et al., 2015 . P1). Informally is useful to refer to governance as ‘the ways of making things happen’ (Fehr, pers comm. 2025), and you can’t get more trans-disciplinary and outcome focussed than that! Worrying, there is still a fissure between the ‘what to do’ research and the ‘how to do it’ research. As a discipline epidemiology have an important role here, it is well-suited to advance urban-health knowledge. In addition to the surveillance of the urban physical and policy environment, the current development of inferential tools for evaluating the impact of group-level actions, such as interventions and policies could provide new opportunities for advancing the systemic evidence-base ( Garber et al., 2025 ). The WHO itself has long recognised an ‘implementation gap’, with capacity being critical to assess as a first step towards action. It has developed an Urban health capacities assessment and response resource kit to support multi-sectoral teams in assessing whether a proposed initiative can meet its goals in the complex urban environment ( WHO, 2024 ). 7. Moving forward on urban health Over the last 75 years, a host of real-world events and our reactions to them have enriched our construct of urban health dynamics. Prodigious urbanisation, a rise in non-communicable diseases, a global pandemic, better knowledge about the determinants of urban health, improved collection and handling of data, and the development of coalitions of stakeholders in cities, academia and practice have all contributed to conceptual shifts. Recent development of the urban health paradigm illustrate continuing and steady growth, from the strong founding principles of the right to health during the previous century, towards an ever richer breadth of research activity, policy and practice in the modern day. Due to its systemic nature, as an operational concept, urban health has many points of entry. A consequence too is that it has the ability to be supported by a wide variety of resources, tools, and an ever-growing body of both evidence research and implementation experience. Over the last few decades, the paradigm of urban health has been transformed. Insights from an evolved understanding of health and wellbeing and humanity's impact on the planet weave through Agenda 2030 and the Sustainable Development Goals, and urban health is arguable the most significant thread for humankind. As such, we have witnessed interest in urban health grow independently, and in parallel, in separate domains, including many not traditionally thought of as having a public health interest. This has been made is possible since the fundamental principles of urban health and wellbeing are readily understood by those outside the health field. A firm foundation is place for urban health to provide a vehicle to: • reduce the burden of disease and its associated societal costs, including those falling to the health care sector; • bind more strongly sustainable development with population health, through promoting local health solutions that have planetary health co-benefits; • broaden the stakeholder base with co-benefits by supporting collaborations of health and non-health policy actors, including city planners and urban designers, economists, transport planners, architects, landscape practitioners and others; • address both communicable and non-communicable diseases, through urban design, city planning, and city governance that benefits health and health equity. However, the emergence of a systemic transdisciplinary approach is far from universal. Verifiable and transferable methodologies that are within its remit are still rare. Vlahov and Galea laid down a challenge in 2003; how can urban health become consolidated as a discipline? Reaching that, as a goal, to similar to climbing a mountain, with many false summits. However, is testament to the power of the concept in real-world application, and the coalescence of the ‘urban problem’- that urban health will continue to evolve as a potent force for finding solutions. Challenges will remain. Some of the challenges outlined, demographics and climate, have trends with predicable elements and can be planned for. For others the degree of predicability is less, for example war, pandemics, and catastrophic geological events, with these preparedness is the approach. Where are we now? The technological know-how, and mechanisms to assess what is wrong and identify potential solutions is largely in place. • We have a constellation of tools and other support, such as Health Observatories, designed to meet many contemporary challenges and opportunities. • We have digital health too, which may help us bridge gaps in health, in addition to healthcare, in urban areas. • We have the building-blocks for professional urban health literacy education at all levels for many sectors. However, is the main challenge is still existential? At a fundamental level, although there are glimpses of an emerging urban health paradigm, it is far from embedded across society. As a habit of thinking and practice, unfortunately it is still lacking even in for many in the public health fraternity. The Ottawa Charter, with ambition to reorient health services beyond clinical and treatment-based services, is largely overlooked. And moreover outside the health sector, both commercial and public agents, require a stronger steer to demonstrate how including urban health in their policy and investment decisions can work to their advantage. The entry points for co-benefits are numerous, however are there remain three significant questions: • of urban health literacy: How do we inform those whose activities impact health and wellbeing, for good or for ill, of the health outcomes of their actions? • of governance: Whose role is it to engage non-public health actors in urban health action? • of resource: Do the actors needed for urban health have the required capability and capacity? Many of the essential characteristics of the paradigm of urban health are emergent, and will be shaped by an ever widening assemblage of actors in year to come. The groundwork has been laid for those actors to: • Be better able to capturing experiential knowledge from local action. • Empower citizens in their understanding of how their quality of life is impacted by urban health challenges and engage them in finding and implementing solutions. • Use urban health across the policy agenda as a unifying platform for urban stakeholders in their attempts to their solve problems. • Accelerate the spread of evidence-informed decision-making to solve wicked problems, both as they present locally, and crucially upstream - attending to the policies and institutions that created them. This briefing has attempted to describe the key shaping factors and some of the drivers of that transformation. However, it only represents a snapshot in time. The actions of many actors can exacerbate or diminish health. Good governance for urban health demands that health is a deliberate goal. If population health, health equity and planetary health are not deliberate inputs when designing solutions for urban problems, then evidence and experience shows, it is highly unlikely that they will be outcomes. The transformation of urban health continues, and with many global pressures now bringing into focus how vulnerable human health is on this planet - this transformation is set to accelerate. Data availability No data are associated with this article. Acknowledgements The authors would like to acknowledge the guidance and support of José Siri from the WHO Urban Health team. References Acuto M, Ratti C, Mateen BA, et al. : Digital Transformations and Urban Health: Current Challenges and Opportunities [version 1; peer review: awaiting peer review]. F1000Research. 2025; 14 : 587. Publisher Full Text Ali S, Smith MJ, Stranges S: Where did public health go wrong? Seven lessons from the COVID-19 pandemic. Eur. J. Public Health. 2024; 34 (4): 618–619. 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Publisher Full Text Footnotes 1 https://www.who.int/tools/heat-for-walking-and-cycling . 2 https://www.who.int/europe/tools-and-toolkits/isthat--the-integrated-sustainable-transport-and-health-assessment-tool 3 https://www.who.int/europe/tools-and-toolkits/greenur--the-green-urban-spaces-and-health-tool 4 https://www.who.int/publications/i/item/9789241550376 5 https://www.who.int/initiatives/urban-health-initiative 6 https://www.ccacoalition.org/content/breathelife 7 Local action for health: a repository of WHO resources at https://urbanhealth-repository.who.int/home (30 June 24) Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 02 Sep 2024 ADD YOUR COMMENT Comment Author details Author details 1 Environmental Stewardship for Health, Bristol, UK 2 University of Montreal, Montreal, Canada 3 Universidade Federal de Minas Gerais, Belo Horizonte, Brazil 4 New York Academy of Medicine, New York, New York, USA 5 International Society for Urban Health, New York, USA 6 University of Cape Town, Cape Town, South Africa Marcus Grant Roles: Conceptualization, Project Administration, Writing – Original Draft Preparation, Writing – Review & Editing Evelyne de Leeuw Roles: Conceptualization, Writing – Review & Editing Waleska Teixeira Caiaffa Roles: Writing – Review & Editing Jo Ivey Boufford Roles: Writing – Review & Editing Carlos Dora Roles: Writing – Review & Editing Susan Parnell Roles: Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information The author(s) declared that no grants were involved in supporting this work. Article Versions (2) version 2 Revised Published: 06 Oct 2025, 13:987 https://doi.org/10.12688/f1000research.154294.2 version 1 Published: 02 Sep 2024, 13:987 https://doi.org/10.12688/f1000research.154294.1 Copyright © 2025 Grant M et al . This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Download Export To Sciwheel Bibtex EndNote ProCite Ref. Manager (RIS) Sente metrics Views Downloads F1000Research - - PubMed Central info_outline Data from PMC are received and updated monthly. - - Citations open_in_new 0 open_in_new 0 open_in_new SEE MORE DETAILS CITE how to cite this article Grant M, de Leeuw E, Teixeira Caiaffa W et al. The emergence of a modern paradigm for urban health [version 2; peer review: 2 approved, 2 approved with reservations, 1 not approved] . F1000Research 2025, 13 :987 ( https://doi.org/10.12688/f1000research.154294.2 ) NOTE: If applicable, it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS track receive updates on this article Track an article to receive email alerts on any updates to this article. TRACK THIS ARTICLE Share Open Peer Review Current Reviewer Status: ? Key to Reviewer Statuses VIEW HIDE Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Version 2 VERSION 2 PUBLISHED 06 Oct 2025 Revised Views 0 Cite How to cite this report: Juba OO and Oritsemeyiwa GO. Reviewer Report For: The emergence of a modern paradigm for urban health [version 2; peer review: 2 approved, 2 approved with reservations, 1 not approved] . F1000Research 2025, 13 :987 ( https://doi.org/10.5256/f1000research.185447.r424215 ) The direct URL for this report is: https://f1000research.com/articles/13-987/v2#referee-response-424215 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 29 Oct 2025 Omolara Oluseun Juba , Cardiff Metropolitan University, Cardiff, Wales, UK Gabriel Orugboh Oritsemeyiwa , Computing with Placement, Cardiff University School of Computer Science and Informatics, Cardiff, Wales, UK Approved VIEWS 0 https://doi.org/10.5256/f1000research.185447.r424215 Title: The Emergence of a Modern Paradigm for Urban Health Authors: Marcus Grant, Evelyne de Leeuw, Waleska Teixeira Caiaffa, Jo Ivey Boufford, Carlos Dora, Susan Parnell Journal: F1000Research (Version 2, 2025, Article 13:987) Reviewer: Omolara Oluseun Juba / ... Continue reading READ ALL Title: The Emergence of a Modern Paradigm for Urban Health Authors: Marcus Grant, Evelyne de Leeuw, Waleska Teixeira Caiaffa, Jo Ivey Boufford, Carlos Dora, Susan Parnell Journal: F1000Research (Version 2, 2025, Article 13:987) Reviewer: Omolara Oluseun Juba / Adultprime Safety Health & Wellness Foundation Co-Reviewer: Oritsemeyiwa Gabriel Orugboh / Cardiff University, Cardiff United Kingdom Date: 19/10/2025 Article summary The manuscript is an historical narrative review of 75 years of the emergence of the "urban health" paradigm. The authors in this study shows the transition of the construct from limited biomedical health service models to expansive systems-based and multi-sectoral frameworks. The paper highlights some of the most relevant moments in this trajectory, including early WHO declarations (Alma Ata and Ottawa Charter), the expansion of Healthy Cities initiatives, the solidification of Health in All Policies (HiAP), and the uptake of complexity science and systems thinking. My Evaluation 1. Is the topic of the review discussed comprehensively in the context of the current literature? Answer: Yes, The manuscript stands out because of its significant breadth. The work creates an invaluable historical integration of decades of theoretical development by international organizations (mainly WHO) combined with academic research and practical application. The manuscript demonstrates clear value by including up to date literature on commercial and political determinants. 2. Are all factual statements correct and adequately supported by citations? Answer: Yes, The manuscript is well researched and referenced. Statements of fact about past events, WHO efforts, theoretical constructs and major publications are correct. The references include an appropriate combination of peer reviewed and grey literature from WHO, UN-Habitat and other international agencies. Citations are appropriate. This is great. 3. Is the review written in accessible language? Answer: Partly, The authors have a clear and logical writing style, but I'm a bit concerned the language might shut out some of the very people they're hoping to bring into the conversation. Using the words or terms like "salutogenic," "transdisciplinarity," and "upstream drivers" maybe okay for academic public health researchers but i am certain readers from other sectors like a planner, a traffic engineer, or maybe a local council member getting lost and tuning out. If the goal is truly to build bridges across different fields, the paper could do a better job of translating its key concepts for a broader audience on first use. 4. Are the conclusions drawn appropriate in the context of the current research literature? Answer: Yes, The conclusions in section 7 accurately name long-term, structural challenges on governance, resources, and capacity. The formulation of the "three significant questions" (regarding urban health literacy, governance, and resources) is very good and very fitting. My recommendation To make the paper more welcoming to that wider audience, i will advise to do a simple modification. When you first introduce an important term of art, just add a quick, plain English explanation in parentheses right after it. This will strengthen the readability. A little bit of translation wouldn't disrupt the flow for experts, but it would be a lifeline for readers from other sectors, making them feel included rather than excluded. Is the topic of the review discussed comprehensively in the context of the current literature? Yes Are all factual statements correct and adequately supported by citations? Yes Is the review written in accessible language? Partly Are the conclusions drawn appropriate in the context of the current research literature? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Occupational Health, Safety and Wellbeing, Gerontology, Healthcare Safety, Occupational Safety, Dementia, Public Health We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Juba OO and Oritsemeyiwa GO. Reviewer Report For: The emergence of a modern paradigm for urban health [version 2; peer review: 2 approved, 2 approved with reservations, 1 not approved] . F1000Research 2025, 13 :987 ( https://doi.org/10.5256/f1000research.185447.r424215 ) The direct URL for this report is: https://f1000research.com/articles/13-987/v2#referee-response-424215 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Freudenberg N. Reviewer Report For: The emergence of a modern paradigm for urban health [version 2; peer review: 2 approved, 2 approved with reservations, 1 not approved] . F1000Research 2025, 13 :987 ( https://doi.org/10.5256/f1000research.185447.r420807 ) The direct URL for this report is: https://f1000research.com/articles/13-987/v2#referee-response-420807 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 28 Oct 2025 Nicholas Freudenberg , City University of New York, New York City, NY, USA Approved VIEWS 0 https://doi.org/10.5256/f1000research.185447.r420807 I read the revised version and I believe it addresses most reviewer concerns and is now ready for indexing. It will make a useful contribution to the literature. I continue to see some gaps but I believe ... Continue reading READ ALL I read the revised version and I believe it addresses most reviewer concerns and is now ready for indexing. It will make a useful contribution to the literature. I continue to see some gaps but I believe these can be addressed by other authors in other publications. These gaps include: The review focuses almost entirely on reports from academics , established international organizations, and governments, thus missing the perspectives of social movement activists and other less mainstream actors. However, in my view, social movements, activists , and citizen organizations have often been the main force leading to improvements in the health of urban populations in the last century or two. Other authors will need to fill this gap. It is not sufficient to describe in passing the role of civil society organizations, a broad term that does not distinguish among the diverse players in this sector. While no single report can fully cover all influences on the health of urban populations, this report does not fully consider the growing influence of changing political economies on the health of urban populations. Barely discussed are the roles of growing global income and wealth inequities, monopoly concentration, privatization of formerly public services, threats to democracy and democratic governance , new limits on immigration and migration, or new communications and information processing technologies. In my view these factors are likely to be the predominant influences on urban health in the coming decades. In sum, the report under review makes important contributions to our understanding of recent developments in urban health but also encourages others to review these developments with different and wider lenses. Competing Interests: No competing interests were disclosed. Reviewer Expertise: urban health, health equity, role of social movements in health I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Freudenberg N. Reviewer Report For: The emergence of a modern paradigm for urban health [version 2; peer review: 2 approved, 2 approved with reservations, 1 not approved] . F1000Research 2025, 13 :987 ( https://doi.org/10.5256/f1000research.185447.r420807 ) The direct URL for this report is: https://f1000research.com/articles/13-987/v2#referee-response-420807 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Respond or Comment COMMENT ON THIS REPORT Version 1 VERSION 1 PUBLISHED 02 Sep 2024 Views 0 Cite How to cite this report: Hancock T. Reviewer Report For: The emergence of a modern paradigm for urban health [version 2; peer review: 2 approved, 2 approved with reservations, 1 not approved] . F1000Research 2025, 13 :987 ( https://doi.org/10.5256/f1000research.169300.r353478 ) The direct URL for this report is: https://f1000research.com/articles/13-987/v1#referee-response-353478 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 22 Jan 2025 Trevor Hancock , University of Victoria, Victoria, British Columbia, Canada Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.169300.r353478 I answered ‘partly’ to three of the four questions because : a) it would be hard, if not impossible, to be comprehensive given such a large field of thought and practice extending over several decades. However, this review covers ... Continue reading READ ALL I answered ‘partly’ to three of the four questions because : a) it would be hard, if not impossible, to be comprehensive given such a large field of thought and practice extending over several decades. However, this review covers the major global developments and initiatives well. b) language accessibiliutry depends upon the audience. This would not be accessible to the general public, and perhaps not to an academic audience not familiar with some of the concepts. However, it is well written and is accessible for me. c) There is no ‘Conclusions’ section, but Section 7 is about ‘Moving Forward, and I have some thoughts, noted below, about how this section could be strengthened. Here are my main comments; I also noted some minor typos that I list at the end. 1. Given “The modern urban context requires fresh thinking about how best to maximise urban health and wellbeing”, maybe change the title to read “The emergence of a modern paradigm for urban health and wellbeing” 2. Given several references to wellbeing, I was surprised to see no reference to the Geneva Charter for Well-being (WHO, 2021) and no expansion on the concept of a wellbeing society as it would apply to a city or community, one that would be committed to “achieving equitable health now and for future generations without breaching ecological limits”. This would be a useful idea to consider in Section 7 3. On P 5 – the section on HPP should reference the 1984 Beyond Health Care conference that launched the concept and the 1988 Second WHO Health Promotion conference on Healthy Public Policy in Adelaide that resulted in the Adelaide Statement, and included a section on Healthy Public Policy at the Local Level that resulted in an edited book (A. Evers et al . (eds.), Healthy Public Policy at the Local Level . Frankfurt/Boulder: Campus/Westview, 1990) 4. Towards the end of section 3, in the discussion of health and planetary boundaries and sustainability, it is worth noting that the links between health and sustainability were developed in the 1990s (see e.g. Hancock, Trevor (1996) “Planning and creating healthy and sustainable cities: the challenge for the 21st century.” In C. Price and A. Tsouros (eds.), Our Cities, Our Future: Policies and Action for Health and Sustainable Development . Copenhagen: WHO Healthy Cities Project Office; Hancock, Trevor (1996) Healthy, sustainable communities: concept, fledgling practice and implications for governance Alternatives 22 (2), pp 18-23; Hancock, Trevor (2000) Healthy Communities Must Be Sustainable Communities Too Public Health Reports 115 (2 and 3): 151–6) 5. There is no mention of ecology or ecosystems at all, and only a brief discussion of planetary boundaries in section 3.4 (Complexity and the ‘causes of the causes’ of ill-health ). I see a need for a paragraph or two expanding on “we are starting to see the creation of a more widespread contemporary understanding of urban health” that would incorporate the concept of the ecological determinants of health, planetary health and planetary boundaries (e.g. Hancock, 2018: “Healthy Cities 2.0: Transitioning towards ‘One Planet’ cities” (Key challenges facing 21st century cities, Part 3) Cities & Health 1 (3) 6. There is only a passing reference to the new economics (e.g. the application of Donut Economics at the urban level) and the importance of the commercial determinants for urban health (including the role of the private sector in urban development, housing, food systems and urban heating and urban pollution). These are new/emerging areas that merit some expanded discussion in section 7 7. P 12, section 7 – I would add to “Prodigious urbanisation . . .” the emerging threat to health posed by what the UN calls “the triple planetary crisis” of climate change, biodiversity loss and pollution as well as other global ecological changes that are crossing planetary boundaries. Also, a brief discussion of the ecological injustice dimensions of declining planetary health Typos P 7, first line – “towards a systemic approach to urban health.the WHO European Regional Office” should read “towards a systemic approach to urban health. The WHO European Regional Office” P 7, section 4.2 - “a centre unique in its placement within in a built environment faculty” - delete ‘in’ P 7, section 4.2 - “the Health Map now been adopted by a wide range of actors” should read “the Health Map has now been adopted by a wide range of actors” P 12, section 6 – “has been gleaned from implementation has accumulated in part” should read “has been gleaned from implementation that has accumulated in part” P 12, section 6 – “those embracing a community assets-focussed and action-oriented agendas” – delete one ‘s’ in ‘focussed’ and the ‘s’ on ‘agendas’ Is the topic of the review discussed comprehensively in the context of the current literature? Partly Are all factual statements correct and adequately supported by citations? Yes Is the review written in accessible language? Partly Are the conclusions drawn appropriate in the context of the current research literature? Partly Competing Interests: No competing interests were disclosed. Reviewer Expertise: Public health, health promotion, healthy cities and communities, planetary and environmental health, health policy & planning, health futurism I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Hancock T. Reviewer Report For: The emergence of a modern paradigm for urban health [version 2; peer review: 2 approved, 2 approved with reservations, 1 not approved] . F1000Research 2025, 13 :987 ( https://doi.org/10.5256/f1000research.169300.r353478 ) The direct URL for this report is: https://f1000research.com/articles/13-987/v1#referee-response-353478 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 06 Oct 2025 Marcus Grant , Environmental Stewardship for Health, Bristol, UK 06 Oct 2025 Author Response Your comment>>: I answered ‘partly’ to three of the four questions because: a) it would be hard, if not impossible, to be comprehensive given such a large field of thought ... Continue reading Your comment>>: I answered ‘partly’ to three of the four questions because: a) it would be hard, if not impossible, to be comprehensive given such a large field of thought and practice extending over several decades. However, this review covers the major global developments and initiatives well. b) language accessibility depends upon the audience. This would not be accessible to the general public, and perhaps not to an academic audience not familiar with some of the concepts. However, it is well written and is accessible for me. c) There is no ‘Conclusions’ section, but Section 7 is about ‘Moving Forward, and I have some thoughts, noted below, about how this section could be strengthened. Our response: Thank you for both your ratings and the thoughts behind them. We certainly agree, some of the rating questions (e.g ‘a’ and ‘b’) only map tangentially to this type of paper. However, we note all your comments. Thanks for the focus on the conclusions and how to strengthen, very useful. Your comment>>: 1 . Given “The modern urban context requires fresh thinking about how best to maximise urban health and wellbeing”, maybe change the title to read “The emergence of a modern paradigm for urban health and wellbeing” Our response: Thanks for this suggestion. The title is currently 'The emergence of a modern paradigm for urban health’. You suggest the addition of: ‘and wellbeing’. We resist a change to the title; however, we certainly accept the premise of ‘health and wellbeing’ being a powerful phrase with a lot of clarity. We have checked through the paper to see how ‘wellbeing’ is situated, and made some adjustments to ensure its inclusion as key points are made. Your comment>>: 2 . Given several references to wellbeing, I was surprised to see no reference to the Geneva Charter for Well-being (WHO, 2021) and no expansion on the concept of a wellbeing society as it would apply to a city or community, one that would be committed to “achieving equitable health now and for future generations without breaching ecological limits”. This would be a useful idea to consider in Section 7 Our response: Thank you for your reference to the Geneva Charter for Well-being. This would certainly be useful in helping to consolidating chapter 7 ‘Moving forward on urban health ‘. We have also signposted it as a document consolidating other aspects of global health such as planetary health, one health and wellbeing societies. Your comment>>: 3 . On P 5 – the section on HPP should reference the 1984 Beyond Health Care conference that launched the concept and the 1988 Second WHO Health Promotion conference on Healthy Public Policy in Adelaide that resulted in the Adelaide Statement, and included a section on Healthy Public Policy at the Local Level that resulted in an edited book (A. Evers et al. (eds.), Healthy Public Policy at the Local Level. Frankfurt/Boulder: Campus/Westview, 1990) Our response: Thank you for this information about Healthy Public Policy at the 1988 WHO conference. We have looked at the source materials and added some content. This section has been updated. Your comment>>: 4. Towards the end of section 3, in the discussion of health and planetary boundaries and sustainability, it is worth noting that the links between health and sustainability were developed in the 1990s (see e.g. Hancock, Trevor (1996) “Planning and creating healthy and sustainable cities: the challenge for the 21st century.” In C. Price and A. Tsouros (eds.), Our Cities, Our Future: Policies and Action for Health and Sustainable Development. Copenhagen: WHO Healthy Cities Project Office; Hancock, Trevor (1996) Healthy, sustainable communities: concept, fledgling practice and implications for governance Alternatives 22 (2), pp 18-23; Hancock, Trevor (2000) Healthy Communities Must Be Sustainable Communities Too Public Health Reports 115 (2 and 3): 151–6) Our response: Thank you for these references to the work in the 1990s. We will review this material and definitely cite where needed and refer to it. As you can imagine, with such as compacted text on such a large subject, we have sought to be selective in citations and knowingly have omitted many good sources. But we can point to these agorae for genesis in ideas, your knowledge is very helpful with that. Your comment>>: 5. There is no mention of ecology or ecosystems at all, and only a brief discussion of planetary boundaries in section 3.4 (Complexity and the ‘causes of the causes’ of ill-health ). I see a need for a paragraph or two expanding on “we are starting to see the creation of a more widespread contemporary understanding of urban health” that would incorporate the concept of the ecological determinants of health, planetary health and planetary boundaries (e.g. Hancock, 2018: “Healthy Cities 2.0: Transitioning towards ‘One Planet’ cities” (Key challenges facing 21st century cities, Part 3) Cities & Health 1 (3) Our response: As an ecologist myself, this error is glaring. Definitely needs rectifying. Partly also by pointing out how this agenda has been so often overlooked! I am hoping the broader WHO urban health work, of which this is a part, there will be a paper specifically focusing on ecosystems, biodiversity and urban health. We have added a new section 3.7called planetary health to address this. Your comment>>: 6. There is only a passing reference to the new economics (e.g. the application of Donut Economics at the urban level) and the importance of the commercial determinants for urban health (including the role of the private sector in urban development, housing, food systems and urban heating and urban pollution). These are new/emerging areas that merit some expanded discussion in section 7 Our response: Thank you for pointing this out. We are aware of this work and a specific section on the commercial determinants for urban health will allow us to develop some of these points. We also note the need to re-look at the new/emerging areas discussion. We have expanded and brought up to date the section on the commercial determinants of health, also including a new sub-section ‘3.5: The commercial determinants of health, with a resume of recent work as it relates to urban health Your comment>>: 7. P 12, section 7 – I would add to “Prodigious urbanisation . . .” the emerging threat to health posed by what the UN calls “the triple planetary crisis” of climate change, biodiversity loss and pollution as well as other global ecological changes that are crossing planetary boundaries. Also, a brief discussion of the ecological injustice dimensions of declining planetary health Our response: Thank you for this suggestion. Now referred to in a new section 3.7 on planetary health. Your comment>>: P 7, first line – “towards a systemic approach to urban health.the WHO European Regional Office” should read “towards a systemic approach to urban health. The WHO European Regional Office” Our response: Thank you. Corrected Your comment>>: P 7, section 4.2 - “a centre unique in its placement within in a built environment faculty” - delete ‘in’ Our response: Thank you. Corrected Your comment>>: P 7, section 4.2 - “the Health Map now been adopted by a wide range of actors” should read “the Health Map has now been adopted by a wide range of actors” Our response: Thank you. Corrected Your comment>>: P 12, section 6 – “has been gleaned from implementation has accumulated in part” should read “has been gleaned from implementation that has accumulated in part” Our response: Thank you. Corrected Your comment>>: P 12, section 6 – “those embracing a community assets-focussed and action-oriented agendas” – delete one ‘s’ in ‘focussed’ and the ‘s’ on ‘agendas’ Our response: Thank you. Corrected Your comment>>: I answered ‘partly’ to three of the four questions because: a) it would be hard, if not impossible, to be comprehensive given such a large field of thought and practice extending over several decades. However, this review covers the major global developments and initiatives well. b) language accessibility depends upon the audience. This would not be accessible to the general public, and perhaps not to an academic audience not familiar with some of the concepts. However, it is well written and is accessible for me. c) There is no ‘Conclusions’ section, but Section 7 is about ‘Moving Forward, and I have some thoughts, noted below, about how this section could be strengthened. Our response: Thank you for both your ratings and the thoughts behind them. We certainly agree, some of the rating questions (e.g ‘a’ and ‘b’) only map tangentially to this type of paper. However, we note all your comments. Thanks for the focus on the conclusions and how to strengthen, very useful. Your comment>>: 1 . Given “The modern urban context requires fresh thinking about how best to maximise urban health and wellbeing”, maybe change the title to read “The emergence of a modern paradigm for urban health and wellbeing” Our response: Thanks for this suggestion. The title is currently 'The emergence of a modern paradigm for urban health’. You suggest the addition of: ‘and wellbeing’. We resist a change to the title; however, we certainly accept the premise of ‘health and wellbeing’ being a powerful phrase with a lot of clarity. We have checked through the paper to see how ‘wellbeing’ is situated, and made some adjustments to ensure its inclusion as key points are made. Your comment>>: 2 . Given several references to wellbeing, I was surprised to see no reference to the Geneva Charter for Well-being (WHO, 2021) and no expansion on the concept of a wellbeing society as it would apply to a city or community, one that would be committed to “achieving equitable health now and for future generations without breaching ecological limits”. This would be a useful idea to consider in Section 7 Our response: Thank you for your reference to the Geneva Charter for Well-being. This would certainly be useful in helping to consolidating chapter 7 ‘Moving forward on urban health ‘. We have also signposted it as a document consolidating other aspects of global health such as planetary health, one health and wellbeing societies. Your comment>>: 3 . On P 5 – the section on HPP should reference the 1984 Beyond Health Care conference that launched the concept and the 1988 Second WHO Health Promotion conference on Healthy Public Policy in Adelaide that resulted in the Adelaide Statement, and included a section on Healthy Public Policy at the Local Level that resulted in an edited book (A. Evers et al. (eds.), Healthy Public Policy at the Local Level. Frankfurt/Boulder: Campus/Westview, 1990) Our response: Thank you for this information about Healthy Public Policy at the 1988 WHO conference. We have looked at the source materials and added some content. This section has been updated. Your comment>>: 4. Towards the end of section 3, in the discussion of health and planetary boundaries and sustainability, it is worth noting that the links between health and sustainability were developed in the 1990s (see e.g. Hancock, Trevor (1996) “Planning and creating healthy and sustainable cities: the challenge for the 21st century.” In C. Price and A. Tsouros (eds.), Our Cities, Our Future: Policies and Action for Health and Sustainable Development. Copenhagen: WHO Healthy Cities Project Office; Hancock, Trevor (1996) Healthy, sustainable communities: concept, fledgling practice and implications for governance Alternatives 22 (2), pp 18-23; Hancock, Trevor (2000) Healthy Communities Must Be Sustainable Communities Too Public Health Reports 115 (2 and 3): 151–6) Our response: Thank you for these references to the work in the 1990s. We will review this material and definitely cite where needed and refer to it. As you can imagine, with such as compacted text on such a large subject, we have sought to be selective in citations and knowingly have omitted many good sources. But we can point to these agorae for genesis in ideas, your knowledge is very helpful with that. Your comment>>: 5. There is no mention of ecology or ecosystems at all, and only a brief discussion of planetary boundaries in section 3.4 (Complexity and the ‘causes of the causes’ of ill-health ). I see a need for a paragraph or two expanding on “we are starting to see the creation of a more widespread contemporary understanding of urban health” that would incorporate the concept of the ecological determinants of health, planetary health and planetary boundaries (e.g. Hancock, 2018: “Healthy Cities 2.0: Transitioning towards ‘One Planet’ cities” (Key challenges facing 21st century cities, Part 3) Cities & Health 1 (3) Our response: As an ecologist myself, this error is glaring. Definitely needs rectifying. Partly also by pointing out how this agenda has been so often overlooked! I am hoping the broader WHO urban health work, of which this is a part, there will be a paper specifically focusing on ecosystems, biodiversity and urban health. We have added a new section 3.7called planetary health to address this. Your comment>>: 6. There is only a passing reference to the new economics (e.g. the application of Donut Economics at the urban level) and the importance of the commercial determinants for urban health (including the role of the private sector in urban development, housing, food systems and urban heating and urban pollution). These are new/emerging areas that merit some expanded discussion in section 7 Our response: Thank you for pointing this out. We are aware of this work and a specific section on the commercial determinants for urban health will allow us to develop some of these points. We also note the need to re-look at the new/emerging areas discussion. We have expanded and brought up to date the section on the commercial determinants of health, also including a new sub-section ‘3.5: The commercial determinants of health, with a resume of recent work as it relates to urban health Your comment>>: 7. P 12, section 7 – I would add to “Prodigious urbanisation . . .” the emerging threat to health posed by what the UN calls “the triple planetary crisis” of climate change, biodiversity loss and pollution as well as other global ecological changes that are crossing planetary boundaries. Also, a brief discussion of the ecological injustice dimensions of declining planetary health Our response: Thank you for this suggestion. Now referred to in a new section 3.7 on planetary health. Your comment>>: P 7, first line – “towards a systemic approach to urban health.the WHO European Regional Office” should read “towards a systemic approach to urban health. The WHO European Regional Office” Our response: Thank you. Corrected Your comment>>: P 7, section 4.2 - “a centre unique in its placement within in a built environment faculty” - delete ‘in’ Our response: Thank you. Corrected Your comment>>: P 7, section 4.2 - “the Health Map now been adopted by a wide range of actors” should read “the Health Map has now been adopted by a wide range of actors” Our response: Thank you. Corrected Your comment>>: P 12, section 6 – “has been gleaned from implementation has accumulated in part” should read “has been gleaned from implementation that has accumulated in part” Our response: Thank you. Corrected Your comment>>: P 12, section 6 – “those embracing a community assets-focussed and action-oriented agendas” – delete one ‘s’ in ‘focussed’ and the ‘s’ on ‘agendas’ Our response: Thank you. Corrected Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 06 Oct 2025 Marcus Grant , Environmental Stewardship for Health, Bristol, UK 06 Oct 2025 Author Response Your comment>>: I answered ‘partly’ to three of the four questions because: a) it would be hard, if not impossible, to be comprehensive given such a large field of thought ... Continue reading Your comment>>: I answered ‘partly’ to three of the four questions because: a) it would be hard, if not impossible, to be comprehensive given such a large field of thought and practice extending over several decades. However, this review covers the major global developments and initiatives well. b) language accessibility depends upon the audience. This would not be accessible to the general public, and perhaps not to an academic audience not familiar with some of the concepts. However, it is well written and is accessible for me. c) There is no ‘Conclusions’ section, but Section 7 is about ‘Moving Forward, and I have some thoughts, noted below, about how this section could be strengthened. Our response: Thank you for both your ratings and the thoughts behind them. We certainly agree, some of the rating questions (e.g ‘a’ and ‘b’) only map tangentially to this type of paper. However, we note all your comments. Thanks for the focus on the conclusions and how to strengthen, very useful. Your comment>>: 1 . Given “The modern urban context requires fresh thinking about how best to maximise urban health and wellbeing”, maybe change the title to read “The emergence of a modern paradigm for urban health and wellbeing” Our response: Thanks for this suggestion. The title is currently 'The emergence of a modern paradigm for urban health’. You suggest the addition of: ‘and wellbeing’. We resist a change to the title; however, we certainly accept the premise of ‘health and wellbeing’ being a powerful phrase with a lot of clarity. We have checked through the paper to see how ‘wellbeing’ is situated, and made some adjustments to ensure its inclusion as key points are made. Your comment>>: 2 . Given several references to wellbeing, I was surprised to see no reference to the Geneva Charter for Well-being (WHO, 2021) and no expansion on the concept of a wellbeing society as it would apply to a city or community, one that would be committed to “achieving equitable health now and for future generations without breaching ecological limits”. This would be a useful idea to consider in Section 7 Our response: Thank you for your reference to the Geneva Charter for Well-being. This would certainly be useful in helping to consolidating chapter 7 ‘Moving forward on urban health ‘. We have also signposted it as a document consolidating other aspects of global health such as planetary health, one health and wellbeing societies. Your comment>>: 3 . On P 5 – the section on HPP should reference the 1984 Beyond Health Care conference that launched the concept and the 1988 Second WHO Health Promotion conference on Healthy Public Policy in Adelaide that resulted in the Adelaide Statement, and included a section on Healthy Public Policy at the Local Level that resulted in an edited book (A. Evers et al. (eds.), Healthy Public Policy at the Local Level. Frankfurt/Boulder: Campus/Westview, 1990) Our response: Thank you for this information about Healthy Public Policy at the 1988 WHO conference. We have looked at the source materials and added some content. This section has been updated. Your comment>>: 4. Towards the end of section 3, in the discussion of health and planetary boundaries and sustainability, it is worth noting that the links between health and sustainability were developed in the 1990s (see e.g. Hancock, Trevor (1996) “Planning and creating healthy and sustainable cities: the challenge for the 21st century.” In C. Price and A. Tsouros (eds.), Our Cities, Our Future: Policies and Action for Health and Sustainable Development. Copenhagen: WHO Healthy Cities Project Office; Hancock, Trevor (1996) Healthy, sustainable communities: concept, fledgling practice and implications for governance Alternatives 22 (2), pp 18-23; Hancock, Trevor (2000) Healthy Communities Must Be Sustainable Communities Too Public Health Reports 115 (2 and 3): 151–6) Our response: Thank you for these references to the work in the 1990s. We will review this material and definitely cite where needed and refer to it. As you can imagine, with such as compacted text on such a large subject, we have sought to be selective in citations and knowingly have omitted many good sources. But we can point to these agorae for genesis in ideas, your knowledge is very helpful with that. Your comment>>: 5. There is no mention of ecology or ecosystems at all, and only a brief discussion of planetary boundaries in section 3.4 (Complexity and the ‘causes of the causes’ of ill-health ). I see a need for a paragraph or two expanding on “we are starting to see the creation of a more widespread contemporary understanding of urban health” that would incorporate the concept of the ecological determinants of health, planetary health and planetary boundaries (e.g. Hancock, 2018: “Healthy Cities 2.0: Transitioning towards ‘One Planet’ cities” (Key challenges facing 21st century cities, Part 3) Cities & Health 1 (3) Our response: As an ecologist myself, this error is glaring. Definitely needs rectifying. Partly also by pointing out how this agenda has been so often overlooked! I am hoping the broader WHO urban health work, of which this is a part, there will be a paper specifically focusing on ecosystems, biodiversity and urban health. We have added a new section 3.7called planetary health to address this. Your comment>>: 6. There is only a passing reference to the new economics (e.g. the application of Donut Economics at the urban level) and the importance of the commercial determinants for urban health (including the role of the private sector in urban development, housing, food systems and urban heating and urban pollution). These are new/emerging areas that merit some expanded discussion in section 7 Our response: Thank you for pointing this out. We are aware of this work and a specific section on the commercial determinants for urban health will allow us to develop some of these points. We also note the need to re-look at the new/emerging areas discussion. We have expanded and brought up to date the section on the commercial determinants of health, also including a new sub-section ‘3.5: The commercial determinants of health, with a resume of recent work as it relates to urban health Your comment>>: 7. P 12, section 7 – I would add to “Prodigious urbanisation . . .” the emerging threat to health posed by what the UN calls “the triple planetary crisis” of climate change, biodiversity loss and pollution as well as other global ecological changes that are crossing planetary boundaries. Also, a brief discussion of the ecological injustice dimensions of declining planetary health Our response: Thank you for this suggestion. Now referred to in a new section 3.7 on planetary health. Your comment>>: P 7, first line – “towards a systemic approach to urban health.the WHO European Regional Office” should read “towards a systemic approach to urban health. The WHO European Regional Office” Our response: Thank you. Corrected Your comment>>: P 7, section 4.2 - “a centre unique in its placement within in a built environment faculty” - delete ‘in’ Our response: Thank you. Corrected Your comment>>: P 7, section 4.2 - “the Health Map now been adopted by a wide range of actors” should read “the Health Map has now been adopted by a wide range of actors” Our response: Thank you. Corrected Your comment>>: P 12, section 6 – “has been gleaned from implementation has accumulated in part” should read “has been gleaned from implementation that has accumulated in part” Our response: Thank you. Corrected Your comment>>: P 12, section 6 – “those embracing a community assets-focussed and action-oriented agendas” – delete one ‘s’ in ‘focussed’ and the ‘s’ on ‘agendas’ Our response: Thank you. Corrected Your comment>>: I answered ‘partly’ to three of the four questions because: a) it would be hard, if not impossible, to be comprehensive given such a large field of thought and practice extending over several decades. However, this review covers the major global developments and initiatives well. b) language accessibility depends upon the audience. This would not be accessible to the general public, and perhaps not to an academic audience not familiar with some of the concepts. However, it is well written and is accessible for me. c) There is no ‘Conclusions’ section, but Section 7 is about ‘Moving Forward, and I have some thoughts, noted below, about how this section could be strengthened. Our response: Thank you for both your ratings and the thoughts behind them. We certainly agree, some of the rating questions (e.g ‘a’ and ‘b’) only map tangentially to this type of paper. However, we note all your comments. Thanks for the focus on the conclusions and how to strengthen, very useful. Your comment>>: 1 . Given “The modern urban context requires fresh thinking about how best to maximise urban health and wellbeing”, maybe change the title to read “The emergence of a modern paradigm for urban health and wellbeing” Our response: Thanks for this suggestion. The title is currently 'The emergence of a modern paradigm for urban health’. You suggest the addition of: ‘and wellbeing’. We resist a change to the title; however, we certainly accept the premise of ‘health and wellbeing’ being a powerful phrase with a lot of clarity. We have checked through the paper to see how ‘wellbeing’ is situated, and made some adjustments to ensure its inclusion as key points are made. Your comment>>: 2 . Given several references to wellbeing, I was surprised to see no reference to the Geneva Charter for Well-being (WHO, 2021) and no expansion on the concept of a wellbeing society as it would apply to a city or community, one that would be committed to “achieving equitable health now and for future generations without breaching ecological limits”. This would be a useful idea to consider in Section 7 Our response: Thank you for your reference to the Geneva Charter for Well-being. This would certainly be useful in helping to consolidating chapter 7 ‘Moving forward on urban health ‘. We have also signposted it as a document consolidating other aspects of global health such as planetary health, one health and wellbeing societies. Your comment>>: 3 . On P 5 – the section on HPP should reference the 1984 Beyond Health Care conference that launched the concept and the 1988 Second WHO Health Promotion conference on Healthy Public Policy in Adelaide that resulted in the Adelaide Statement, and included a section on Healthy Public Policy at the Local Level that resulted in an edited book (A. Evers et al. (eds.), Healthy Public Policy at the Local Level. Frankfurt/Boulder: Campus/Westview, 1990) Our response: Thank you for this information about Healthy Public Policy at the 1988 WHO conference. We have looked at the source materials and added some content. This section has been updated. Your comment>>: 4. Towards the end of section 3, in the discussion of health and planetary boundaries and sustainability, it is worth noting that the links between health and sustainability were developed in the 1990s (see e.g. Hancock, Trevor (1996) “Planning and creating healthy and sustainable cities: the challenge for the 21st century.” In C. Price and A. Tsouros (eds.), Our Cities, Our Future: Policies and Action for Health and Sustainable Development. Copenhagen: WHO Healthy Cities Project Office; Hancock, Trevor (1996) Healthy, sustainable communities: concept, fledgling practice and implications for governance Alternatives 22 (2), pp 18-23; Hancock, Trevor (2000) Healthy Communities Must Be Sustainable Communities Too Public Health Reports 115 (2 and 3): 151–6) Our response: Thank you for these references to the work in the 1990s. We will review this material and definitely cite where needed and refer to it. As you can imagine, with such as compacted text on such a large subject, we have sought to be selective in citations and knowingly have omitted many good sources. But we can point to these agorae for genesis in ideas, your knowledge is very helpful with that. Your comment>>: 5. There is no mention of ecology or ecosystems at all, and only a brief discussion of planetary boundaries in section 3.4 (Complexity and the ‘causes of the causes’ of ill-health ). I see a need for a paragraph or two expanding on “we are starting to see the creation of a more widespread contemporary understanding of urban health” that would incorporate the concept of the ecological determinants of health, planetary health and planetary boundaries (e.g. Hancock, 2018: “Healthy Cities 2.0: Transitioning towards ‘One Planet’ cities” (Key challenges facing 21st century cities, Part 3) Cities & Health 1 (3) Our response: As an ecologist myself, this error is glaring. Definitely needs rectifying. Partly also by pointing out how this agenda has been so often overlooked! I am hoping the broader WHO urban health work, of which this is a part, there will be a paper specifically focusing on ecosystems, biodiversity and urban health. We have added a new section 3.7called planetary health to address this. Your comment>>: 6. There is only a passing reference to the new economics (e.g. the application of Donut Economics at the urban level) and the importance of the commercial determinants for urban health (including the role of the private sector in urban development, housing, food systems and urban heating and urban pollution). These are new/emerging areas that merit some expanded discussion in section 7 Our response: Thank you for pointing this out. We are aware of this work and a specific section on the commercial determinants for urban health will allow us to develop some of these points. We also note the need to re-look at the new/emerging areas discussion. We have expanded and brought up to date the section on the commercial determinants of health, also including a new sub-section ‘3.5: The commercial determinants of health, with a resume of recent work as it relates to urban health Your comment>>: 7. P 12, section 7 – I would add to “Prodigious urbanisation . . .” the emerging threat to health posed by what the UN calls “the triple planetary crisis” of climate change, biodiversity loss and pollution as well as other global ecological changes that are crossing planetary boundaries. Also, a brief discussion of the ecological injustice dimensions of declining planetary health Our response: Thank you for this suggestion. Now referred to in a new section 3.7 on planetary health. Your comment>>: P 7, first line – “towards a systemic approach to urban health.the WHO European Regional Office” should read “towards a systemic approach to urban health. The WHO European Regional Office” Our response: Thank you. Corrected Your comment>>: P 7, section 4.2 - “a centre unique in its placement within in a built environment faculty” - delete ‘in’ Our response: Thank you. Corrected Your comment>>: P 7, section 4.2 - “the Health Map now been adopted by a wide range of actors” should read “the Health Map has now been adopted by a wide range of actors” Our response: Thank you. Corrected Your comment>>: P 12, section 6 – “has been gleaned from implementation has accumulated in part” should read “has been gleaned from implementation that has accumulated in part” Our response: Thank you. Corrected Your comment>>: P 12, section 6 – “those embracing a community assets-focussed and action-oriented agendas” – delete one ‘s’ in ‘focussed’ and the ‘s’ on ‘agendas’ Our response: Thank you. Corrected Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Freudenberg N. Reviewer Report For: The emergence of a modern paradigm for urban health [version 2; peer review: 2 approved, 2 approved with reservations, 1 not approved] . F1000Research 2025, 13 :987 ( https://doi.org/10.5256/f1000research.169300.r353471 ) The direct URL for this report is: https://f1000research.com/articles/13-987/v1#referee-response-353471 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 09 Jan 2025 Nicholas Freudenberg , City University of New York, New York City, NY, USA Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.169300.r353471 The paper is a competent and useful summary of some of the developments in urban health. In this review, I highlight gaps and concerns to give the authors an opportunity to consider these points. The review feels ... Continue reading READ ALL The paper is a competent and useful summary of some of the developments in urban health. In this review, I highlight gaps and concerns to give the authors an opportunity to consider these points. The review feels curiously dated with more emphasis on the developments of the first 30 years and less on the last 10 years. Of the 75 references, only 30 were published in the last 10 years. Since others have written about the earlier years, I was hoping for more focus on recent developments. Some issues that could receive more attention include: 1. The emergence of the frameworks of commercial and political determinants of health. These are mentioned only briefly but, in my view, they pose existential and profound threats to the health of urban residents in particular and deserve more attention. More broadly, a summary of the body of literature on the political economy of cities and its impact of health would be valuable. 2. Worldwide and in cities, challenges to democracy pose serious threats to the health of populations and to health equity. How does this play out in cities and what have we learned in the last 10 years about the threats and possible responses? 3. Covid 19 is barely mentioned yet is has had a profound influence on the health of urban populations and the scholarly discourse on urban health. What have we learned and what are priorities for further research on pandemic threats to cities? 4. In my read of urban health history over the last 150 years, it has been social movements that have led to the most significant advances in population health and health equity yet there is almost no mention of social movements and their potential and limitations. Some discussion of this would enhance the article. It is easy for a reviewer to identify gaps, and it is authors who decide how best to use their limited space. In my view, addressing the issues listed here would make a useful report more useful. Is the topic of the review discussed comprehensively in the context of the current literature? Partly Are all factual statements correct and adequately supported by citations? Yes Is the review written in accessible language? Yes Are the conclusions drawn appropriate in the context of the current research literature? Partly Competing Interests: No competing interests were disclosed. Reviewer Expertise: urban health, health equity, role of social movments in health I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Freudenberg N. Reviewer Report For: The emergence of a modern paradigm for urban health [version 2; peer review: 2 approved, 2 approved with reservations, 1 not approved] . F1000Research 2025, 13 :987 ( https://doi.org/10.5256/f1000research.169300.r353471 ) The direct URL for this report is: https://f1000research.com/articles/13-987/v1#referee-response-353471 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 06 Oct 2025 Marcus Grant , Environmental Stewardship for Health, Bristol, UK 06 Oct 2025 Author Response Your comment>>: The paper is a competent and useful summary of some of the developments in urban health. In this review, I highlight gaps and concerns to give the authors ... Continue reading Your comment>>: The paper is a competent and useful summary of some of the developments in urban health. In this review, I highlight gaps and concerns to give the authors an opportunity to consider these points. Our response: Thank you for reading the paper and bringing these issues to our attention. Your comment>>: The review feels curiously dated with more emphasis on the developments of the first 30 years and less on the last 10 years. Of the 75 references, only 30 were published in the last 10 years. Since others have written about the earlier years, I was hoping for more focus on recent developments. Some issues that could receive more attention include: Our response: Noting your useful observation here. We are aiming this paper at those who were not as aware of that historic arc of development. However, in doing so, we may have neglected more recent developments. Thank you for drawing attention to some of the more recent developments which we now acknowledge, a few only in passing, others more deeply, and to better frame the paper. Your comment>>: 1. The emergence of the frameworks of commercial and political determinants of health. These are mentioned only briefly but, in my view, they pose existential and profound threats to the health of urban residents in particular and deserve more attention. More broadly, a summary of the body of literature on the political economy of cities and its impact of health would be valuable. Our response: As you indicate, the paper has become a victim of its own tightly drawn brief. This self-imposed constraint needs to be better articulated at the outset to help frame what comes later. Having said that, the authors agree that the arguably more recent discourses on the commercial and political determinants of health need to be better addressed. As does the political economy of cities and its impact on health. Introduction and background have been re-written in several places to reflect the importance of commercial and political determinants of health. We have added a new sub-section ‘3.6: The political economy’, including more recent references. We have expanded and brought up to date the section on the commercial determinants of health, also including a new sub-section ‘3.5: The commercial determinants of health, with a resume of recent work as it relates to urban health Your comment>>: 2. Worldwide and in cities, challenges to democracy pose serious threats to the health of populations and to health equity. How does this play out in cities and what have we learned in the last 10 years about the threats and possible responses? Our response: You raise an important point here. We think it lies outside the scope of this paper to examine in detail. However, we must certainly acknowledge the threats to health, especially with the recent move in the USA to remove support for the WHO and for a seemingly more transactional and superficial approach to underlying structural issues, without, of course, making the paper into a topical commentary. We have added material about global and national (political and democratic) contexts as a determinant of health. Citing: Buse, K. et al. "What are healthy societies? A thematic analysis of relevant conceptual frameworks." International journal of health policy and management 12 (2023): 7450. Your comment>>: 3. Covid 19 is barely mentioned yet it has had a profound influence on the health of urban populations and the scholarly discourse on urban health. What have we learned and what are the priorities for further research on pandemic threats to cities? Our response: Thank you for pointing out this oversight. The paper does need updating in this regard. Analysis of COVID-19 impact on urban health thinking and policy was still emerging during the initial writing process, and we neglected this in later drafts. Material, as relevant to COVID-19 and lessons for urban health, has been added in several places, most notably the section on health equity. In addition, a specific discussion has been writing in section ‘3.2 Urban health beyond the health sector; from treatment to prevention’, focusing on how town planners had to adapt many public spaces to reduce transmission and how this led to a greater visibility of the importance of non-medical measures for urban health. Your comment>>: 4. In my read of urban health history over the last 150 years, it has been social movements that have led to the most significant advances in population health and health equity, yet there is almost no mention of social movements and their potential and limitations. Some discussion of this would enhance the article. Our response: Thank you for this comment. We have now included some material noting the roles of social moments. Paragraph of text was added addressing the influence of grassroots movements for social change in the introductory section. Your comment>>: It is easy for a reviewer to identify gaps, and it is authors who decide how best to use their limited space. In my view, addressing the issues listed here would make a useful report more useful. Our response: Thank you for your suggestions. Your comments have been very useful. Your comment>>: The paper is a competent and useful summary of some of the developments in urban health. In this review, I highlight gaps and concerns to give the authors an opportunity to consider these points. Our response: Thank you for reading the paper and bringing these issues to our attention. Your comment>>: The review feels curiously dated with more emphasis on the developments of the first 30 years and less on the last 10 years. Of the 75 references, only 30 were published in the last 10 years. Since others have written about the earlier years, I was hoping for more focus on recent developments. Some issues that could receive more attention include: Our response: Noting your useful observation here. We are aiming this paper at those who were not as aware of that historic arc of development. However, in doing so, we may have neglected more recent developments. Thank you for drawing attention to some of the more recent developments which we now acknowledge, a few only in passing, others more deeply, and to better frame the paper. Your comment>>: 1. The emergence of the frameworks of commercial and political determinants of health. These are mentioned only briefly but, in my view, they pose existential and profound threats to the health of urban residents in particular and deserve more attention. More broadly, a summary of the body of literature on the political economy of cities and its impact of health would be valuable. Our response: As you indicate, the paper has become a victim of its own tightly drawn brief. This self-imposed constraint needs to be better articulated at the outset to help frame what comes later. Having said that, the authors agree that the arguably more recent discourses on the commercial and political determinants of health need to be better addressed. As does the political economy of cities and its impact on health. Introduction and background have been re-written in several places to reflect the importance of commercial and political determinants of health. We have added a new sub-section ‘3.6: The political economy’, including more recent references. We have expanded and brought up to date the section on the commercial determinants of health, also including a new sub-section ‘3.5: The commercial determinants of health, with a resume of recent work as it relates to urban health Your comment>>: 2. Worldwide and in cities, challenges to democracy pose serious threats to the health of populations and to health equity. How does this play out in cities and what have we learned in the last 10 years about the threats and possible responses? Our response: You raise an important point here. We think it lies outside the scope of this paper to examine in detail. However, we must certainly acknowledge the threats to health, especially with the recent move in the USA to remove support for the WHO and for a seemingly more transactional and superficial approach to underlying structural issues, without, of course, making the paper into a topical commentary. We have added material about global and national (political and democratic) contexts as a determinant of health. Citing: Buse, K. et al. "What are healthy societies? A thematic analysis of relevant conceptual frameworks." International journal of health policy and management 12 (2023): 7450. Your comment>>: 3. Covid 19 is barely mentioned yet it has had a profound influence on the health of urban populations and the scholarly discourse on urban health. What have we learned and what are the priorities for further research on pandemic threats to cities? Our response: Thank you for pointing out this oversight. The paper does need updating in this regard. Analysis of COVID-19 impact on urban health thinking and policy was still emerging during the initial writing process, and we neglected this in later drafts. Material, as relevant to COVID-19 and lessons for urban health, has been added in several places, most notably the section on health equity. In addition, a specific discussion has been writing in section ‘3.2 Urban health beyond the health sector; from treatment to prevention’, focusing on how town planners had to adapt many public spaces to reduce transmission and how this led to a greater visibility of the importance of non-medical measures for urban health. Your comment>>: 4. In my read of urban health history over the last 150 years, it has been social movements that have led to the most significant advances in population health and health equity, yet there is almost no mention of social movements and their potential and limitations. Some discussion of this would enhance the article. Our response: Thank you for this comment. We have now included some material noting the roles of social moments. Paragraph of text was added addressing the influence of grassroots movements for social change in the introductory section. Your comment>>: It is easy for a reviewer to identify gaps, and it is authors who decide how best to use their limited space. In my view, addressing the issues listed here would make a useful report more useful. Our response: Thank you for your suggestions. Your comments have been very useful. Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 06 Oct 2025 Marcus Grant , Environmental Stewardship for Health, Bristol, UK 06 Oct 2025 Author Response Your comment>>: The paper is a competent and useful summary of some of the developments in urban health. In this review, I highlight gaps and concerns to give the authors ... Continue reading Your comment>>: The paper is a competent and useful summary of some of the developments in urban health. In this review, I highlight gaps and concerns to give the authors an opportunity to consider these points. Our response: Thank you for reading the paper and bringing these issues to our attention. Your comment>>: The review feels curiously dated with more emphasis on the developments of the first 30 years and less on the last 10 years. Of the 75 references, only 30 were published in the last 10 years. Since others have written about the earlier years, I was hoping for more focus on recent developments. Some issues that could receive more attention include: Our response: Noting your useful observation here. We are aiming this paper at those who were not as aware of that historic arc of development. However, in doing so, we may have neglected more recent developments. Thank you for drawing attention to some of the more recent developments which we now acknowledge, a few only in passing, others more deeply, and to better frame the paper. Your comment>>: 1. The emergence of the frameworks of commercial and political determinants of health. These are mentioned only briefly but, in my view, they pose existential and profound threats to the health of urban residents in particular and deserve more attention. More broadly, a summary of the body of literature on the political economy of cities and its impact of health would be valuable. Our response: As you indicate, the paper has become a victim of its own tightly drawn brief. This self-imposed constraint needs to be better articulated at the outset to help frame what comes later. Having said that, the authors agree that the arguably more recent discourses on the commercial and political determinants of health need to be better addressed. As does the political economy of cities and its impact on health. Introduction and background have been re-written in several places to reflect the importance of commercial and political determinants of health. We have added a new sub-section ‘3.6: The political economy’, including more recent references. We have expanded and brought up to date the section on the commercial determinants of health, also including a new sub-section ‘3.5: The commercial determinants of health, with a resume of recent work as it relates to urban health Your comment>>: 2. Worldwide and in cities, challenges to democracy pose serious threats to the health of populations and to health equity. How does this play out in cities and what have we learned in the last 10 years about the threats and possible responses? Our response: You raise an important point here. We think it lies outside the scope of this paper to examine in detail. However, we must certainly acknowledge the threats to health, especially with the recent move in the USA to remove support for the WHO and for a seemingly more transactional and superficial approach to underlying structural issues, without, of course, making the paper into a topical commentary. We have added material about global and national (political and democratic) contexts as a determinant of health. Citing: Buse, K. et al. "What are healthy societies? A thematic analysis of relevant conceptual frameworks." International journal of health policy and management 12 (2023): 7450. Your comment>>: 3. Covid 19 is barely mentioned yet it has had a profound influence on the health of urban populations and the scholarly discourse on urban health. What have we learned and what are the priorities for further research on pandemic threats to cities? Our response: Thank you for pointing out this oversight. The paper does need updating in this regard. Analysis of COVID-19 impact on urban health thinking and policy was still emerging during the initial writing process, and we neglected this in later drafts. Material, as relevant to COVID-19 and lessons for urban health, has been added in several places, most notably the section on health equity. In addition, a specific discussion has been writing in section ‘3.2 Urban health beyond the health sector; from treatment to prevention’, focusing on how town planners had to adapt many public spaces to reduce transmission and how this led to a greater visibility of the importance of non-medical measures for urban health. Your comment>>: 4. In my read of urban health history over the last 150 years, it has been social movements that have led to the most significant advances in population health and health equity, yet there is almost no mention of social movements and their potential and limitations. Some discussion of this would enhance the article. Our response: Thank you for this comment. We have now included some material noting the roles of social moments. Paragraph of text was added addressing the influence of grassroots movements for social change in the introductory section. Your comment>>: It is easy for a reviewer to identify gaps, and it is authors who decide how best to use their limited space. In my view, addressing the issues listed here would make a useful report more useful. Our response: Thank you for your suggestions. Your comments have been very useful. Your comment>>: The paper is a competent and useful summary of some of the developments in urban health. In this review, I highlight gaps and concerns to give the authors an opportunity to consider these points. Our response: Thank you for reading the paper and bringing these issues to our attention. Your comment>>: The review feels curiously dated with more emphasis on the developments of the first 30 years and less on the last 10 years. Of the 75 references, only 30 were published in the last 10 years. Since others have written about the earlier years, I was hoping for more focus on recent developments. Some issues that could receive more attention include: Our response: Noting your useful observation here. We are aiming this paper at those who were not as aware of that historic arc of development. However, in doing so, we may have neglected more recent developments. Thank you for drawing attention to some of the more recent developments which we now acknowledge, a few only in passing, others more deeply, and to better frame the paper. Your comment>>: 1. The emergence of the frameworks of commercial and political determinants of health. These are mentioned only briefly but, in my view, they pose existential and profound threats to the health of urban residents in particular and deserve more attention. More broadly, a summary of the body of literature on the political economy of cities and its impact of health would be valuable. Our response: As you indicate, the paper has become a victim of its own tightly drawn brief. This self-imposed constraint needs to be better articulated at the outset to help frame what comes later. Having said that, the authors agree that the arguably more recent discourses on the commercial and political determinants of health need to be better addressed. As does the political economy of cities and its impact on health. Introduction and background have been re-written in several places to reflect the importance of commercial and political determinants of health. We have added a new sub-section ‘3.6: The political economy’, including more recent references. We have expanded and brought up to date the section on the commercial determinants of health, also including a new sub-section ‘3.5: The commercial determinants of health, with a resume of recent work as it relates to urban health Your comment>>: 2. Worldwide and in cities, challenges to democracy pose serious threats to the health of populations and to health equity. How does this play out in cities and what have we learned in the last 10 years about the threats and possible responses? Our response: You raise an important point here. We think it lies outside the scope of this paper to examine in detail. However, we must certainly acknowledge the threats to health, especially with the recent move in the USA to remove support for the WHO and for a seemingly more transactional and superficial approach to underlying structural issues, without, of course, making the paper into a topical commentary. We have added material about global and national (political and democratic) contexts as a determinant of health. Citing: Buse, K. et al. "What are healthy societies? A thematic analysis of relevant conceptual frameworks." International journal of health policy and management 12 (2023): 7450. Your comment>>: 3. Covid 19 is barely mentioned yet it has had a profound influence on the health of urban populations and the scholarly discourse on urban health. What have we learned and what are the priorities for further research on pandemic threats to cities? Our response: Thank you for pointing out this oversight. The paper does need updating in this regard. Analysis of COVID-19 impact on urban health thinking and policy was still emerging during the initial writing process, and we neglected this in later drafts. Material, as relevant to COVID-19 and lessons for urban health, has been added in several places, most notably the section on health equity. In addition, a specific discussion has been writing in section ‘3.2 Urban health beyond the health sector; from treatment to prevention’, focusing on how town planners had to adapt many public spaces to reduce transmission and how this led to a greater visibility of the importance of non-medical measures for urban health. Your comment>>: 4. In my read of urban health history over the last 150 years, it has been social movements that have led to the most significant advances in population health and health equity, yet there is almost no mention of social movements and their potential and limitations. Some discussion of this would enhance the article. Our response: Thank you for this comment. We have now included some material noting the roles of social moments. Paragraph of text was added addressing the influence of grassroots movements for social change in the introductory section. Your comment>>: It is easy for a reviewer to identify gaps, and it is authors who decide how best to use their limited space. In my view, addressing the issues listed here would make a useful report more useful. Our response: Thank you for your suggestions. Your comments have been very useful. Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Balasubramaniam P. Reviewer Report For: The emergence of a modern paradigm for urban health [version 2; peer review: 2 approved, 2 approved with reservations, 1 not approved] . F1000Research 2025, 13 :987 ( https://doi.org/10.5256/f1000research.169300.r331697 ) The direct URL for this report is: https://f1000research.com/articles/13-987/v1#referee-response-331697 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 09 Dec 2024 Priya Balasubramaniam , Public Health Foundation of India, Gurugram,, Haryana, India; Centre for Sustainable Health Innovations, Singapore, Singapore Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.169300.r331697 This article robustly traces the evolution of the urban health paradigm that highlights key past frameworks like the Health in All Policies (HiAP), the Ottawa Charter, and Healthy Public Policy. It also references systems thinking, equity, and complexity as core ... Continue reading READ ALL This article robustly traces the evolution of the urban health paradigm that highlights key past frameworks like the Health in All Policies (HiAP), the Ottawa Charter, and Healthy Public Policy. It also references systems thinking, equity, and complexity as core theoretical lenses for understanding urban health dynamics and a bold recommendation to move away from older frameworks to newer paradigms and emerging issues in Urban Health . These provide a strong foundation, but there are a few gaps that could be addressed in the remit of this article. Strengths: The focus on the settings-based approach and systemic determinants of health is comprehensive. Incorporation of complexity science to frame urban health challenges is forward-thinking. Historical references to the Alma Ata Declaration and WHO initiatives contextualize the paradigm's evolution. Gaps: The frameworks largely neglect the integration of digital health transformation in urban health , which is rapidly reshaping urban health systems. The article could incorporate frameworks like digital ecosystems and their potential to address urban health inequities through data analytics, telemedicine, and AI-driven decision-making. The private health sector's role is also underemphasized who is often a key play in urban health systems in emerging economies with mixed health systems. A pragmatic discussion of mixed health systems and private sector dynamics could strengthen the conceptual framing, especially regarding regulatory frameworks, financing models, and partnerships. 2. Digital Health Transformation The omission of digital health as a transformative tool is a significant gap, given its increasing relevance in urban health: Suggested Additions: Include a discussion on the role of digital platforms in improving access to urban health services, particularly for underserved populations. Explore frameworks like the Digital Health Ecosystem Model , emphasizing the interplay between governance, technology, and stakeholders in urban settings. Highlight innovations such as mobile health (mHealth), eHealth tools, and AI applications in predictive urban health surveillance. Rationale: Digital health can bridge gaps in healthcare access and quality in urban areas, where infrastructure is often unevenly distributed. Including this dimension would make the article more relevant to contemporary challenges and opportunities. 3. Role of the Private Health Sector The private health sector is critical in urban settings, especially in low- and middle-income countries, where it often fills service delivery gaps: Suggestions for Inclusion: Discuss how private providers can complement public health efforts through partnerships, performance-based contracting, or shared accountability models. Examine innovative financing mechanisms (e.g., social impact bonds) and their role in incentivizing private sector participation in urban health initiatives. Incorporate case studies that illustrate successful integration of private sector solutions in urban health systems (e.g., public-private partnerships in urban clinics or insurance schemes tailored to urban populations). Theoretical Contribution: The article could introduce theories of market dynamics and public-private synergies , focusing on balancing equity, efficiency, and accessibility in urban health. 4. Suggestions would be useful in the scope of this forward thinking article if The authors should explicitly recognize the transformative potential of digital health and private sector partnerships as key drivers of the next phase of the urban health paradigm. A section dedicated to exploring how these two elements can operationalize the theoretical concepts of systems thinking and equity would enrich the discussion. Is the topic of the review discussed comprehensively in the context of the current literature? Yes Are all factual statements correct and adequately supported by citations? Yes Is the review written in accessible language? Yes Are the conclusions drawn appropriate in the context of the current research literature? Partly Competing Interests: No competing interests were disclosed. Reviewer Expertise: Mixed Health Systems, Digital Health Transformation, Private Sector Innovation in Health care provision and access I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Balasubramaniam P. Reviewer Report For: The emergence of a modern paradigm for urban health [version 2; peer review: 2 approved, 2 approved with reservations, 1 not approved] . F1000Research 2025, 13 :987 ( https://doi.org/10.5256/f1000research.169300.r331697 ) The direct URL for this report is: https://f1000research.com/articles/13-987/v1#referee-response-331697 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 06 Oct 2025 Marcus Grant , Environmental Stewardship for Health, Bristol, UK 06 Oct 2025 Author Response Your comment > > This article robustly traces the evolution of the urban health paradigm that highlights key past frameworks like the Health in All Policies (HiAP), the Ottawa Charter, and ... Continue reading Your comment > > This article robustly traces the evolution of the urban health paradigm that highlights key past frameworks like the Health in All Policies (HiAP), the Ottawa Charter, and Healthy Public Policy. It also references systems thinking, equity, and complexity as core theoretical lenses for understanding urban health dynamics and a bold recommendation to move away from older frameworks to newer paradigms and emerging issues in Urban Health. These provide a strong foundation, but there are a few gaps that could be addressed in the remit of this article. Our response: Thank you for your review. Useful summary for us, but even more useful identification of several gaps. > >Strengths: * The focus on the settings-based approach and systemic determinants of health is comprehensive. * Incorporation of complexity science to frame urban health challenges is forward-thinking. * Historical references to the Alma Ata Declaration and WHO initiatives contextualize the paradigm's evolution. Our response: Thank you for noting these strengths. It is always good to see how the ‘message’ is landing. Your comment > > Gaps: * The frameworks largely neglect the integration of digital health transformation in urban health , which is rapidly reshaping urban health systems. The article could incorporate frameworks like digital ecosystems and their potential to address urban health inequities through data analytics, telemedicine, and AI-driven decision-making. * The private health sector's role is also underemphasized who is often a key play in urban health systems in emerging economies with mixed health systems. A pragmatic discussion of mixed health systems and private sector dynamics could strengthen the conceptual framing, especially regarding regulatory frameworks, financing models, and partnerships. Our response: We appreciate you setting out your concerns above and in more detail below, where you will find our responses. Your comment > > 2. Digital Health Transformation The omission of digital health as a transformative tool is a significant gap, given its increasing relevance in urban health: Suggested Additions: * Include a discussion on the role of digital platforms in improving access to urban health services, particularly for underserved populations. * Explore frameworks like the Digital Health Ecosystem Model , emphasizing the interplay between governance, technology, and stakeholders in urban settings. * Highlight innovations such as mobile health (mHealth), eHealth tools, and AI applications in predictive urban health surveillance. Rationale: Digital health can bridge gaps in healthcare access and quality in urban areas, where infrastructure is often unevenly distributed. Including this dimension would make the article more relevant to contemporary challenges and opportunities. Our response: Thank you for this observation and useful suggestions. This paper lies within the WHO F1000 collection ‘Making the Case for Urban Health: Defining Value and Relevance to Contemporary Challenges’. There is forthcoming paper in this collections specifically covering digital transformations and urban health (by Acuto et al.). We will refer to that and some of its content. We have also added a few sentences later on, in Section 6 (Urban health in policy, practice and process), to highlight this emerging issue. However, the focus of the paper is not health service provision, so our discussion of digital advances will be restricted to their application in population-centred primary public health. ‘Digital health can bridge gaps in healthcare access and quality in urban areas, where infrastructure is often unevenly distributed.’ → Excellent point' and we now refer to this as a ‘contemporary challenge and opportunity’. We have now referred in our paper to digital transformations and urban health (by Acuto et al.) with a paragraph in Section 6 (Urban health in policy, practice and process). We improved references to available digital urban health tools and platforms and determinants of health data and added to the concluding section re: contemporary challenges and opportunities. Your comment > > 3. Role of the Private Health Sector The private health sector is critical in urban settings, especially in low- and middle-income countries, where it often fills service delivery gaps: Suggestions for Inclusion: * Discuss how private providers can complement public health efforts through partnerships, performance-based contracting, or shared accountability models. * Examine innovative financing mechanisms (e.g., social impact bonds) and their role in incentivizing private sector participation in urban health initiatives. * Incorporate case studies that illustrate successful integration of private sector solutions in urban health systems (e.g., public-private partnerships in urban clinics or insurance schemes tailored to urban populations). Our response: Thank you for these comments. Especially the note about the situation in low- and middle-income countries. We have added a clearer articulation of the scope of the paper to clarify that we are not covering either private, state or NGO health service or health care sectors. However, we have added content on public and private finance which affects urban health (section 2) and innovative finance for healthier placemaking. Hence the upstream determinants of health (e.g. urban development and related private financial constraints) and reference to the Commerical Determinants of Health (and WHO’s work in this space) has now been included. We have expanded and brought up to date the section on the commercial determinants of health, also including a new sub-section ‘3.5: The commercial determinants of health, with a resume of recent work as it relates to urban health. mentioning work on upstream determinants of health including social impact bond and with urban developers. We have added material in Section 6 (Urban health in policy, practice and process) to highlight these issues. Section 7 Moving forward on urban health, now notes the emerging issue role of private health sector. Your comment > > Cont…3. Role of the Private Health Sector Theoretical Contribution: The article could introduce theories of market dynamics and public-private synergies , focusing on balancing equity, efficiency, and accessibility in urban health. Our response: Thank you for the comment. We have been careful in the article not to address health care and the health service sector. However, we may need to better articulate that stance. We have added a clearer articulation of the scope of the paper in the introduction to clarify that we are not covering either private, state or NGO health service or health care sectors. In line with comments from other reviewers, we have strengthened and added additional material about the place of the Commerical Determinants of Health and the urban health paradigm. There is certainly a role to talk to market dynamics and health especially with respect to urban environments. Keeping within the scope of the paper this has focussed on the wider determinants of health and non health care provision – an important factor, but outside our scope. Your comment > > 4. Suggestions would be useful in the scope of this forward thinking article if * The authors should explicitly recognize the transformative potential of digital health and private sector partnerships as key drivers of the next phase of the urban health paradigm. * A section dedicated to exploring how these two elements can operationalize the theoretical concepts of systems thinking and equity would enrich the discussion. Our response: Yes, we certainly need to develop the ‘forward think’ elements of the paper, e.g.future trends/development of the concept of urban health. Other reviewers have made similar comments. We have added a new section on the potential of digital health and clarified the relationship between this paper and health care services, public and private. We have noted the transformative potential of digital health and private sector partnerships within our remit which does not include health care delivery, where detail is outside our scope. We have drawn on proceeding sections to new write some new text looking at these issues as potential drivers of future change. Your comment > > This article robustly traces the evolution of the urban health paradigm that highlights key past frameworks like the Health in All Policies (HiAP), the Ottawa Charter, and Healthy Public Policy. It also references systems thinking, equity, and complexity as core theoretical lenses for understanding urban health dynamics and a bold recommendation to move away from older frameworks to newer paradigms and emerging issues in Urban Health. These provide a strong foundation, but there are a few gaps that could be addressed in the remit of this article. Our response: Thank you for your review. Useful summary for us, but even more useful identification of several gaps. > >Strengths: * The focus on the settings-based approach and systemic determinants of health is comprehensive. * Incorporation of complexity science to frame urban health challenges is forward-thinking. * Historical references to the Alma Ata Declaration and WHO initiatives contextualize the paradigm's evolution. Our response: Thank you for noting these strengths. It is always good to see how the ‘message’ is landing. Your comment > > Gaps: * The frameworks largely neglect the integration of digital health transformation in urban health , which is rapidly reshaping urban health systems. The article could incorporate frameworks like digital ecosystems and their potential to address urban health inequities through data analytics, telemedicine, and AI-driven decision-making. * The private health sector's role is also underemphasized who is often a key play in urban health systems in emerging economies with mixed health systems. A pragmatic discussion of mixed health systems and private sector dynamics could strengthen the conceptual framing, especially regarding regulatory frameworks, financing models, and partnerships. Our response: We appreciate you setting out your concerns above and in more detail below, where you will find our responses. Your comment > > 2. Digital Health Transformation The omission of digital health as a transformative tool is a significant gap, given its increasing relevance in urban health: Suggested Additions: * Include a discussion on the role of digital platforms in improving access to urban health services, particularly for underserved populations. * Explore frameworks like the Digital Health Ecosystem Model , emphasizing the interplay between governance, technology, and stakeholders in urban settings. * Highlight innovations such as mobile health (mHealth), eHealth tools, and AI applications in predictive urban health surveillance. Rationale: Digital health can bridge gaps in healthcare access and quality in urban areas, where infrastructure is often unevenly distributed. Including this dimension would make the article more relevant to contemporary challenges and opportunities. Our response: Thank you for this observation and useful suggestions. This paper lies within the WHO F1000 collection ‘Making the Case for Urban Health: Defining Value and Relevance to Contemporary Challenges’. There is forthcoming paper in this collections specifically covering digital transformations and urban health (by Acuto et al.). We will refer to that and some of its content. We have also added a few sentences later on, in Section 6 (Urban health in policy, practice and process), to highlight this emerging issue. However, the focus of the paper is not health service provision, so our discussion of digital advances will be restricted to their application in population-centred primary public health. ‘Digital health can bridge gaps in healthcare access and quality in urban areas, where infrastructure is often unevenly distributed.’ → Excellent point' and we now refer to this as a ‘contemporary challenge and opportunity’. We have now referred in our paper to digital transformations and urban health (by Acuto et al.) with a paragraph in Section 6 (Urban health in policy, practice and process). We improved references to available digital urban health tools and platforms and determinants of health data and added to the concluding section re: contemporary challenges and opportunities. Your comment > > 3. Role of the Private Health Sector The private health sector is critical in urban settings, especially in low- and middle-income countries, where it often fills service delivery gaps: Suggestions for Inclusion: * Discuss how private providers can complement public health efforts through partnerships, performance-based contracting, or shared accountability models. * Examine innovative financing mechanisms (e.g., social impact bonds) and their role in incentivizing private sector participation in urban health initiatives. * Incorporate case studies that illustrate successful integration of private sector solutions in urban health systems (e.g., public-private partnerships in urban clinics or insurance schemes tailored to urban populations). Our response: Thank you for these comments. Especially the note about the situation in low- and middle-income countries. We have added a clearer articulation of the scope of the paper to clarify that we are not covering either private, state or NGO health service or health care sectors. However, we have added content on public and private finance which affects urban health (section 2) and innovative finance for healthier placemaking. Hence the upstream determinants of health (e.g. urban development and related private financial constraints) and reference to the Commerical Determinants of Health (and WHO’s work in this space) has now been included. We have expanded and brought up to date the section on the commercial determinants of health, also including a new sub-section ‘3.5: The commercial determinants of health, with a resume of recent work as it relates to urban health. mentioning work on upstream determinants of health including social impact bond and with urban developers. We have added material in Section 6 (Urban health in policy, practice and process) to highlight these issues. Section 7 Moving forward on urban health, now notes the emerging issue role of private health sector. Your comment > > Cont…3. Role of the Private Health Sector Theoretical Contribution: The article could introduce theories of market dynamics and public-private synergies , focusing on balancing equity, efficiency, and accessibility in urban health. Our response: Thank you for the comment. We have been careful in the article not to address health care and the health service sector. However, we may need to better articulate that stance. We have added a clearer articulation of the scope of the paper in the introduction to clarify that we are not covering either private, state or NGO health service or health care sectors. In line with comments from other reviewers, we have strengthened and added additional material about the place of the Commerical Determinants of Health and the urban health paradigm. There is certainly a role to talk to market dynamics and health especially with respect to urban environments. Keeping within the scope of the paper this has focussed on the wider determinants of health and non health care provision – an important factor, but outside our scope. Your comment > > 4. Suggestions would be useful in the scope of this forward thinking article if * The authors should explicitly recognize the transformative potential of digital health and private sector partnerships as key drivers of the next phase of the urban health paradigm. * A section dedicated to exploring how these two elements can operationalize the theoretical concepts of systems thinking and equity would enrich the discussion. Our response: Yes, we certainly need to develop the ‘forward think’ elements of the paper, e.g.future trends/development of the concept of urban health. Other reviewers have made similar comments. We have added a new section on the potential of digital health and clarified the relationship between this paper and health care services, public and private. We have noted the transformative potential of digital health and private sector partnerships within our remit which does not include health care delivery, where detail is outside our scope. We have drawn on proceeding sections to new write some new text looking at these issues as potential drivers of future change. Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 06 Oct 2025 Marcus Grant , Environmental Stewardship for Health, Bristol, UK 06 Oct 2025 Author Response Your comment > > This article robustly traces the evolution of the urban health paradigm that highlights key past frameworks like the Health in All Policies (HiAP), the Ottawa Charter, and ... Continue reading Your comment > > This article robustly traces the evolution of the urban health paradigm that highlights key past frameworks like the Health in All Policies (HiAP), the Ottawa Charter, and Healthy Public Policy. It also references systems thinking, equity, and complexity as core theoretical lenses for understanding urban health dynamics and a bold recommendation to move away from older frameworks to newer paradigms and emerging issues in Urban Health. These provide a strong foundation, but there are a few gaps that could be addressed in the remit of this article. Our response: Thank you for your review. Useful summary for us, but even more useful identification of several gaps. > >Strengths: * The focus on the settings-based approach and systemic determinants of health is comprehensive. * Incorporation of complexity science to frame urban health challenges is forward-thinking. * Historical references to the Alma Ata Declaration and WHO initiatives contextualize the paradigm's evolution. Our response: Thank you for noting these strengths. It is always good to see how the ‘message’ is landing. Your comment > > Gaps: * The frameworks largely neglect the integration of digital health transformation in urban health , which is rapidly reshaping urban health systems. The article could incorporate frameworks like digital ecosystems and their potential to address urban health inequities through data analytics, telemedicine, and AI-driven decision-making. * The private health sector's role is also underemphasized who is often a key play in urban health systems in emerging economies with mixed health systems. A pragmatic discussion of mixed health systems and private sector dynamics could strengthen the conceptual framing, especially regarding regulatory frameworks, financing models, and partnerships. Our response: We appreciate you setting out your concerns above and in more detail below, where you will find our responses. Your comment > > 2. Digital Health Transformation The omission of digital health as a transformative tool is a significant gap, given its increasing relevance in urban health: Suggested Additions: * Include a discussion on the role of digital platforms in improving access to urban health services, particularly for underserved populations. * Explore frameworks like the Digital Health Ecosystem Model , emphasizing the interplay between governance, technology, and stakeholders in urban settings. * Highlight innovations such as mobile health (mHealth), eHealth tools, and AI applications in predictive urban health surveillance. Rationale: Digital health can bridge gaps in healthcare access and quality in urban areas, where infrastructure is often unevenly distributed. Including this dimension would make the article more relevant to contemporary challenges and opportunities. Our response: Thank you for this observation and useful suggestions. This paper lies within the WHO F1000 collection ‘Making the Case for Urban Health: Defining Value and Relevance to Contemporary Challenges’. There is forthcoming paper in this collections specifically covering digital transformations and urban health (by Acuto et al.). We will refer to that and some of its content. We have also added a few sentences later on, in Section 6 (Urban health in policy, practice and process), to highlight this emerging issue. However, the focus of the paper is not health service provision, so our discussion of digital advances will be restricted to their application in population-centred primary public health. ‘Digital health can bridge gaps in healthcare access and quality in urban areas, where infrastructure is often unevenly distributed.’ → Excellent point' and we now refer to this as a ‘contemporary challenge and opportunity’. We have now referred in our paper to digital transformations and urban health (by Acuto et al.) with a paragraph in Section 6 (Urban health in policy, practice and process). We improved references to available digital urban health tools and platforms and determinants of health data and added to the concluding section re: contemporary challenges and opportunities. Your comment > > 3. Role of the Private Health Sector The private health sector is critical in urban settings, especially in low- and middle-income countries, where it often fills service delivery gaps: Suggestions for Inclusion: * Discuss how private providers can complement public health efforts through partnerships, performance-based contracting, or shared accountability models. * Examine innovative financing mechanisms (e.g., social impact bonds) and their role in incentivizing private sector participation in urban health initiatives. * Incorporate case studies that illustrate successful integration of private sector solutions in urban health systems (e.g., public-private partnerships in urban clinics or insurance schemes tailored to urban populations). Our response: Thank you for these comments. Especially the note about the situation in low- and middle-income countries. We have added a clearer articulation of the scope of the paper to clarify that we are not covering either private, state or NGO health service or health care sectors. However, we have added content on public and private finance which affects urban health (section 2) and innovative finance for healthier placemaking. Hence the upstream determinants of health (e.g. urban development and related private financial constraints) and reference to the Commerical Determinants of Health (and WHO’s work in this space) has now been included. We have expanded and brought up to date the section on the commercial determinants of health, also including a new sub-section ‘3.5: The commercial determinants of health, with a resume of recent work as it relates to urban health. mentioning work on upstream determinants of health including social impact bond and with urban developers. We have added material in Section 6 (Urban health in policy, practice and process) to highlight these issues. Section 7 Moving forward on urban health, now notes the emerging issue role of private health sector. Your comment > > Cont…3. Role of the Private Health Sector Theoretical Contribution: The article could introduce theories of market dynamics and public-private synergies , focusing on balancing equity, efficiency, and accessibility in urban health. Our response: Thank you for the comment. We have been careful in the article not to address health care and the health service sector. However, we may need to better articulate that stance. We have added a clearer articulation of the scope of the paper in the introduction to clarify that we are not covering either private, state or NGO health service or health care sectors. In line with comments from other reviewers, we have strengthened and added additional material about the place of the Commerical Determinants of Health and the urban health paradigm. There is certainly a role to talk to market dynamics and health especially with respect to urban environments. Keeping within the scope of the paper this has focussed on the wider determinants of health and non health care provision – an important factor, but outside our scope. Your comment > > 4. Suggestions would be useful in the scope of this forward thinking article if * The authors should explicitly recognize the transformative potential of digital health and private sector partnerships as key drivers of the next phase of the urban health paradigm. * A section dedicated to exploring how these two elements can operationalize the theoretical concepts of systems thinking and equity would enrich the discussion. Our response: Yes, we certainly need to develop the ‘forward think’ elements of the paper, e.g.future trends/development of the concept of urban health. Other reviewers have made similar comments. We have added a new section on the potential of digital health and clarified the relationship between this paper and health care services, public and private. We have noted the transformative potential of digital health and private sector partnerships within our remit which does not include health care delivery, where detail is outside our scope. We have drawn on proceeding sections to new write some new text looking at these issues as potential drivers of future change. Your comment > > This article robustly traces the evolution of the urban health paradigm that highlights key past frameworks like the Health in All Policies (HiAP), the Ottawa Charter, and Healthy Public Policy. It also references systems thinking, equity, and complexity as core theoretical lenses for understanding urban health dynamics and a bold recommendation to move away from older frameworks to newer paradigms and emerging issues in Urban Health. These provide a strong foundation, but there are a few gaps that could be addressed in the remit of this article. Our response: Thank you for your review. Useful summary for us, but even more useful identification of several gaps. > >Strengths: * The focus on the settings-based approach and systemic determinants of health is comprehensive. * Incorporation of complexity science to frame urban health challenges is forward-thinking. * Historical references to the Alma Ata Declaration and WHO initiatives contextualize the paradigm's evolution. Our response: Thank you for noting these strengths. It is always good to see how the ‘message’ is landing. Your comment > > Gaps: * The frameworks largely neglect the integration of digital health transformation in urban health , which is rapidly reshaping urban health systems. The article could incorporate frameworks like digital ecosystems and their potential to address urban health inequities through data analytics, telemedicine, and AI-driven decision-making. * The private health sector's role is also underemphasized who is often a key play in urban health systems in emerging economies with mixed health systems. A pragmatic discussion of mixed health systems and private sector dynamics could strengthen the conceptual framing, especially regarding regulatory frameworks, financing models, and partnerships. Our response: We appreciate you setting out your concerns above and in more detail below, where you will find our responses. Your comment > > 2. Digital Health Transformation The omission of digital health as a transformative tool is a significant gap, given its increasing relevance in urban health: Suggested Additions: * Include a discussion on the role of digital platforms in improving access to urban health services, particularly for underserved populations. * Explore frameworks like the Digital Health Ecosystem Model , emphasizing the interplay between governance, technology, and stakeholders in urban settings. * Highlight innovations such as mobile health (mHealth), eHealth tools, and AI applications in predictive urban health surveillance. Rationale: Digital health can bridge gaps in healthcare access and quality in urban areas, where infrastructure is often unevenly distributed. Including this dimension would make the article more relevant to contemporary challenges and opportunities. Our response: Thank you for this observation and useful suggestions. This paper lies within the WHO F1000 collection ‘Making the Case for Urban Health: Defining Value and Relevance to Contemporary Challenges’. There is forthcoming paper in this collections specifically covering digital transformations and urban health (by Acuto et al.). We will refer to that and some of its content. We have also added a few sentences later on, in Section 6 (Urban health in policy, practice and process), to highlight this emerging issue. However, the focus of the paper is not health service provision, so our discussion of digital advances will be restricted to their application in population-centred primary public health. ‘Digital health can bridge gaps in healthcare access and quality in urban areas, where infrastructure is often unevenly distributed.’ → Excellent point' and we now refer to this as a ‘contemporary challenge and opportunity’. We have now referred in our paper to digital transformations and urban health (by Acuto et al.) with a paragraph in Section 6 (Urban health in policy, practice and process). We improved references to available digital urban health tools and platforms and determinants of health data and added to the concluding section re: contemporary challenges and opportunities. Your comment > > 3. Role of the Private Health Sector The private health sector is critical in urban settings, especially in low- and middle-income countries, where it often fills service delivery gaps: Suggestions for Inclusion: * Discuss how private providers can complement public health efforts through partnerships, performance-based contracting, or shared accountability models. * Examine innovative financing mechanisms (e.g., social impact bonds) and their role in incentivizing private sector participation in urban health initiatives. * Incorporate case studies that illustrate successful integration of private sector solutions in urban health systems (e.g., public-private partnerships in urban clinics or insurance schemes tailored to urban populations). Our response: Thank you for these comments. Especially the note about the situation in low- and middle-income countries. We have added a clearer articulation of the scope of the paper to clarify that we are not covering either private, state or NGO health service or health care sectors. However, we have added content on public and private finance which affects urban health (section 2) and innovative finance for healthier placemaking. Hence the upstream determinants of health (e.g. urban development and related private financial constraints) and reference to the Commerical Determinants of Health (and WHO’s work in this space) has now been included. We have expanded and brought up to date the section on the commercial determinants of health, also including a new sub-section ‘3.5: The commercial determinants of health, with a resume of recent work as it relates to urban health. mentioning work on upstream determinants of health including social impact bond and with urban developers. We have added material in Section 6 (Urban health in policy, practice and process) to highlight these issues. Section 7 Moving forward on urban health, now notes the emerging issue role of private health sector. Your comment > > Cont…3. Role of the Private Health Sector Theoretical Contribution: The article could introduce theories of market dynamics and public-private synergies , focusing on balancing equity, efficiency, and accessibility in urban health. Our response: Thank you for the comment. We have been careful in the article not to address health care and the health service sector. However, we may need to better articulate that stance. We have added a clearer articulation of the scope of the paper in the introduction to clarify that we are not covering either private, state or NGO health service or health care sectors. In line with comments from other reviewers, we have strengthened and added additional material about the place of the Commerical Determinants of Health and the urban health paradigm. There is certainly a role to talk to market dynamics and health especially with respect to urban environments. Keeping within the scope of the paper this has focussed on the wider determinants of health and non health care provision – an important factor, but outside our scope. Your comment > > 4. Suggestions would be useful in the scope of this forward thinking article if * The authors should explicitly recognize the transformative potential of digital health and private sector partnerships as key drivers of the next phase of the urban health paradigm. * A section dedicated to exploring how these two elements can operationalize the theoretical concepts of systems thinking and equity would enrich the discussion. Our response: Yes, we certainly need to develop the ‘forward think’ elements of the paper, e.g.future trends/development of the concept of urban health. Other reviewers have made similar comments. We have added a new section on the potential of digital health and clarified the relationship between this paper and health care services, public and private. We have noted the transformative potential of digital health and private sector partnerships within our remit which does not include health care delivery, where detail is outside our scope. We have drawn on proceeding sections to new write some new text looking at these issues as potential drivers of future change. Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Views 0 Cite How to cite this report: Afable A. Reviewer Report For: The emergence of a modern paradigm for urban health [version 2; peer review: 2 approved, 2 approved with reservations, 1 not approved] . F1000Research 2025, 13 :987 ( https://doi.org/10.5256/f1000research.169300.r331691 ) The direct URL for this report is: https://f1000research.com/articles/13-987/v1#referee-response-331691 NOTE: it is important to ensure the information in square brackets after the title is included in this citation. Close Copy Citation Details Reviewer Report 22 Nov 2024 Aimee Afable , State University of New York (SUNY) Downstate Health Sciences University, brook, New York, USA Not Approved VIEWS 0 https://doi.org/10.5256/f1000research.169300.r331691 While the paper does a fairly comprehensive treatment outlining the history of the urban health paradigm, it relies heavily on authoritative global health agency practice, positions, and frameworks. My review concerns two areas: ... Continue reading READ ALL While the paper does a fairly comprehensive treatment outlining the history of the urban health paradigm, it relies heavily on authoritative global health agency practice, positions, and frameworks. My review concerns two areas: 1) Authors conclude the following: While some of the insights from 75 years of evolving understanding of urban health and wellbeing have been incorporated into the Sustainable Development Goals, it is far from clear that the global agenda has taken sufficient account of lessons learned. However, this statement lacks a thorough discussion of what lessons were learned in the past 75 years -- other than the evolving frameworks. What is the evidence base? This may be too broad but perhaps illustrative examples would be useful. 2) Related to above, what do authors opine are the major global pressures of our time? How do these new global pressures inform this new urban health paradigm? The authors do not seem to clearly articulate what the emerging health paradigm is. There is limited discussion and treatment of both classic and contemporary theoretical frameworks that exist in the social sciences that may advance this thinking. Section 5 highlights Vlahov and Galea. However, in the spirit of transdisciplinary approaches to solving the major urban health challenges of our time -- shift from communicable to NCDs, emergence of novel viral pandemics, crisis management/adaption in the face of climate change, rising inequality/health inequity in established/older cities in more affluent countries, gentrification -- there is no consideration of some of the critical frameworks from other disciplines that can help advance our thinking on how to inform a new health paradigm. There is much insight that can be learned from the fields of social epidemiology (in public health with emphasis on the social determinants of health) and urban planning/development theory (Lewis, Mumford). Is the topic of the review discussed comprehensively in the context of the current literature? Partly Are all factual statements correct and adequately supported by citations? Partly Is the review written in accessible language? Yes Are the conclusions drawn appropriate in the context of the current research literature? Partly Competing Interests: No competing interests were disclosed. Reviewer Expertise: Health equity research, maternal health, immigrant and urban health I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. Close READ LESS CITE CITE HOW TO CITE THIS REPORT Afable A. Reviewer Report For: The emergence of a modern paradigm for urban health [version 2; peer review: 2 approved, 2 approved with reservations, 1 not approved] . F1000Research 2025, 13 :987 ( https://doi.org/10.5256/f1000research.169300.r331691 ) The direct URL for this report is: https://f1000research.com/articles/13-987/v1#referee-response-331691 NOTE: it is important to ensure the information in square brackets after the title is included in all citations of this article. COPY CITATION DETAILS Report a concern Author Response 06 Oct 2025 Marcus Grant , Environmental Stewardship for Health, Bristol, UK 06 Oct 2025 Author Response Your comment >>: While the paper does a fairly comprehensive treatment outlining the history of the urban health paradigm, it relies heavily on authoritative global health agency practice, positions, and ... Continue reading Your comment >>: While the paper does a fairly comprehensive treatment outlining the history of the urban health paradigm, it relies heavily on authoritative global health agency practice, positions, and frameworks. My review concerns two areas (1 & 2): Our response: First, thank you for your comprehensive and useful review. The paper takes that stance deliberately; we attempted to track that history and not what may be a more inclusive or open use of the concept and term urban health. What we take from your comment is that this framing needs to be sign-posted better in the introduction as context. Your comment >>: 1) Authors conclude the following: ‘While some of the insights from 75 years of evolving understanding of urban health and wellbeing have been incorporated into the Sustainable Development Goals, it is far from clear that the global agenda has taken sufficient account of lessons learned.’ However, this statement lacks a thorough discussion of what lessons were learned in the past 75 years -- other than the evolving frameworks. What is the evidence base? This may be too broad but perhaps illustrative examples would be useful. Our response: Thank you for pointing this out, we agree that the statement is too sweeping which leaves it unsubstantiated in relation the preceding sections. Replacement text has now been used to better clarify the focus: ‘Many of the insights from 75 years of an evolving understanding of urban health and wellbeing have been incorporated into the Sustainable Development Goals. However, observing the all-to-common disconnects between health policy and urban policy at the local level, it is clear that progress made at the global level has yet to have much ‘on-the-ground’ impact.’ With respect to your comment on the SDGs, there is a separate paper coming, within this WHO collection ‘Making the Case for Urban Health: Defining Value and Relevance to Contemporary Challenges’ (by Susan Parnell) that will deal with the Sustainable Development framework. We will be including a reference to that paper earlier in our paper and supporting text had been added. Your comment >>: 2) Related to above, what do authors opine are the major global pressures of our time? Our response: With respect to material on global pressures. There is already a fair amount, we will check for gaps that are significant to our themes, and also gather together what we cover in a paragraph in the introduction. We have included extra depth covering the Commercial Determinants of Health, Health equity and COVID-19 legacy and material on contemporary issue of democracy and the political economy. Your comment >>: How do these new global pressures inform this new urban health paradigm? Our response: Yes. Thanks for pointing out this omission, text now added to the concluding section. Your comment >>: The authors do not seem to clearly articulate what the emerging health paradigm is. Our response: Yes. Thanks for this observation, that section was too weak. We have revised the concluding section. Your comment >>: There is limited discussion and treatment of both classic and contemporary theoretical frameworks that exist in the social sciences that may advance this thinking. Our response: Thanks for this useful comment. The paper obviously Wil have its limitation, I am sure a book can be written her. We have not wanted to go into any depth on theoretical frameworks to keep with a remit of begin focussed on what may be more directly useful for policy and a policy audience, rather than an academic audience. We have though, in our broad sweep, sought to cover a number of social science topics such as human rights, equity, governance, global conflicts, participation and agency. Many of these issues have all been developed further in the current revision. Your comment >>: Section 5 highlights Vlahov and Galea. However, in the spirit of transdisciplinary approaches to solving the major urban health challenges of our time -- shift from communicable to NCDs, emergence of novel viral pandemics, crisis management/adaption in the face of climate change, rising inequality/health inequity in established/older cities in more affluent countries, gentrification -- there is no consideration of some of the critical frameworks from other disciplines that can help advance our thinking on how to inform a new health paradigm. Our response: Thank you for this comment. We have re-examined relevant sections. Material has been added to reflect some of the missing elements you have highlighted. However, within the scope of the current paper, we are unable to go too far into discussing the several critical frameworks that would be relevant here. In response to this comment, and others, we have added material on sociology and social epidemiology. We have also added a useful conclusion from Krefis, et al, (2018) that there is a lack of interdisciplinary approaches that highlight the complexity of urban structures and dynamics and their possible influence on urban health and well-being. [Krefis, A. C., Augustin, M., Schlünzen, K. H., Oßenbrügge, J., & Augustin, J. (2018). How Does the Urban Environment Affect Health and Well-Being? A Systematic Review. Urban Science , 2 (1), 21. https://doi.org/10.3390/urbansci2010021]. Your comment >>: There is much insight that can be learned from the fields of social epidemiology (in public health with emphasis on the social determinants of health) and urban planning/development theory (Lewis, Mumford). Our response: We certainly agree. Much has been written about the historic link between social epidemiology, the emergence of town planning and public health delivered through town planning acts. Many texts, field leaders and analyses could be cited. However, in our attempt to cover more recent developments, we don’t want to delve into this area. But to make sure there is an outline for those who may not be aware of this history we have added he following ‘In terms of urban spatial planning, much has been written about the close historic relationships - at the advert of formal city planning - between sociologist traditions looking for betterment of the working classes, public health seeking to minimize health risk, and the aims and techniques of those involved with spatial policy, layout and design. The close interplay between these three elements weakened following the post-war period as their separate disciplines evolved.’ We have also added elsewhere a note about sociology with a cite of this paper: Kelly, M. P. and Green, J. (2019) ‘What can sociology offer urban public health?’, Critical Public Health, 29(5), pp. 517–521. doi: 10.1080/09581596.2019.1654193. Your comment >>: While the paper does a fairly comprehensive treatment outlining the history of the urban health paradigm, it relies heavily on authoritative global health agency practice, positions, and frameworks. My review concerns two areas (1 & 2): Our response: First, thank you for your comprehensive and useful review. The paper takes that stance deliberately; we attempted to track that history and not what may be a more inclusive or open use of the concept and term urban health. What we take from your comment is that this framing needs to be sign-posted better in the introduction as context. Your comment >>: 1) Authors conclude the following: ‘While some of the insights from 75 years of evolving understanding of urban health and wellbeing have been incorporated into the Sustainable Development Goals, it is far from clear that the global agenda has taken sufficient account of lessons learned.’ However, this statement lacks a thorough discussion of what lessons were learned in the past 75 years -- other than the evolving frameworks. What is the evidence base? This may be too broad but perhaps illustrative examples would be useful. Our response: Thank you for pointing this out, we agree that the statement is too sweeping which leaves it unsubstantiated in relation the preceding sections. Replacement text has now been used to better clarify the focus: ‘Many of the insights from 75 years of an evolving understanding of urban health and wellbeing have been incorporated into the Sustainable Development Goals. However, observing the all-to-common disconnects between health policy and urban policy at the local level, it is clear that progress made at the global level has yet to have much ‘on-the-ground’ impact.’ With respect to your comment on the SDGs, there is a separate paper coming, within this WHO collection ‘Making the Case for Urban Health: Defining Value and Relevance to Contemporary Challenges’ (by Susan Parnell) that will deal with the Sustainable Development framework. We will be including a reference to that paper earlier in our paper and supporting text had been added. Your comment >>: 2) Related to above, what do authors opine are the major global pressures of our time? Our response: With respect to material on global pressures. There is already a fair amount, we will check for gaps that are significant to our themes, and also gather together what we cover in a paragraph in the introduction. We have included extra depth covering the Commercial Determinants of Health, Health equity and COVID-19 legacy and material on contemporary issue of democracy and the political economy. Your comment >>: How do these new global pressures inform this new urban health paradigm? Our response: Yes. Thanks for pointing out this omission, text now added to the concluding section. Your comment >>: The authors do not seem to clearly articulate what the emerging health paradigm is. Our response: Yes. Thanks for this observation, that section was too weak. We have revised the concluding section. Your comment >>: There is limited discussion and treatment of both classic and contemporary theoretical frameworks that exist in the social sciences that may advance this thinking. Our response: Thanks for this useful comment. The paper obviously Wil have its limitation, I am sure a book can be written her. We have not wanted to go into any depth on theoretical frameworks to keep with a remit of begin focussed on what may be more directly useful for policy and a policy audience, rather than an academic audience. We have though, in our broad sweep, sought to cover a number of social science topics such as human rights, equity, governance, global conflicts, participation and agency. Many of these issues have all been developed further in the current revision. Your comment >>: Section 5 highlights Vlahov and Galea. However, in the spirit of transdisciplinary approaches to solving the major urban health challenges of our time -- shift from communicable to NCDs, emergence of novel viral pandemics, crisis management/adaption in the face of climate change, rising inequality/health inequity in established/older cities in more affluent countries, gentrification -- there is no consideration of some of the critical frameworks from other disciplines that can help advance our thinking on how to inform a new health paradigm. Our response: Thank you for this comment. We have re-examined relevant sections. Material has been added to reflect some of the missing elements you have highlighted. However, within the scope of the current paper, we are unable to go too far into discussing the several critical frameworks that would be relevant here. In response to this comment, and others, we have added material on sociology and social epidemiology. We have also added a useful conclusion from Krefis, et al, (2018) that there is a lack of interdisciplinary approaches that highlight the complexity of urban structures and dynamics and their possible influence on urban health and well-being. [Krefis, A. C., Augustin, M., Schlünzen, K. H., Oßenbrügge, J., & Augustin, J. (2018). How Does the Urban Environment Affect Health and Well-Being? A Systematic Review. Urban Science , 2 (1), 21. https://doi.org/10.3390/urbansci2010021]. Your comment >>: There is much insight that can be learned from the fields of social epidemiology (in public health with emphasis on the social determinants of health) and urban planning/development theory (Lewis, Mumford). Our response: We certainly agree. Much has been written about the historic link between social epidemiology, the emergence of town planning and public health delivered through town planning acts. Many texts, field leaders and analyses could be cited. However, in our attempt to cover more recent developments, we don’t want to delve into this area. But to make sure there is an outline for those who may not be aware of this history we have added he following ‘In terms of urban spatial planning, much has been written about the close historic relationships - at the advert of formal city planning - between sociologist traditions looking for betterment of the working classes, public health seeking to minimize health risk, and the aims and techniques of those involved with spatial policy, layout and design. The close interplay between these three elements weakened following the post-war period as their separate disciplines evolved.’ We have also added elsewhere a note about sociology with a cite of this paper: Kelly, M. P. and Green, J. (2019) ‘What can sociology offer urban public health?’, Critical Public Health, 29(5), pp. 517–521. doi: 10.1080/09581596.2019.1654193. Competing Interests: No competing interests were disclosed. Close Report a concern Respond or Comment COMMENTS ON THIS REPORT Author Response 06 Oct 2025 Marcus Grant , Environmental Stewardship for Health, Bristol, UK 06 Oct 2025 Author Response Your comment >>: While the paper does a fairly comprehensive treatment outlining the history of the urban health paradigm, it relies heavily on authoritative global health agency practice, positions, and ... Continue reading Your comment >>: While the paper does a fairly comprehensive treatment outlining the history of the urban health paradigm, it relies heavily on authoritative global health agency practice, positions, and frameworks. My review concerns two areas (1 & 2): Our response: First, thank you for your comprehensive and useful review. The paper takes that stance deliberately; we attempted to track that history and not what may be a more inclusive or open use of the concept and term urban health. What we take from your comment is that this framing needs to be sign-posted better in the introduction as context. Your comment >>: 1) Authors conclude the following: ‘While some of the insights from 75 years of evolving understanding of urban health and wellbeing have been incorporated into the Sustainable Development Goals, it is far from clear that the global agenda has taken sufficient account of lessons learned.’ However, this statement lacks a thorough discussion of what lessons were learned in the past 75 years -- other than the evolving frameworks. What is the evidence base? This may be too broad but perhaps illustrative examples would be useful. Our response: Thank you for pointing this out, we agree that the statement is too sweeping which leaves it unsubstantiated in relation the preceding sections. Replacement text has now been used to better clarify the focus: ‘Many of the insights from 75 years of an evolving understanding of urban health and wellbeing have been incorporated into the Sustainable Development Goals. However, observing the all-to-common disconnects between health policy and urban policy at the local level, it is clear that progress made at the global level has yet to have much ‘on-the-ground’ impact.’ With respect to your comment on the SDGs, there is a separate paper coming, within this WHO collection ‘Making the Case for Urban Health: Defining Value and Relevance to Contemporary Challenges’ (by Susan Parnell) that will deal with the Sustainable Development framework. We will be including a reference to that paper earlier in our paper and supporting text had been added. Your comment >>: 2) Related to above, what do authors opine are the major global pressures of our time? Our response: With respect to material on global pressures. There is already a fair amount, we will check for gaps that are significant to our themes, and also gather together what we cover in a paragraph in the introduction. We have included extra depth covering the Commercial Determinants of Health, Health equity and COVID-19 legacy and material on contemporary issue of democracy and the political economy. Your comment >>: How do these new global pressures inform this new urban health paradigm? Our response: Yes. Thanks for pointing out this omission, text now added to the concluding section. Your comment >>: The authors do not seem to clearly articulate what the emerging health paradigm is. Our response: Yes. Thanks for this observation, that section was too weak. We have revised the concluding section. Your comment >>: There is limited discussion and treatment of both classic and contemporary theoretical frameworks that exist in the social sciences that may advance this thinking. Our response: Thanks for this useful comment. The paper obviously Wil have its limitation, I am sure a book can be written her. We have not wanted to go into any depth on theoretical frameworks to keep with a remit of begin focussed on what may be more directly useful for policy and a policy audience, rather than an academic audience. We have though, in our broad sweep, sought to cover a number of social science topics such as human rights, equity, governance, global conflicts, participation and agency. Many of these issues have all been developed further in the current revision. Your comment >>: Section 5 highlights Vlahov and Galea. However, in the spirit of transdisciplinary approaches to solving the major urban health challenges of our time -- shift from communicable to NCDs, emergence of novel viral pandemics, crisis management/adaption in the face of climate change, rising inequality/health inequity in established/older cities in more affluent countries, gentrification -- there is no consideration of some of the critical frameworks from other disciplines that can help advance our thinking on how to inform a new health paradigm. Our response: Thank you for this comment. We have re-examined relevant sections. Material has been added to reflect some of the missing elements you have highlighted. However, within the scope of the current paper, we are unable to go too far into discussing the several critical frameworks that would be relevant here. In response to this comment, and others, we have added material on sociology and social epidemiology. We have also added a useful conclusion from Krefis, et al, (2018) that there is a lack of interdisciplinary approaches that highlight the complexity of urban structures and dynamics and their possible influence on urban health and well-being. [Krefis, A. C., Augustin, M., Schlünzen, K. H., Oßenbrügge, J., & Augustin, J. (2018). How Does the Urban Environment Affect Health and Well-Being? A Systematic Review. Urban Science , 2 (1), 21. https://doi.org/10.3390/urbansci2010021]. Your comment >>: There is much insight that can be learned from the fields of social epidemiology (in public health with emphasis on the social determinants of health) and urban planning/development theory (Lewis, Mumford). Our response: We certainly agree. Much has been written about the historic link between social epidemiology, the emergence of town planning and public health delivered through town planning acts. Many texts, field leaders and analyses could be cited. However, in our attempt to cover more recent developments, we don’t want to delve into this area. But to make sure there is an outline for those who may not be aware of this history we have added he following ‘In terms of urban spatial planning, much has been written about the close historic relationships - at the advert of formal city planning - between sociologist traditions looking for betterment of the working classes, public health seeking to minimize health risk, and the aims and techniques of those involved with spatial policy, layout and design. The close interplay between these three elements weakened following the post-war period as their separate disciplines evolved.’ We have also added elsewhere a note about sociology with a cite of this paper: Kelly, M. P. and Green, J. (2019) ‘What can sociology offer urban public health?’, Critical Public Health, 29(5), pp. 517–521. doi: 10.1080/09581596.2019.1654193. Your comment >>: While the paper does a fairly comprehensive treatment outlining the history of the urban health paradigm, it relies heavily on authoritative global health agency practice, positions, and frameworks. My review concerns two areas (1 & 2): Our response: First, thank you for your comprehensive and useful review. The paper takes that stance deliberately; we attempted to track that history and not what may be a more inclusive or open use of the concept and term urban health. What we take from your comment is that this framing needs to be sign-posted better in the introduction as context. Your comment >>: 1) Authors conclude the following: ‘While some of the insights from 75 years of evolving understanding of urban health and wellbeing have been incorporated into the Sustainable Development Goals, it is far from clear that the global agenda has taken sufficient account of lessons learned.’ However, this statement lacks a thorough discussion of what lessons were learned in the past 75 years -- other than the evolving frameworks. What is the evidence base? This may be too broad but perhaps illustrative examples would be useful. Our response: Thank you for pointing this out, we agree that the statement is too sweeping which leaves it unsubstantiated in relation the preceding sections. Replacement text has now been used to better clarify the focus: ‘Many of the insights from 75 years of an evolving understanding of urban health and wellbeing have been incorporated into the Sustainable Development Goals. However, observing the all-to-common disconnects between health policy and urban policy at the local level, it is clear that progress made at the global level has yet to have much ‘on-the-ground’ impact.’ With respect to your comment on the SDGs, there is a separate paper coming, within this WHO collection ‘Making the Case for Urban Health: Defining Value and Relevance to Contemporary Challenges’ (by Susan Parnell) that will deal with the Sustainable Development framework. We will be including a reference to that paper earlier in our paper and supporting text had been added. Your comment >>: 2) Related to above, what do authors opine are the major global pressures of our time? Our response: With respect to material on global pressures. There is already a fair amount, we will check for gaps that are significant to our themes, and also gather together what we cover in a paragraph in the introduction. We have included extra depth covering the Commercial Determinants of Health, Health equity and COVID-19 legacy and material on contemporary issue of democracy and the political economy. Your comment >>: How do these new global pressures inform this new urban health paradigm? Our response: Yes. Thanks for pointing out this omission, text now added to the concluding section. Your comment >>: The authors do not seem to clearly articulate what the emerging health paradigm is. Our response: Yes. Thanks for this observation, that section was too weak. We have revised the concluding section. Your comment >>: There is limited discussion and treatment of both classic and contemporary theoretical frameworks that exist in the social sciences that may advance this thinking. Our response: Thanks for this useful comment. The paper obviously Wil have its limitation, I am sure a book can be written her. We have not wanted to go into any depth on theoretical frameworks to keep with a remit of begin focussed on what may be more directly useful for policy and a policy audience, rather than an academic audience. We have though, in our broad sweep, sought to cover a number of social science topics such as human rights, equity, governance, global conflicts, participation and agency. Many of these issues have all been developed further in the current revision. Your comment >>: Section 5 highlights Vlahov and Galea. However, in the spirit of transdisciplinary approaches to solving the major urban health challenges of our time -- shift from communicable to NCDs, emergence of novel viral pandemics, crisis management/adaption in the face of climate change, rising inequality/health inequity in established/older cities in more affluent countries, gentrification -- there is no consideration of some of the critical frameworks from other disciplines that can help advance our thinking on how to inform a new health paradigm. Our response: Thank you for this comment. We have re-examined relevant sections. Material has been added to reflect some of the missing elements you have highlighted. However, within the scope of the current paper, we are unable to go too far into discussing the several critical frameworks that would be relevant here. In response to this comment, and others, we have added material on sociology and social epidemiology. We have also added a useful conclusion from Krefis, et al, (2018) that there is a lack of interdisciplinary approaches that highlight the complexity of urban structures and dynamics and their possible influence on urban health and well-being. [Krefis, A. C., Augustin, M., Schlünzen, K. H., Oßenbrügge, J., & Augustin, J. (2018). How Does the Urban Environment Affect Health and Well-Being? A Systematic Review. Urban Science , 2 (1), 21. https://doi.org/10.3390/urbansci2010021]. Your comment >>: There is much insight that can be learned from the fields of social epidemiology (in public health with emphasis on the social determinants of health) and urban planning/development theory (Lewis, Mumford). Our response: We certainly agree. Much has been written about the historic link between social epidemiology, the emergence of town planning and public health delivered through town planning acts. Many texts, field leaders and analyses could be cited. However, in our attempt to cover more recent developments, we don’t want to delve into this area. But to make sure there is an outline for those who may not be aware of this history we have added he following ‘In terms of urban spatial planning, much has been written about the close historic relationships - at the advert of formal city planning - between sociologist traditions looking for betterment of the working classes, public health seeking to minimize health risk, and the aims and techniques of those involved with spatial policy, layout and design. The close interplay between these three elements weakened following the post-war period as their separate disciplines evolved.’ We have also added elsewhere a note about sociology with a cite of this paper: Kelly, M. P. and Green, J. (2019) ‘What can sociology offer urban public health?’, Critical Public Health, 29(5), pp. 517–521. doi: 10.1080/09581596.2019.1654193. Competing Interests: No competing interests were disclosed. Close Report a concern COMMENT ON THIS REPORT Comments on this article Comments (0) Version 2 VERSION 2 PUBLISHED 02 Sep 2024 ADD YOUR COMMENT Comment keyboard_arrow_left keyboard_arrow_right Open Peer Review Reviewer Status info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Reviewer Reports Invited Reviewers 1 2 3 4 5 Version 2 (revision) 06 Oct 25 read read Version 1 02 Sep 24 read read read read Aimee Afable , State University of New York (SUNY) Downstate Health Sciences University, brook, USA Priya Balasubramaniam , Public Health Foundation of India, Gurugram,, India; Centre for Sustainable Health Innovations, Singapore, Singapore Nicholas Freudenberg , City University of New York, New York City, USA Trevor Hancock , University of Victoria, Victoria, Canada Omolara Oluseun Juba , Cardiff Metropolitan University, Cardiff, UK Gabriel Orugboh Oritsemeyiwa , Cardiff University School of Computer Science and Informatics, Cardiff, UK Comments on this article All Comments (0) Add a comment Sign up for content alerts Sign Up You are now signed up to receive this alert Browse by related subjects keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Juba O et al. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 29 Oct 2025 | for Version 2 Omolara Oluseun Juba , Cardiff Metropolitan University, Cardiff, Wales, UK Gabriel Orugboh Oritsemeyiwa , Computing with Placement, Cardiff University School of Computer Science and Informatics, Cardiff, Wales, UK 0 Views copyright © 2025 Juba O et al. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions Title: The Emergence of a Modern Paradigm for Urban Health Authors: Marcus Grant, Evelyne de Leeuw, Waleska Teixeira Caiaffa, Jo Ivey Boufford, Carlos Dora, Susan Parnell Journal: F1000Research (Version 2, 2025, Article 13:987) Reviewer: Omolara Oluseun Juba / Adultprime Safety Health & Wellness Foundation Co-Reviewer: Oritsemeyiwa Gabriel Orugboh / Cardiff University, Cardiff United Kingdom Date: 19/10/2025 Article summary The manuscript is an historical narrative review of 75 years of the emergence of the "urban health" paradigm. The authors in this study shows the transition of the construct from limited biomedical health service models to expansive systems-based and multi-sectoral frameworks. The paper highlights some of the most relevant moments in this trajectory, including early WHO declarations (Alma Ata and Ottawa Charter), the expansion of Healthy Cities initiatives, the solidification of Health in All Policies (HiAP), and the uptake of complexity science and systems thinking. My Evaluation 1. Is the topic of the review discussed comprehensively in the context of the current literature? Answer: Yes, The manuscript stands out because of its significant breadth. The work creates an invaluable historical integration of decades of theoretical development by international organizations (mainly WHO) combined with academic research and practical application. The manuscript demonstrates clear value by including up to date literature on commercial and political determinants. 2. Are all factual statements correct and adequately supported by citations? Answer: Yes, The manuscript is well researched and referenced. Statements of fact about past events, WHO efforts, theoretical constructs and major publications are correct. The references include an appropriate combination of peer reviewed and grey literature from WHO, UN-Habitat and other international agencies. Citations are appropriate. This is great. 3. Is the review written in accessible language? Answer: Partly, The authors have a clear and logical writing style, but I'm a bit concerned the language might shut out some of the very people they're hoping to bring into the conversation. Using the words or terms like "salutogenic," "transdisciplinarity," and "upstream drivers" maybe okay for academic public health researchers but i am certain readers from other sectors like a planner, a traffic engineer, or maybe a local council member getting lost and tuning out. If the goal is truly to build bridges across different fields, the paper could do a better job of translating its key concepts for a broader audience on first use. 4. Are the conclusions drawn appropriate in the context of the current research literature? Answer: Yes, The conclusions in section 7 accurately name long-term, structural challenges on governance, resources, and capacity. The formulation of the "three significant questions" (regarding urban health literacy, governance, and resources) is very good and very fitting. My recommendation To make the paper more welcoming to that wider audience, i will advise to do a simple modification. When you first introduce an important term of art, just add a quick, plain English explanation in parentheses right after it. This will strengthen the readability. A little bit of translation wouldn't disrupt the flow for experts, but it would be a lifeline for readers from other sectors, making them feel included rather than excluded. Is the topic of the review discussed comprehensively in the context of the current literature? Yes Are all factual statements correct and adequately supported by citations? Yes Is the review written in accessible language? Partly Are the conclusions drawn appropriate in the context of the current research literature? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Occupational Health, Safety and Wellbeing, Gerontology, Healthcare Safety, Occupational Safety, Dementia, Public Health We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Juba OO and Oritsemeyiwa GO. Peer Review Report For: The emergence of a modern paradigm for urban health [version 2; peer review: 2 approved, 2 approved with reservations, 1 not approved] . F1000Research 2025, 13 :987 ( https://doi.org/10.5256/f1000research.185447.r424215) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-987/v2#referee-response-424215 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Freudenberg N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 28 Oct 2025 | for Version 2 Nicholas Freudenberg , City University of New York, New York City, NY, USA 0 Views copyright © 2025 Freudenberg N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (0) Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions I read the revised version and I believe it addresses most reviewer concerns and is now ready for indexing. It will make a useful contribution to the literature. I continue to see some gaps but I believe these can be addressed by other authors in other publications. These gaps include: The review focuses almost entirely on reports from academics , established international organizations, and governments, thus missing the perspectives of social movement activists and other less mainstream actors. However, in my view, social movements, activists , and citizen organizations have often been the main force leading to improvements in the health of urban populations in the last century or two. Other authors will need to fill this gap. It is not sufficient to describe in passing the role of civil society organizations, a broad term that does not distinguish among the diverse players in this sector. While no single report can fully cover all influences on the health of urban populations, this report does not fully consider the growing influence of changing political economies on the health of urban populations. Barely discussed are the roles of growing global income and wealth inequities, monopoly concentration, privatization of formerly public services, threats to democracy and democratic governance , new limits on immigration and migration, or new communications and information processing technologies. In my view these factors are likely to be the predominant influences on urban health in the coming decades. In sum, the report under review makes important contributions to our understanding of recent developments in urban health but also encourages others to review these developments with different and wider lenses. Competing Interests No competing interests were disclosed. Reviewer Expertise urban health, health equity, role of social movements in health I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard. reply Respond to this report Responses (0) Freudenberg N. Peer Review Report For: The emergence of a modern paradigm for urban health [version 2; peer review: 2 approved, 2 approved with reservations, 1 not approved] . F1000Research 2025, 13 :987 ( https://doi.org/10.5256/f1000research.185447.r420807) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-987/v2#referee-response-420807 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Hancock T. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 22 Jan 2025 | for Version 1 Trevor Hancock , University of Victoria, Victoria, British Columbia, Canada 0 Views copyright © 2025 Hancock T. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions I answered ‘partly’ to three of the four questions because : a) it would be hard, if not impossible, to be comprehensive given such a large field of thought and practice extending over several decades. However, this review covers the major global developments and initiatives well. b) language accessibiliutry depends upon the audience. This would not be accessible to the general public, and perhaps not to an academic audience not familiar with some of the concepts. However, it is well written and is accessible for me. c) There is no ‘Conclusions’ section, but Section 7 is about ‘Moving Forward, and I have some thoughts, noted below, about how this section could be strengthened. Here are my main comments; I also noted some minor typos that I list at the end. 1. Given “The modern urban context requires fresh thinking about how best to maximise urban health and wellbeing”, maybe change the title to read “The emergence of a modern paradigm for urban health and wellbeing” 2. Given several references to wellbeing, I was surprised to see no reference to the Geneva Charter for Well-being (WHO, 2021) and no expansion on the concept of a wellbeing society as it would apply to a city or community, one that would be committed to “achieving equitable health now and for future generations without breaching ecological limits”. This would be a useful idea to consider in Section 7 3. On P 5 – the section on HPP should reference the 1984 Beyond Health Care conference that launched the concept and the 1988 Second WHO Health Promotion conference on Healthy Public Policy in Adelaide that resulted in the Adelaide Statement, and included a section on Healthy Public Policy at the Local Level that resulted in an edited book (A. Evers et al . (eds.), Healthy Public Policy at the Local Level . Frankfurt/Boulder: Campus/Westview, 1990) 4. Towards the end of section 3, in the discussion of health and planetary boundaries and sustainability, it is worth noting that the links between health and sustainability were developed in the 1990s (see e.g. Hancock, Trevor (1996) “Planning and creating healthy and sustainable cities: the challenge for the 21st century.” In C. Price and A. Tsouros (eds.), Our Cities, Our Future: Policies and Action for Health and Sustainable Development . Copenhagen: WHO Healthy Cities Project Office; Hancock, Trevor (1996) Healthy, sustainable communities: concept, fledgling practice and implications for governance Alternatives 22 (2), pp 18-23; Hancock, Trevor (2000) Healthy Communities Must Be Sustainable Communities Too Public Health Reports 115 (2 and 3): 151–6) 5. There is no mention of ecology or ecosystems at all, and only a brief discussion of planetary boundaries in section 3.4 (Complexity and the ‘causes of the causes’ of ill-health ). I see a need for a paragraph or two expanding on “we are starting to see the creation of a more widespread contemporary understanding of urban health” that would incorporate the concept of the ecological determinants of health, planetary health and planetary boundaries (e.g. Hancock, 2018: “Healthy Cities 2.0: Transitioning towards ‘One Planet’ cities” (Key challenges facing 21st century cities, Part 3) Cities & Health 1 (3) 6. There is only a passing reference to the new economics (e.g. the application of Donut Economics at the urban level) and the importance of the commercial determinants for urban health (including the role of the private sector in urban development, housing, food systems and urban heating and urban pollution). These are new/emerging areas that merit some expanded discussion in section 7 7. P 12, section 7 – I would add to “Prodigious urbanisation . . .” the emerging threat to health posed by what the UN calls “the triple planetary crisis” of climate change, biodiversity loss and pollution as well as other global ecological changes that are crossing planetary boundaries. Also, a brief discussion of the ecological injustice dimensions of declining planetary health Typos P 7, first line – “towards a systemic approach to urban health.the WHO European Regional Office” should read “towards a systemic approach to urban health. The WHO European Regional Office” P 7, section 4.2 - “a centre unique in its placement within in a built environment faculty” - delete ‘in’ P 7, section 4.2 - “the Health Map now been adopted by a wide range of actors” should read “the Health Map has now been adopted by a wide range of actors” P 12, section 6 – “has been gleaned from implementation has accumulated in part” should read “has been gleaned from implementation that has accumulated in part” P 12, section 6 – “those embracing a community assets-focussed and action-oriented agendas” – delete one ‘s’ in ‘focussed’ and the ‘s’ on ‘agendas’ Is the topic of the review discussed comprehensively in the context of the current literature? Partly Are all factual statements correct and adequately supported by citations? Yes Is the review written in accessible language? Partly Are the conclusions drawn appropriate in the context of the current research literature? Partly Competing Interests No competing interests were disclosed. Reviewer Expertise Public health, health promotion, healthy cities and communities, planetary and environmental health, health policy & planning, health futurism I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 06 Oct 2025 Marcus Grant, Environmental Stewardship for Health, Bristol, UK Your comment>>: I answered ‘partly’ to three of the four questions because: a) it would be hard, if not impossible, to be comprehensive given such a large field of thought and practice extending over several decades. However, this review covers the major global developments and initiatives well. b) language accessibility depends upon the audience. This would not be accessible to the general public, and perhaps not to an academic audience not familiar with some of the concepts. However, it is well written and is accessible for me. c) There is no ‘Conclusions’ section, but Section 7 is about ‘Moving Forward, and I have some thoughts, noted below, about how this section could be strengthened. Our response: Thank you for both your ratings and the thoughts behind them. We certainly agree, some of the rating questions (e.g ‘a’ and ‘b’) only map tangentially to this type of paper. However, we note all your comments. Thanks for the focus on the conclusions and how to strengthen, very useful. Your comment>>: 1 . Given “The modern urban context requires fresh thinking about how best to maximise urban health and wellbeing”, maybe change the title to read “The emergence of a modern paradigm for urban health and wellbeing” Our response: Thanks for this suggestion. The title is currently 'The emergence of a modern paradigm for urban health’. You suggest the addition of: ‘and wellbeing’. We resist a change to the title; however, we certainly accept the premise of ‘health and wellbeing’ being a powerful phrase with a lot of clarity. We have checked through the paper to see how ‘wellbeing’ is situated, and made some adjustments to ensure its inclusion as key points are made. Your comment>>: 2 . Given several references to wellbeing, I was surprised to see no reference to the Geneva Charter for Well-being (WHO, 2021) and no expansion on the concept of a wellbeing society as it would apply to a city or community, one that would be committed to “achieving equitable health now and for future generations without breaching ecological limits”. This would be a useful idea to consider in Section 7 Our response: Thank you for your reference to the Geneva Charter for Well-being. This would certainly be useful in helping to consolidating chapter 7 ‘Moving forward on urban health ‘. We have also signposted it as a document consolidating other aspects of global health such as planetary health, one health and wellbeing societies. Your comment>>: 3 . On P 5 – the section on HPP should reference the 1984 Beyond Health Care conference that launched the concept and the 1988 Second WHO Health Promotion conference on Healthy Public Policy in Adelaide that resulted in the Adelaide Statement, and included a section on Healthy Public Policy at the Local Level that resulted in an edited book (A. Evers et al. (eds.), Healthy Public Policy at the Local Level. Frankfurt/Boulder: Campus/Westview, 1990) Our response: Thank you for this information about Healthy Public Policy at the 1988 WHO conference. We have looked at the source materials and added some content. This section has been updated. Your comment>>: 4. Towards the end of section 3, in the discussion of health and planetary boundaries and sustainability, it is worth noting that the links between health and sustainability were developed in the 1990s (see e.g. Hancock, Trevor (1996) “Planning and creating healthy and sustainable cities: the challenge for the 21st century.” In C. Price and A. Tsouros (eds.), Our Cities, Our Future: Policies and Action for Health and Sustainable Development. Copenhagen: WHO Healthy Cities Project Office; Hancock, Trevor (1996) Healthy, sustainable communities: concept, fledgling practice and implications for governance Alternatives 22 (2), pp 18-23; Hancock, Trevor (2000) Healthy Communities Must Be Sustainable Communities Too Public Health Reports 115 (2 and 3): 151–6) Our response: Thank you for these references to the work in the 1990s. We will review this material and definitely cite where needed and refer to it. As you can imagine, with such as compacted text on such a large subject, we have sought to be selective in citations and knowingly have omitted many good sources. But we can point to these agorae for genesis in ideas, your knowledge is very helpful with that. Your comment>>: 5. There is no mention of ecology or ecosystems at all, and only a brief discussion of planetary boundaries in section 3.4 (Complexity and the ‘causes of the causes’ of ill-health ). I see a need for a paragraph or two expanding on “we are starting to see the creation of a more widespread contemporary understanding of urban health” that would incorporate the concept of the ecological determinants of health, planetary health and planetary boundaries (e.g. Hancock, 2018: “Healthy Cities 2.0: Transitioning towards ‘One Planet’ cities” (Key challenges facing 21st century cities, Part 3) Cities & Health 1 (3) Our response: As an ecologist myself, this error is glaring. Definitely needs rectifying. Partly also by pointing out how this agenda has been so often overlooked! I am hoping the broader WHO urban health work, of which this is a part, there will be a paper specifically focusing on ecosystems, biodiversity and urban health. We have added a new section 3.7called planetary health to address this. Your comment>>: 6. There is only a passing reference to the new economics (e.g. the application of Donut Economics at the urban level) and the importance of the commercial determinants for urban health (including the role of the private sector in urban development, housing, food systems and urban heating and urban pollution). These are new/emerging areas that merit some expanded discussion in section 7 Our response: Thank you for pointing this out. We are aware of this work and a specific section on the commercial determinants for urban health will allow us to develop some of these points. We also note the need to re-look at the new/emerging areas discussion. We have expanded and brought up to date the section on the commercial determinants of health, also including a new sub-section ‘3.5: The commercial determinants of health, with a resume of recent work as it relates to urban health Your comment>>: 7. P 12, section 7 – I would add to “Prodigious urbanisation . . .” the emerging threat to health posed by what the UN calls “the triple planetary crisis” of climate change, biodiversity loss and pollution as well as other global ecological changes that are crossing planetary boundaries. Also, a brief discussion of the ecological injustice dimensions of declining planetary health Our response: Thank you for this suggestion. Now referred to in a new section 3.7 on planetary health. Your comment>>: P 7, first line – “towards a systemic approach to urban health.the WHO European Regional Office” should read “towards a systemic approach to urban health. The WHO European Regional Office” Our response: Thank you. Corrected Your comment>>: P 7, section 4.2 - “a centre unique in its placement within in a built environment faculty” - delete ‘in’ Our response: Thank you. Corrected Your comment>>: P 7, section 4.2 - “the Health Map now been adopted by a wide range of actors” should read “the Health Map has now been adopted by a wide range of actors” Our response: Thank you. Corrected Your comment>>: P 12, section 6 – “has been gleaned from implementation has accumulated in part” should read “has been gleaned from implementation that has accumulated in part” Our response: Thank you. Corrected Your comment>>: P 12, section 6 – “those embracing a community assets-focussed and action-oriented agendas” – delete one ‘s’ in ‘focussed’ and the ‘s’ on ‘agendas’ Our response: Thank you. Corrected View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Hancock T. Peer Review Report For: The emergence of a modern paradigm for urban health [version 2; peer review: 2 approved, 2 approved with reservations, 1 not approved] . F1000Research 2025, 13 :987 ( https://doi.org/10.5256/f1000research.169300.r353478) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-987/v1#referee-response-353478 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Freudenberg N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 09 Jan 2025 | for Version 1 Nicholas Freudenberg , City University of New York, New York City, NY, USA 0 Views copyright © 2025 Freudenberg N. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions The paper is a competent and useful summary of some of the developments in urban health. In this review, I highlight gaps and concerns to give the authors an opportunity to consider these points. The review feels curiously dated with more emphasis on the developments of the first 30 years and less on the last 10 years. Of the 75 references, only 30 were published in the last 10 years. Since others have written about the earlier years, I was hoping for more focus on recent developments. Some issues that could receive more attention include: 1. The emergence of the frameworks of commercial and political determinants of health. These are mentioned only briefly but, in my view, they pose existential and profound threats to the health of urban residents in particular and deserve more attention. More broadly, a summary of the body of literature on the political economy of cities and its impact of health would be valuable. 2. Worldwide and in cities, challenges to democracy pose serious threats to the health of populations and to health equity. How does this play out in cities and what have we learned in the last 10 years about the threats and possible responses? 3. Covid 19 is barely mentioned yet is has had a profound influence on the health of urban populations and the scholarly discourse on urban health. What have we learned and what are priorities for further research on pandemic threats to cities? 4. In my read of urban health history over the last 150 years, it has been social movements that have led to the most significant advances in population health and health equity yet there is almost no mention of social movements and their potential and limitations. Some discussion of this would enhance the article. It is easy for a reviewer to identify gaps, and it is authors who decide how best to use their limited space. In my view, addressing the issues listed here would make a useful report more useful. Is the topic of the review discussed comprehensively in the context of the current literature? Partly Are all factual statements correct and adequately supported by citations? Yes Is the review written in accessible language? Yes Are the conclusions drawn appropriate in the context of the current research literature? Partly Competing Interests No competing interests were disclosed. Reviewer Expertise urban health, health equity, role of social movments in health I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 06 Oct 2025 Marcus Grant, Environmental Stewardship for Health, Bristol, UK Your comment>>: The paper is a competent and useful summary of some of the developments in urban health. In this review, I highlight gaps and concerns to give the authors an opportunity to consider these points. Our response: Thank you for reading the paper and bringing these issues to our attention. Your comment>>: The review feels curiously dated with more emphasis on the developments of the first 30 years and less on the last 10 years. Of the 75 references, only 30 were published in the last 10 years. Since others have written about the earlier years, I was hoping for more focus on recent developments. Some issues that could receive more attention include: Our response: Noting your useful observation here. We are aiming this paper at those who were not as aware of that historic arc of development. However, in doing so, we may have neglected more recent developments. Thank you for drawing attention to some of the more recent developments which we now acknowledge, a few only in passing, others more deeply, and to better frame the paper. Your comment>>: 1. The emergence of the frameworks of commercial and political determinants of health. These are mentioned only briefly but, in my view, they pose existential and profound threats to the health of urban residents in particular and deserve more attention. More broadly, a summary of the body of literature on the political economy of cities and its impact of health would be valuable. Our response: As you indicate, the paper has become a victim of its own tightly drawn brief. This self-imposed constraint needs to be better articulated at the outset to help frame what comes later. Having said that, the authors agree that the arguably more recent discourses on the commercial and political determinants of health need to be better addressed. As does the political economy of cities and its impact on health. Introduction and background have been re-written in several places to reflect the importance of commercial and political determinants of health. We have added a new sub-section ‘3.6: The political economy’, including more recent references. We have expanded and brought up to date the section on the commercial determinants of health, also including a new sub-section ‘3.5: The commercial determinants of health, with a resume of recent work as it relates to urban health Your comment>>: 2. Worldwide and in cities, challenges to democracy pose serious threats to the health of populations and to health equity. How does this play out in cities and what have we learned in the last 10 years about the threats and possible responses? Our response: You raise an important point here. We think it lies outside the scope of this paper to examine in detail. However, we must certainly acknowledge the threats to health, especially with the recent move in the USA to remove support for the WHO and for a seemingly more transactional and superficial approach to underlying structural issues, without, of course, making the paper into a topical commentary. We have added material about global and national (political and democratic) contexts as a determinant of health. Citing: Buse, K. et al. "What are healthy societies? A thematic analysis of relevant conceptual frameworks." International journal of health policy and management 12 (2023): 7450. Your comment>>: 3. Covid 19 is barely mentioned yet it has had a profound influence on the health of urban populations and the scholarly discourse on urban health. What have we learned and what are the priorities for further research on pandemic threats to cities? Our response: Thank you for pointing out this oversight. The paper does need updating in this regard. Analysis of COVID-19 impact on urban health thinking and policy was still emerging during the initial writing process, and we neglected this in later drafts. Material, as relevant to COVID-19 and lessons for urban health, has been added in several places, most notably the section on health equity. In addition, a specific discussion has been writing in section ‘3.2 Urban health beyond the health sector; from treatment to prevention’, focusing on how town planners had to adapt many public spaces to reduce transmission and how this led to a greater visibility of the importance of non-medical measures for urban health. Your comment>>: 4. In my read of urban health history over the last 150 years, it has been social movements that have led to the most significant advances in population health and health equity, yet there is almost no mention of social movements and their potential and limitations. Some discussion of this would enhance the article. Our response: Thank you for this comment. We have now included some material noting the roles of social moments. Paragraph of text was added addressing the influence of grassroots movements for social change in the introductory section. Your comment>>: It is easy for a reviewer to identify gaps, and it is authors who decide how best to use their limited space. In my view, addressing the issues listed here would make a useful report more useful. Our response: Thank you for your suggestions. Your comments have been very useful. View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Freudenberg N. Peer Review Report For: The emergence of a modern paradigm for urban health [version 2; peer review: 2 approved, 2 approved with reservations, 1 not approved] . F1000Research 2025, 13 :987 ( https://doi.org/10.5256/f1000research.169300.r353471) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-987/v1#referee-response-353471 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Balasubramaniam P. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 09 Dec 2024 | for Version 1 Priya Balasubramaniam , Public Health Foundation of India, Gurugram,, Haryana, India; Centre for Sustainable Health Innovations, Singapore, Singapore 0 Views copyright © 2024 Balasubramaniam P. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Approved With Reservations info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions This article robustly traces the evolution of the urban health paradigm that highlights key past frameworks like the Health in All Policies (HiAP), the Ottawa Charter, and Healthy Public Policy. It also references systems thinking, equity, and complexity as core theoretical lenses for understanding urban health dynamics and a bold recommendation to move away from older frameworks to newer paradigms and emerging issues in Urban Health . These provide a strong foundation, but there are a few gaps that could be addressed in the remit of this article. Strengths: The focus on the settings-based approach and systemic determinants of health is comprehensive. Incorporation of complexity science to frame urban health challenges is forward-thinking. Historical references to the Alma Ata Declaration and WHO initiatives contextualize the paradigm's evolution. Gaps: The frameworks largely neglect the integration of digital health transformation in urban health , which is rapidly reshaping urban health systems. The article could incorporate frameworks like digital ecosystems and their potential to address urban health inequities through data analytics, telemedicine, and AI-driven decision-making. The private health sector's role is also underemphasized who is often a key play in urban health systems in emerging economies with mixed health systems. A pragmatic discussion of mixed health systems and private sector dynamics could strengthen the conceptual framing, especially regarding regulatory frameworks, financing models, and partnerships. 2. Digital Health Transformation The omission of digital health as a transformative tool is a significant gap, given its increasing relevance in urban health: Suggested Additions: Include a discussion on the role of digital platforms in improving access to urban health services, particularly for underserved populations. Explore frameworks like the Digital Health Ecosystem Model , emphasizing the interplay between governance, technology, and stakeholders in urban settings. Highlight innovations such as mobile health (mHealth), eHealth tools, and AI applications in predictive urban health surveillance. Rationale: Digital health can bridge gaps in healthcare access and quality in urban areas, where infrastructure is often unevenly distributed. Including this dimension would make the article more relevant to contemporary challenges and opportunities. 3. Role of the Private Health Sector The private health sector is critical in urban settings, especially in low- and middle-income countries, where it often fills service delivery gaps: Suggestions for Inclusion: Discuss how private providers can complement public health efforts through partnerships, performance-based contracting, or shared accountability models. Examine innovative financing mechanisms (e.g., social impact bonds) and their role in incentivizing private sector participation in urban health initiatives. Incorporate case studies that illustrate successful integration of private sector solutions in urban health systems (e.g., public-private partnerships in urban clinics or insurance schemes tailored to urban populations). Theoretical Contribution: The article could introduce theories of market dynamics and public-private synergies , focusing on balancing equity, efficiency, and accessibility in urban health. 4. Suggestions would be useful in the scope of this forward thinking article if The authors should explicitly recognize the transformative potential of digital health and private sector partnerships as key drivers of the next phase of the urban health paradigm. A section dedicated to exploring how these two elements can operationalize the theoretical concepts of systems thinking and equity would enrich the discussion. Is the topic of the review discussed comprehensively in the context of the current literature? Yes Are all factual statements correct and adequately supported by citations? Yes Is the review written in accessible language? Yes Are the conclusions drawn appropriate in the context of the current research literature? Partly Competing Interests No competing interests were disclosed. Reviewer Expertise Mixed Health Systems, Digital Health Transformation, Private Sector Innovation in Health care provision and access I confirm that I have read this submission and believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above. reply Respond to this report Responses (1) Author Response 06 Oct 2025 Marcus Grant, Environmental Stewardship for Health, Bristol, UK Your comment > > This article robustly traces the evolution of the urban health paradigm that highlights key past frameworks like the Health in All Policies (HiAP), the Ottawa Charter, and Healthy Public Policy. It also references systems thinking, equity, and complexity as core theoretical lenses for understanding urban health dynamics and a bold recommendation to move away from older frameworks to newer paradigms and emerging issues in Urban Health. These provide a strong foundation, but there are a few gaps that could be addressed in the remit of this article. Our response: Thank you for your review. Useful summary for us, but even more useful identification of several gaps. > >Strengths: * The focus on the settings-based approach and systemic determinants of health is comprehensive. * Incorporation of complexity science to frame urban health challenges is forward-thinking. * Historical references to the Alma Ata Declaration and WHO initiatives contextualize the paradigm's evolution. Our response: Thank you for noting these strengths. It is always good to see how the ‘message’ is landing. Your comment > > Gaps: * The frameworks largely neglect the integration of digital health transformation in urban health , which is rapidly reshaping urban health systems. The article could incorporate frameworks like digital ecosystems and their potential to address urban health inequities through data analytics, telemedicine, and AI-driven decision-making. * The private health sector's role is also underemphasized who is often a key play in urban health systems in emerging economies with mixed health systems. A pragmatic discussion of mixed health systems and private sector dynamics could strengthen the conceptual framing, especially regarding regulatory frameworks, financing models, and partnerships. Our response: We appreciate you setting out your concerns above and in more detail below, where you will find our responses. Your comment > > 2. Digital Health Transformation The omission of digital health as a transformative tool is a significant gap, given its increasing relevance in urban health: Suggested Additions: * Include a discussion on the role of digital platforms in improving access to urban health services, particularly for underserved populations. * Explore frameworks like the Digital Health Ecosystem Model , emphasizing the interplay between governance, technology, and stakeholders in urban settings. * Highlight innovations such as mobile health (mHealth), eHealth tools, and AI applications in predictive urban health surveillance. Rationale: Digital health can bridge gaps in healthcare access and quality in urban areas, where infrastructure is often unevenly distributed. Including this dimension would make the article more relevant to contemporary challenges and opportunities. Our response: Thank you for this observation and useful suggestions. This paper lies within the WHO F1000 collection ‘Making the Case for Urban Health: Defining Value and Relevance to Contemporary Challenges’. There is forthcoming paper in this collections specifically covering digital transformations and urban health (by Acuto et al.). We will refer to that and some of its content. We have also added a few sentences later on, in Section 6 (Urban health in policy, practice and process), to highlight this emerging issue. However, the focus of the paper is not health service provision, so our discussion of digital advances will be restricted to their application in population-centred primary public health. ‘Digital health can bridge gaps in healthcare access and quality in urban areas, where infrastructure is often unevenly distributed.’ → Excellent point' and we now refer to this as a ‘contemporary challenge and opportunity’. We have now referred in our paper to digital transformations and urban health (by Acuto et al.) with a paragraph in Section 6 (Urban health in policy, practice and process). We improved references to available digital urban health tools and platforms and determinants of health data and added to the concluding section re: contemporary challenges and opportunities. Your comment > > 3. Role of the Private Health Sector The private health sector is critical in urban settings, especially in low- and middle-income countries, where it often fills service delivery gaps: Suggestions for Inclusion: * Discuss how private providers can complement public health efforts through partnerships, performance-based contracting, or shared accountability models. * Examine innovative financing mechanisms (e.g., social impact bonds) and their role in incentivizing private sector participation in urban health initiatives. * Incorporate case studies that illustrate successful integration of private sector solutions in urban health systems (e.g., public-private partnerships in urban clinics or insurance schemes tailored to urban populations). Our response: Thank you for these comments. Especially the note about the situation in low- and middle-income countries. We have added a clearer articulation of the scope of the paper to clarify that we are not covering either private, state or NGO health service or health care sectors. However, we have added content on public and private finance which affects urban health (section 2) and innovative finance for healthier placemaking. Hence the upstream determinants of health (e.g. urban development and related private financial constraints) and reference to the Commerical Determinants of Health (and WHO’s work in this space) has now been included. We have expanded and brought up to date the section on the commercial determinants of health, also including a new sub-section ‘3.5: The commercial determinants of health, with a resume of recent work as it relates to urban health. mentioning work on upstream determinants of health including social impact bond and with urban developers. We have added material in Section 6 (Urban health in policy, practice and process) to highlight these issues. Section 7 Moving forward on urban health, now notes the emerging issue role of private health sector. Your comment > > Cont…3. Role of the Private Health Sector Theoretical Contribution: The article could introduce theories of market dynamics and public-private synergies , focusing on balancing equity, efficiency, and accessibility in urban health. Our response: Thank you for the comment. We have been careful in the article not to address health care and the health service sector. However, we may need to better articulate that stance. We have added a clearer articulation of the scope of the paper in the introduction to clarify that we are not covering either private, state or NGO health service or health care sectors. In line with comments from other reviewers, we have strengthened and added additional material about the place of the Commerical Determinants of Health and the urban health paradigm. There is certainly a role to talk to market dynamics and health especially with respect to urban environments. Keeping within the scope of the paper this has focussed on the wider determinants of health and non health care provision – an important factor, but outside our scope. Your comment > > 4. Suggestions would be useful in the scope of this forward thinking article if * The authors should explicitly recognize the transformative potential of digital health and private sector partnerships as key drivers of the next phase of the urban health paradigm. * A section dedicated to exploring how these two elements can operationalize the theoretical concepts of systems thinking and equity would enrich the discussion. Our response: Yes, we certainly need to develop the ‘forward think’ elements of the paper, e.g.future trends/development of the concept of urban health. Other reviewers have made similar comments. We have added a new section on the potential of digital health and clarified the relationship between this paper and health care services, public and private. We have noted the transformative potential of digital health and private sector partnerships within our remit which does not include health care delivery, where detail is outside our scope. We have drawn on proceeding sections to new write some new text looking at these issues as potential drivers of future change. View more View less Competing Interests No competing interests were disclosed. reply Respond Report a concern Balasubramaniam P. Peer Review Report For: The emergence of a modern paradigm for urban health [version 2; peer review: 2 approved, 2 approved with reservations, 1 not approved] . F1000Research 2025, 13 :987 ( https://doi.org/10.5256/f1000research.169300.r331697) NOTE: it is important to ensure the information in square brackets after the title is included in this citation. The direct URL for this report is: https://f1000research.com/articles/13-987/v1#referee-response-331697 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2024 Afable A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 22 Nov 2024 | for Version 1 Aimee Afable , State University of New York (SUNY) Downstate Health Sciences University, brook, New York, USA 0 Views copyright © 2024 Afable A. This is an open access peer review report distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. format_quote Cite this report speaker_notes Responses (1) Not Approved info_outline Alongside their report, reviewers assign a status to the article: Approved The paper is scientifically sound in its current form and only minor, if any, improvements are suggested Approved with reservations A number of small changes, sometimes more significant revisions are required to address specific details and improve the papers academic merit. Not approved Fundamental flaws in the paper seriously undermine the findings and conclusions While the paper does a fairly comprehensive treatment outlining the history of the urban health paradigm, it relies heavily on authoritative global health agency practice, positions, and frameworks. My review concerns two areas: 1) Authors conclude the following: While some of the insights from 75 years of evolving understanding of urban health and wellbeing have been incorporated into the Sustainable Development Goals, it is far from clear that the global agenda has taken sufficient account of lessons learned. However, this statement lacks a thorough discussion of what lessons were learned in the past 75 years -- other than the evolving frameworks. What is the evidence base? This may be too broad but perhaps illustrative examples would be useful. 2) Related to above, what do authors opine are the major global pressures of our time? How do these new global pressures inform this new urban health paradigm? The authors do not seem to clearly articulate what the emerging health paradigm is. There is limited discussion and treatment of both classic and contemporary theoretical frameworks that exist in the social sciences that may advance this thinking. Section 5 highlights Vlahov and Galea. However, in the spirit of transdisciplinary approaches to solving the major urban health challenges of our time -- shift from communicable to NCDs, emergence of novel viral pandemics, crisis management/adaption in the face of climate change, rising inequality/health inequity in established/older cities in more affluent countries, gentrification -- there is no consideration of some of the critical frameworks from other disciplines that can help advance our thinking on how to inform a new health paradigm. There is much insight that can be learned from the fields of social epidemiology (in public health with emphasis on the social determinants of health) and urban planning/development theory (Lewis, Mumford). Is the topic of the review discussed comprehensively in the context of the current literature? Partly Are all factual statements correct and adequately supported by citations? Partly Is the review written in accessible language? Yes Are the conclusions drawn appropriate in the context of the current research literature? Partly Competing Interests No competing interests were disclosed. Reviewer Expertise Health equity research, maternal health, immigrant and urban health I confirm that I have read this submission and believe that I have an appropriate level of expertise to state that I do not consider it to be of an acceptable scientific standard, for reasons outlined above. reply Respond to this report Responses (1) Author Response 06 Oct 2025 Marcus Grant, Environmental Stewardship for Health, Bristol, UK Your comment >>: While the paper does a fairly comprehensive treatment outlining the history of the urban health paradigm, it relies heavily on authoritative global health agency practice, positions, and frameworks. My review concerns two areas (1 & 2): Our response: First, thank you for your comprehensive and useful review. The paper takes that stance deliberately; we attempted to track that history and not what may be a more inclusive or open use of the concept and term urban health. What we take from your comment is that this framing needs to be sign-posted better in the introduction as context. Your comment >>: 1) Authors conclude the following: ‘While some of the insights from 75 years of evolving understanding of urban health and wellbeing have been incorporated into the Sustainable Development Goals, it is far from clear that the global agenda has taken sufficient account of lessons learned.’ However, this statement lacks a thorough discussion of what lessons were learned in the past 75 years -- other than the evolving frameworks. What is the evidence base? This may be too broad but perhaps illustrative examples would be useful. Our response: Thank you for pointing this out, we agree that the statement is too sweeping which leaves it unsubstantiated in relation the preceding sections. Replacement text has now been used to better clarify the focus: ‘Many of the insights from 75 years of an evolving understanding of urban health and wellbeing have been incorporated into the Sustainable Development Goals. However, observing the all-to-common disconnects between health policy and urban policy at the local level, it is clear that progress made at the global level has yet to have much ‘on-the-ground’ impact.’ With respect to your comment on the SDGs, there is a separate paper coming, within this WHO collection ‘Making the Case for Urban Health: Defining Value and Relevance to Contemporary Challenges’ (by Susan Parnell) that will deal with the Sustainable Development framework. We will be including a reference to that paper earlier in our paper and supporting text had been added. Your comment >>: 2) Related to above, what do authors opine are the major global pressures of our time? Our response: With respect to material on global pressures. There is already a fair amount, we will check for gaps that are significant to our themes, and also gather together what we cover in a paragraph in the introduction. We have included extra depth covering the Commercial Determinants of Health, Health equity and COVID-19 legacy and material on contemporary issue of democracy and the political economy. Your comment >>: How do these new global pressures inform this new urban health paradigm? Our response: Yes. Thanks for pointing out this omission, text now added to the concluding section. Your comment >>: The authors do not seem to clearly articulate what the emerging health paradigm is. Our response: Yes. Thanks for this observation, that section was too weak. We have revised the concluding section. Your comment >>: There is limited discussion and treatment of both classic and contemporary theoretical frameworks that exist in the social sciences that may advance this thinking. Our response: Thanks for this useful comment. The paper obviously Wil have its limitation, I am sure a book can be written her. We have not wanted to go into any depth on theoretical frameworks to keep with a remit of begin focussed on what may be more directly useful for policy and a policy audience, rather than an academic audience. We have though, in our broad sweep, sought to cover a number of social science topics such as human rights, equity, governance, global conflicts, participation and agency. Many of these issues have all been developed further in the current revision. Your comment >>: Section 5 highlights Vlahov and Galea. However, in the spirit of transdisciplinary approaches to solving the major urban health challenges of our time -- shift from communicable to NCDs, emergence of novel viral pandemics, crisis management/adaption in the face of climate change, rising inequality/health inequity in established/older cities in more affluent countries, gentrification -- there is no consideration of some of the critical frameworks from other disciplines that can help advance our thinking on how to inform a new health paradigm. Our response: Thank you for this comment. We have re-examined relevant sections. Material has been added to reflect some of the missing elements you have highlighted. However, within the scope of the current paper, we are unable to go too far into discussing the several critical frameworks that would be relevant here. In response to this comment, and others, we have added material on sociology and social epidemiology. We have also added a useful conclusion from Krefis, et al, (2018) that there is a lack of interdisciplinary approaches that highlight the complexity of urban structures and dynamics and their possible influence on urban health and well-being. [Krefis, A. C., Augustin, M., Schlünzen, K. H., Oßenbrügge, J., & Augustin, J. (2018). How Does the Urban Environment Affect Health and Well-Being? A Systematic Review. Urban Science , 2 (1), 21. https://doi.org/10.3390/urbansci2010021]. Your comment >>: There is much insight that can be learned from the fields of social epidemiology (in public health with emphasis on the social determinants of health) and urban planning/development theory (Lewis, Mumford). Our response: We certainly agree. Much has been written about the historic link between social epidemiology, the emergence of town planning and public health delivered through town planning acts. Many texts, field leaders and analyses could be cited. However, in our attempt to cover more recent developments, we don’t want to delve into this area. But to make sure there is an outline for those who may not be aware of this history we have added he following ‘In terms of urban spatial planning, much has been written about the close historic relationships - at the advert of formal city planning - between sociologist traditions looking for betterment of the working classes, public health seeking to minimize health risk, and the aims and techniques of those involved with spatial policy, layout and design. The close interplay between these three elements weakened following the post-war period as their separate disciplines evolved.’ We have also added elsewhere a note about sociology with a cite of this paper: Kelly, M. P. and Green, J. (2019) ‘What can sociology offer urban public health?’, Critical Public Health, 29(5), pp. 517–521. doi: 10.1080/09581596.2019.1654193. 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