Defining Urban Health for Strategic Action

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As such, urban health is an increasingly important facet of public, global, and planetary health, and its profound links to other areas of sustainable development make it an important nexus issue. However, there is considerable variation in how urban health is conceived and understood, including different ideas about its scope and boundaries, proper remit, subjects, protagonists, locus and sources of authority, and relationships to other rubrics. These differences derive from the complexity of urban environments and the emergence and evolution of the field of urban health from actions and perspectives spanning multiple sectors, scales, and domains. Recognizing the value of diverse viewpoints and usages, we explore and clarify several conceptual issues and debates and propose a definition of urban health as a shared basis for strategic action." } { "@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/14-144", "name": "Defining Urban Health for Strategic Action" } } ] } Home Browse Defining Urban Health for Strategic Action ALL Metrics - Views Downloads Get PDF Get XML Cite How to cite this article Siri JG, Kim J, Indvik K et al. Defining Urban Health for Strategic Action [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :144 ( https://doi.org/10.12688/f1000research.159970.1 ) 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 Defining Urban Health for Strategic Action [version 1; peer review: 2 approved with reservations] José Gabriel Siri https://orcid.org/0000-0001-7041-0310 1 , Jinhee Kim https://orcid.org/0000-0002-6439-792X 2 , Katherine Indvik 3 , [...] Evelyne de Leeuw https://orcid.org/0000-0003-3434-1439 2,4 , Carlos Dora 5 , Franz Gatzweiler 6 , Elsa Holm 7 , Deljana Iossifova https://orcid.org/0000-0003-0477-1462 7 , Francisco Obando 1 , Jean Simos https://orcid.org/0000-0003-1340-5739 8,9 José Gabriel Siri https://orcid.org/0000-0001-7041-0310 1 , Jinhee Kim https://orcid.org/0000-0002-6439-792X 2 , [...] Katherine Indvik 3 , Evelyne de Leeuw https://orcid.org/0000-0003-3434-1439 2,4 , Carlos Dora 5 , Franz Gatzweiler 6 , Elsa Holm 7 , Deljana Iossifova https://orcid.org/0000-0003-0477-1462 7 , Francisco Obando 1 , Jean Simos https://orcid.org/0000-0003-1340-5739 8,9 PUBLISHED 30 Jan 2025 Author details Author details 1 Urban Health Unit, World Health Organization, Geneva, Switzerland 2 Cities Institute, University of New South Wales, Sydney, Australia 3 Urban Health Collaborative, Drexel University, Philadelphia, PA, USA 4 Université de Montréal, Québec, Canada 5 International Society for Urban Health, Geneva, Switzerland 6 Institute of Urban Environment, Chinese Academy of Sciences, Xiamen, China 7 Manchester Urban Institute, University of Manchester, Manchester, UK 8 Société Francophone de Santé et Environnement, Paris, France 9 Institute of Global Health, University of Geneva, Geneva, Switzerland José Gabriel Siri Roles: Conceptualization, Project Administration, Supervision, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Jinhee Kim Roles: Conceptualization, Writing – Original Draft Preparation, Writing – Review & Editing Katherine Indvik Roles: Conceptualization, Writing – Original Draft Preparation, Writing – Review & Editing Evelyne de Leeuw Roles: Conceptualization, Writing – Original Draft Preparation, Writing – Review & Editing Carlos Dora Roles: Conceptualization, Writing – Original Draft Preparation, Writing – Review & Editing Franz Gatzweiler Roles: Conceptualization, Writing – Original Draft Preparation, Writing – Review & Editing Elsa Holm Roles: Conceptualization, Writing – Original Draft Preparation, Writing – Review & Editing Deljana Iossifova Roles: Conceptualization, Writing – Original Draft Preparation, Writing – Review & Editing Francisco Obando Roles: Conceptualization, Writing – Original Draft Preparation, Writing – Review & Editing Jean Simos Roles: Conceptualization, Writing – Original Draft Preparation, 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 Cities play a dominant and expanding role in human lives and civilization. As such, urban health is an increasingly important facet of public, global, and planetary health, and its profound links to other areas of sustainable development make it an important nexus issue. However, there is considerable variation in how urban health is conceived and understood, including different ideas about its scope and boundaries, proper remit, subjects, protagonists, locus and sources of authority, and relationships to other rubrics. These differences derive from the complexity of urban environments and the emergence and evolution of the field of urban health from actions and perspectives spanning multiple sectors, scales, and domains. Recognizing the value of diverse viewpoints and usages, we explore and clarify several conceptual issues and debates and propose a definition of urban health as a shared basis for strategic action. READ ALL READ LESS Keywords urban health, health equity, sustainable development, public health, social determinants of health, urbanization, complex systems, intersectoral collaboration, healthy cities Corresponding Author(s) José Gabriel Siri ( [email protected] ) Close Corresponding author: José Gabriel Siri Competing interests: No competing interests were disclosed. Grant information: This work was supported by the World Health Organization Urban Health Unit. Copyright: © 2025 Siri JG 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: Siri JG, Kim J, Indvik K et al. Defining Urban Health for Strategic Action [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :144 ( https://doi.org/10.12688/f1000research.159970.1 ) First published: 30 Jan 2025, 14 :144 ( https://doi.org/10.12688/f1000research.159970.1 ) Latest published: 30 Jan 2025, 14 :144 ( https://doi.org/10.12688/f1000research.159970.1 ) Key messages • Urban areas are increasingly important to health, equity, and sustainable development. • Well-designed action to promote urban health can produce co-benefits for and advance the objectives of sustainable development across all sectors and scales. • Strategic action for urban health requires epistemological humility, patience, and effective communication to foster shared understanding across multiple stakeholders and perspectives. • Urban health terminology is conceived of and used in different ways by different actors and knowledge communities, potentially giving rise to ambiguities and miscommunication that can reduce effectiveness. • A common definition of urban health and related terminology is vital for strategic action and coordinated advocacy. • Among the ambiguities that pose challenges for a common definition are variations in how terms like “urban” and “health” are understood, as well as different ideas about the boundaries, scope, and remit of urban health. • Translation into multiple languages is critical to securing shared understanding and essential to identifying ambiguities or incongruities that would limit a common definition’s applicability across diverse cultures and contexts. • A common definition must also be legible to stakeholders representing the wide variety of disciplinary languages and professional cultures that characterize urban health. • Urban health must encompass all social groups and geographical contexts, and deliberate efforts are needed to address inequities in knowledge, action, and outcomes. • Any actor that ensures the existence of healthy situations and opportunities and/or the resilience and sustainability of health-supporting systems is practicing urban health. • A conceptual framework that considers the directness and magnitude of impacts is useful in defining the scope and remit of urban health. • Rubrics like planetary health, resilience, ecohealth, and One Health encompass concerns and pursue goals that are coherent with—albeit different from—urban health, and thus represent valuable complementary conceptual frameworks. Introduction About three in five human beings live in cities today—more than three in four if towns and other semi-dense areas are included ( Dijkstra et al., 2021 ; Ritchie et al., 2024 ). As such, urban areas have become the primary habitat for most people—the “[setting] of their everyday life; where they learn, work, play, and love” ( WHO, 1986 ). This is the result both of natural increase among urban populations and of the powerful pull that urban opportunities, amenities, culture, and other factors exert on people everywhere. Urban areas also exercise tremendous influence on economies, societies, and environments at all scales. To cite just a few examples, cities are responsible for 80% of GDP ( McKinsey Global Institute, 2011 ), over 70% of carbon emissions from energy use ( Seto et al., 2014 ), and the vast majority of innovation (e.g., patents) and knowledge production ( WIPO, 2019 ). The predominance of urban areas in human lives and societies will continue to increase for the foreseeable future. Current trends imply that achieving health in urban areas will represent a growing challenge everywhere; within a human generation, more than 80% of countries will be majority urban ( Ritchie et al., 2024 ). As such, urban health will increase in scale and importance both relative to rural health and as a component of public and global health. Furthermore, urban health is inseparably intertwined with other facets of sustainable development, and thus represents a nexus issue: actions that affect urban health typically have co-benefits or co-harms for other societal goals. Indeed, the intricate, overlapping patterns created by concentrations of people, pathogens, and processes, ideas and institutions, and material goods and ills (like pollution) are characteristic of urban areas. Urban complexity subjects the health of urban dwellers to a broad set of influences and to the often-unpredictable results of their dynamic interactions. Urban health is thus qualitatively different from rural or public health more generally, and the nature of challenges and solutions in this realm is necessarily cross-sectoral, cross-scale, and cross-domain ( Figure 1 ). Figure 1. The multifaceted nature of urban health challenges and solutions. Urban health arises from the interacting dynamics of actions taken by individuals and institutions representing an array of different sectors, scales, and domains. These actions intersect with one another and with the social and physical features of the urban fabric to generate health outcomes. In this figure, “sector” indicates thematic focus, whereas “domain” indicates the societal category of an individual or institutional actor (N.B., lists of sectors, scales, and domains are not intended to be exhaustive). To attain and sustain the highest levels of urban health, action must be strategic and account for the complex interactions among diverse actors, and between actors and urban environments, over a range of timeframes. One potential counterargument posits that the solutions to specific urban health issues are often well-understood. Yet even straightforward actions are embedded in complex urban—and broader—systems. This can lead to unanticipated or undesired outcomes, depending on the nature of these systemic relationships, even where solutions are seemingly clear. For example, catalyzing a shift to active transport (i.e., walking and cycling) is one of the most impactful and obvious measures to promote urban health, yet in some contexts it can expose travelers to air pollution, disease transmission, or unsafe situations, among other hazards, or can give rise to gentrification that excludes marginalized communities. A strategic approach allocates appropriate levels of oversight to both ostensibly routine and more complex issues, while maintaining awareness of potential systemic interactions. There are significant differences in definitions, usage, and conceptual framing surrounding urban health by different stakeholders and knowledge communities ( Kim et al., 2022 ). Among these are different ideas about its scope and boundaries, proper remit, subjects, protagonists, locus and sources of authority, and relationships to other rubrics. These differences support a rich variety of perspectives on and approaches to urban health, contributing to greater innovation and novel solutions. Yet they may also contribute to faulty communication, mismatched objectives, and/or inefficiencies in research, data, policy development, and practice. Indeed, one review identified a lack of common understanding among the urban health community as a factor limiting its political prioritization at the global scale ( Shawar and Crane, 2017 ). Given the fundamentally different conceptual frameworks, knowledge, heuristics, objectives, and even ethical precepts that diverse actors bring to urban health, one key to successful strategic action is establishing a common understanding of core terminology. In this piece, we propose a common definition of urban health to serve as a shared basis for strategic action. We then explore several salient conceptual issues that underlie the proposed definition. In satisfying the need for clear terminology to underpin strategic action, we assert that it is important to recognize and value diverse perspectives. The intent of this piece is to constructively support strategic action, not to stifle diverse interpretations or permanently settle debates about the conceptual issues involved in urban health. This analysis is intended to be of use to the World Health Organization (WHO) as it seeks to increase the strategic acumen of urban research, policy, and practice, and to other stakeholders interested in improving urban health through strategic approaches. A common definition of urban health for strategic action Urban health n. 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. 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. This definition draws on a range of important precedents. Grant et al. (2024) offer more detail on the emergence of the modern paradigm of urban health, which includes a brief review of the context for and development of the Alma-Ata Declaration, the Ottawa Charter for Health Promotion, the Commission on the Social Determinants of Health, the Rockefeller Foundation-Lancet Commission on Planetary Health, and other foundational efforts that informed the definition presented here. Existing textual references describing or defining “urban health” ( Kim et al., 2023 ; NYU School of Global Public Health, 2024 ; Ompad et al., 2008 ; Urban Design Lab, 2024 ), “healthy city” ( WHO, 2024d ), “Health in All Policies” ( WHO, 2014 ), “health promotion” ( Nutbeam and Muscat, 2021 ; WHO, 1986 ), “One Health” ( One Health High-Level Expert Panel (OHHLEP) et al., 2022 ), “planetary health” ( Whitmee et al., 2015 ), “public health” ( Winslow, 1920 ), and “social determinants of health" ( Hahn, 2021 ), among others, also influenced choices about form and content. Key elements Below we highlight the rationale and implications of specific elements of the proposed definition. By clarifying the emphasis and meaning of these elements, we intend to provide a deeper understanding of the definition itself and to inform its translation into other languages. “ Urban health ” • “Health” is here understood as per the comprehensive definition promulgated by WHO in its Constitution: “… a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” ( WHO, 1948 ). “… 1 the art and science …” • Because urban health is complex and constantly changing, effective action depends on both rigorous evidence, developed to the highest scientific standards (“science”), and practical, heuristic knowledge gained through lived experience in managing people and processes in cities (“art”). “Art”, in this usage, includes the qualitative, intuitive, and creative aspects of understanding and addressing urban health challenges. While perfect information is a practical impossibility, art and science each nevertheless play indispensable roles in informing all aspects of action to promote urban health. “… of improving health and health equity … every person …” • Equity is a fundamental aspect of urban health, both as a measure of systematic health deficits and because urban inequities can themselves drive negative health impacts—for example, via toxic stress-mediated pathways ( Corburn, 2017 ). A strategic approach to urban health requires dedicated planning and ongoing evaluation to ensure that all urban dwellers experience healthy situations and opportunities to thrive. “… securing resilience and sustainability …” • Urban health is a dynamic phenomenon, unfolding over time. As such, it involves ensuring that the state of health is both resilient—i.e., able to resist shocks, recover, and continue to improve—and sustainable—i.e., able to be maintained over the long term—in the face of ongoing change ( Siri and Indvik, 2022 ). “… of health-supporting natural and human systems .” • Ensuring that urban health is resilient and sustainable necessarily implies doing the same for the systems that support it. Some of these systems are natural (e.g., ecosystems, hydrological systems), others anthropogenic (e.g., legal and economic systems, infrastructure, social capital), but all need to be developed and managed over the long term. This effort is a core concern for urban health. “ More than the sum of its parts …” • Just as the state of urban health is an emergent outcome of the combined functioning of urban systems, urban health action also has emergent properties. In other words, urban health, taken as a whole, exhibits qualities that aren’t present in and can’t be predicted from its component activities. The impacts and outcomes of a suite of urban health interventions are not just the sum of their individual impacts and outcomes, but rather depend on the different reactions and interactions they induce among actors, institutions, environments, and each other. “… to create healthy situations and … the chance to thrive …” • Urban health is influenced by both the passive exposure of people to local combinations of the determinants of health (“situations”) and their active pursuit of opportunities to develop their full potential (to “thrive”). This definition emphasizes the importance of the juxtaposition of higher-level governance with individual and collective agency in achieving health. “… now and into the future …” • As it seeks to secure every urban dweller’s health in the face of continual change, urban health necessarily adopts and embraces multiple timeframes. It accounts for the past, respecting the lessons of history and the ongoing impacts of past decisions in tackling the problems of the present. At the same time, it looks toward the future, recognizing the role of path dependency and avoiding taking on long-term negative impacts for ephemeral gains. “… 2. a measure of the health of urban dwellers …” • We recognize the primary focus of urban health to be urban dwellers, including both permanent residents of urban areas and those whose temporary presence exposes them to urban determinants of health and the impacts of urban health action. “… as continually created …” • Just as “Our cities and urban areas are continually created and re-created through large-scale renewal and investment as well as on-going myriad small-scale interventions” ( Grant et al., 2017 ), the state of urban health is also continually created—not static, but rather constantly shifting with changing urban conditions and interactions. As such, urban health action, too, demands habitual reexamination to keep up with evolving situations. “… by their complex interactions …” • In urban spaces, nothing is isolated, and actors, institutions, and environments constantly interact with one another; these interactions influence urban health and can give rise to behaviors and outcomes characteristic of complex systems. “… with urban physical and social environments …” • Both physical and social environments have profound influence on urban health. Physical environments include both natural (e.g., air, water, soil, ecosystems) and anthropogenic (e.g., built environments, pollution) elements, while social environments encompass economic, commercial, and cultural factors, power and politics, institutions, and the broad sweep of social determinants of health. “… and by the decisions and institutions … that shape these interactions …” • Urban health is influenced by the decisions made by every urban stakeholder and by many stakeholders outside cities. This includes decisions about the form and function of institutions, where institutions are both collective decision-making bodies and “the prescriptions that humans use to organize all forms of repetitive and structured interactions” ( Ostrom, 2005 ). Urban health stakeholders include individuals and institutions from across all sectors, scales, and domains. With this definition in mind, we explore several key aspects of urban health in further detail. Defining the subjects of urban health The primary focus of urban health is necessarily the health of people in cities, or urban dwellers, reflecting the intellectual and institutional contexts and traditions within which the concept arose and matured ( Grant et al., 2024 ). “Dweller” is a potentially ambiguous term; here we include both those whose primary residence is in urban areas and those whose temporary presence in such areas exposes them to urban determinants of health, reasoning that this makes them amenable to the influence and impacts of urban health action centered on cities. Below, we discuss several issues with implications for categorizing the subjects of urban health. These include the challenge of defining urban areas, the extra-urban impacts of urban processes, the need for equitable consideration of urban health across spatial and social strata—including the special challenge of slums—and for all geographic regions, and the applicability of urban health to non-human life. What is urban? Given that urban health deals with the health of urban dwellers, the definition of urban is key to understanding its scope and possibilities, yet there is no universally accepted standard, and finding common ground has posed an ongoing challenge ( Dijkstra et al., 2021 ; Iossifova et al., 2017 ). Variable definitions of urban likewise make the identification of urban dwellers less than straightforward. There is a consensus that urban areas, broadly, are characterized by large, dense populations and concentrations of anthropogenic institutions, infrastructure, goods, and services. 1 Yet in deciding whether a particular place is urban, different arbiters emphasize different aspects of urbanicity. These may include population size or density, political status or jurisdictional considerations, the typical occupation of residents or other economic indicators, assessments of infrastructure, or other social or cultural phenomena ( Iossifova et al., 2017 ; Ritchie et al., 2024 ). Based on similar considerations, a multitude of terms has also arisen to describe different types of urban areas, urban features, or varying levels of “urbanicity.” For example, the idea of “settlement hierarchies”, which characterize human settlements along a continuum of size, status, or other features has arisen in various historical contexts, and was propounded more formally by Doxiadis (1970) and others. However, this and other urban-related terms can also have different definitions and usages. While a full discussion of urban terminology is beyond the scope of this paper, resources such as the Multilingual Glossary of Human Settlements Terms developed by UN-Habitat can provide useful context ( UN-Habitat, 1992 ). One important distinction is between the terms “urban area” and “city”, which are sometimes conflated. A “city” is typically defined in political or administrative terms, referring to an area governed by a local authority with the power to create, manage, and enforce rules. In contrast, an “urban area” is a geographical term defined by the presence or absence of typical urban features or characteristics. Cities and urban areas don’t always align; many urban regions extend beyond city boundaries, and some span multiple city jurisdictions ( Duminy et al., 2023 ). Metropolitan areas often incorporate smaller cities along with multiple layers of governance. Additionally, some cities include rural areas within their political boundaries. Global assessments of urbanization typically adopt national definitions, which may differ enormously from country to country and can create inconsistent categories. For example, “Sweden and Denmark set [the] threshold [for defining urban areas] at only 200 inhabitants; Japan at 50,000 (a 250-fold difference)” ( Ritchie et al., 2024 ). Where classification is based on a city’s political status or other considerations not related to its constituent features, definitions can lead to different “urban” areas having significant qualitative differences, or to the exclusion of areas with urban qualities. Efforts have also been made to produce more universal, replicable, and globally comparable definitions of urban using satellite imagery and gridded population data. For example, the Degree of Urbanization (DEGURBA), has been endorsed by the UN Statistical Commission ( UN Statistical Commission, 2020 ). It applies universal criteria based on gridded density and total population thresholds to determine what areas are urban. DEGURBA estimates substantially higher urbanization than traditional assessments based on national definitions, especially for Africa and Asia ( Dijkstra et al., 2021 ). Different disciplinary traditions may also apply different definitions of urban, focusing on the processes and features most relevant to their disciplinary fields and research paradigms (i.e., in academia) or sectoral responsibilities (i.e., in practice); such definitions are strongly influenced by the historical development of the discipline in question ( Wolman et al., 2024 ). There is significant value in specialized national and disciplinary definitions of urban. The former may yield insights more relevant to local conditions; the latter may lend themselves more readily to generating relevant research questions or policy formulations. Yet different definitions may also lead to misclassification, misinterpretation, and miscommunication, and therefore to incompatibilities or a lack of generalizability in data or the insights derived therefrom and to conflicts or inefficiencies among actions taken in consequence. The way that urban is defined in the context of urban health practice must be guided by objectives. Where the goal is to design or evaluate urban health action for a particular place, traditional (i.e., national) definitions may better capture the local governance context and its impacts. Where comparison or generalizable insights are intended, universalized definitions like the Degree of Urbanization likely offer a more useful, harmonized approach. In any case, awareness of the differences between definitions (including nationally vs. globally defined and disciplinary/sectoral) and their implications will lead to more comparable, generalizable insights, better communication, and more effective action. Health impacts beyond urban areas Although we restrict urban health to urban dwellers, actions taken in and for urban areas do have health impacts well beyond their boundaries, given the magnitude of urban processes and cities’ prominence in local, regional, and global systems. There are at least six categories of such extramural effects, including health impacts from: • the spread of environmental pollutants (e.g., air pollution) • the amplification of infectious disease transmission (e.g., COVID-19) • economic and social processes in urban hinterlands that rely on a particular city (e.g., local urban-rural linkages related to food, work, or other factors) • inter-urban exchanges or diffusion of goods and knowledge, sometimes at regional or global scale (e.g., trade, culture, innovation, and policies) • urban influences on planetary systems (e.g., biodiversity, climate, hydrosphere) • urban exposures among temporary visitors, including circular migrants, urban-rural commuters, and tourists (e.g., mental health impacts of commuting, exposure to injury or infectious disease risks). Exposures and outcomes for the first five types occur in urban or rural areas that are separated—sometimes at great distances—from their source. While it is therefore challenging to include these influences in city-level urban health action, awareness of extra-urban impacts can help urban health actors make decisions that improve health more broadly and avoid decisions that harm health outside of their cities. National-level strategic action is better positioned to address specific extra-urban impacts and may incorporate such processes into the remit of urban health authorities. In contrast, the final type of impact involves exposures within urban boundaries and is more amenable to city-level action—thus the inclusion of temporary “dwellers” among the subjects of urban health. Including all urban dwellers: urban health equity Urban areas are, on average, healthier than rural areas, yet are also home to enormous disparities in health and in the determinants of health. Slums and informal settlements experience some of the worst health outcomes ( WHO and UN-Habitat, 2010 ) and house about a quarter of the urban population globally; this proportion has been decreasing while the absolute number of slum dwellers continues to rise ( Ritchie et al., 2024 ). Despite their ubiquity, slums and informal settlements are often left behind in urban policies and priorities. As outlined above, an equity focus is critical to any complete definition of urban health and its subjects. Health inequities, by definition, arise from modifiable factors; they are rooted in the social determinants of health, in many contexts reflect historical inequities in decision-making or contemporary stigma, and are often expressed in well-defined spatial patterns. Redressing such inequities requires not solely an effective overall approach to urban health, but also targeted efforts to reduce disparities and reverse the conditions which generate them ( Lee et al., 2023 ). In general, this requires action on both the upstream, structural determinants of health, such as governance, culture, and social and public policies, and more proximal, intermediary determinants, like material circumstances and behaviors ( Solar and Irwin, 2010 ). Including urban dwellers everywhere: urban health geography Urban health is important and becoming more so in all geographical regions. Indeed, the range of environmental, social, and economic factors at play across different geographical contexts demands the application of diverse perspectives to the practice of urban health. However, urban health thought leadership, narratives, data, and guidance are unequally distributed; these resources are more readily available in the Global North, Western cultures, and larger, wealthier, more prominent cities (e.g., megacities) ( Taylor et al., 2018 ). This is especially challenging because the preponderance of urbanization is taking place in the Global South and in small- to medium-sized cities, under far different conditions than in previous growth centers. To support strategic action, a universal definition must span cultural and communicational differences—and must be available in local languages. However, the diversity of language challenges universality, as different language traditions have different cultural signifiers, content, norms, and value structures. Some concepts are essentially untranslatable, and it is not possible to create a definition that transmits precisely the same information and connotations across all languages. Nevertheless, we attempt to convey the essential messages of the proposed definition through suggested translations into the six languages of the United Nations (see Box 1 ). We welcome constructive debate to improve the accuracy of these translations, and we encourage translation of the definition into additional languages. 2 Box 1. Definition of Urban Health in the six official languages of the United Nations Urban health n. 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. 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. الصحة في المناطق الحضرية : 1) هي فن وعلم تحسين الصحة والعدالة الصحية في المناطق الحضرية، بما في ذلك من خلال ضمان مرونة واستدامة النظم الطبيعية والبشرية الداعمة للصحة؛ وهي تشمل مفهوماً واسعاً يضمن تفاعل الناس والمؤسسات والبيئات لخلق أوضاع صحية وضمان حصول كل شخص على فرصة للازدهار، الآن وفي المستقبل. 2) هي مقياس لصحة سكان المناطق الحضرية في سياق تشكّلها المستمر بفعل تفاعلاتهم المعقدة مع البيئات المادية والاجتماعية الحضرية، وبفعل القرارات والمؤسسات على جميع المستويات التي تشكل هذه التفاعلات. 城市健康 一是改善城市地区健康和健康公平的艺术与科学，包括通过增强保障健康的自然、人类系统的韧性和可持续性；这并非简单地元素叠加，而是确保人类、机构与环境之间的互动能够产生健康的效果，让每个人在当下和将来都能蓬勃发展。二是对城市居民健康状况的一种衡量，这种健康状况是由城市居民与城市物质环境、社会环境之间的复杂互动，以及影响这些互动的各种规模的决策和机构而不断塑造而成的。 Santé urbaine n. 1 art et science visant à améliorer la santé et l’équité en matière de santé en milieu urbain, notamment en garantissant la résilience et la durabilité des systèmes naturels et humains favorables à la santé ; au-delà de la somme de ses différents éléments, la santé urbaine permet aux personnes, aux institutions et aux environnements d’interagir pour créer des situations favorables à la santé et donne à chaque personne la possibilité de s’épanouir, immédiatement et plus tard. 2 mesure de la santé des personnes qui habitent en milieu urbain telle qu’elle est continuellement déterminée par leurs interactions complexes avec les environnements physiques et sociaux urbains, et par les décisions et les institutions à toutes les échelles qui influent sur ces interactions. Городское здравоохранение , 1. творческая и научная дисциплина об укреплении здоровья и равенства в области охраны здоровья на территории городов, в том числе путем обеспечения устойчивости и долгосрочного функционирования поддерживающих здоровье природных и антропогенных систем; городское здравоохранение, будучи больше суммы своих частей, обеспечивает взаимодействие между людьми, институтами и факторами окружающей среды для формирования благоприятных для здоровья условий и дает каждому человеку возможность для процветания в настоящее время и в будущем; 2. понятие, описывающее непрерывно меняющееся состояние здоровья городских жителей в процессе их комплексного взаимодействия с физической и социальной средой городов, а также под влиянием определяющих такое взаимодействие решений и действий институтов на всех уровнях. Salud urbana f. 1 arte y ciencia de mejorar la salud y la equidad en materia de salud en las zonas urbanas, incluso protegiendo la resiliencia y sostenibilidad de los sistemas naturales y humanos favorables a la salud; más que la suma de sus partes, permite garantizar que las personas, las instituciones y los entornos interactúen para generar situaciones saludables y que todas las personas tengan la oportunidad de prosperar, ahora y en el futuro. 2 medida de la salud de los habitantes de las zonas urbanas constantemente creada por las complejas interacciones que estos mantienen con los entornos físicos y sociales urbanos, y por las decisiones e instituciones, a todas las escalas, que dan forma a esas interacciones. Urban health beyond human health Although human health is the end point for urban health practice and its subjects are human beings, there are good reasons for it to consider the health of other organisms and ecosystems, both those in urban areas and those beyond their boundaries that are affected by urban processes. Attention to the health of ecosystems and non-human organisms is critical to achieving human health in urban areas. Ecosystems affect urban health via an extensive range of causal pathways, including those that are environmental (e.g., regulation of microclimate, air quality, or flood risk), ecological (e.g., pollination impacts on agriculture, infectious disease transmission), physiological (e.g., microbial impacts on immune function), or social (e.g., influence on opportunities for recreation and social bonding) in nature. These dynamics and connections are recognized by One Health and related rubrics (see below) and in the definition presented here. Defining the remit of urban health Urban health is the result of interactions among a host of urban stakeholders and institutions with each other and their environments. The tremendous range of actions with potential to influence urban health complicates the delineation of its scope and boundaries. Without a definite sense of these limits, it can also be challenging to define who bears responsibility for urban health and how we should understand their role(s). The answers to these questions have implications regarding how we govern urban health, how we assign specific actions to specific actors, and how we document and evaluate implementation. Better defining the remit of urban health can support stakeholders in understanding and articulating the value of urban action, assessing needs and possibilities, setting expectations, assigning authorities, and designing solutions. Indeed, making the case for strategic, integrated action depends on assumptions about the scope and boundaries of urban health. The nature of urban health challenges Urban areas concentrate people, institutions, infrastructure, goods, and services, and anchor long distance processes like migration, trade, knowledge diffusion, and communications. This density underpins complex interactions among all these factors and with local environments. Moreover, just as every action has economic implications (i.e., costs or benefits, including opportunity costs), every action also has health implications. As such, the panoply of actors and institutions—spanning all sectors and scales—that influence the urban milieu are also contributing to urban health, interacting in complex ways to produce outcomes. While a technical discussion of urban complexity is beyond the scope of this paper, certain aspects of the dynamics of urban systems have critical implications for urban health. For example: • Simple cause-and-effect relationships are invariably part of larger feedback cycles. • Outcomes are not necessarily proportional to the scale of actions. • Actions have multiple effects and produce cascading chains of downstream consequences. • It is not possible to know how all actors are contributing to outcomes. • Overall health patterns may not reflect the planned impacts of individual interventions. This complexity can lead to unpredictable outcomes, low or diminishing effectiveness or efficiency of interventions, and undesirable patterns of behavior, including boom-bust cycles, escalating problems, or collapse. Grappling with complexity and grasping its potential impacts is essential to navigating potential actions and managing its consequences. Conversely, a failure to engage with complexity can lead to policy failures ( Newell and Siri, 2016 ). As such, recognition of complex interactions is essential to strategic action, as recognized in the definition presented here. Who is responsible for urban health action? We distinguish between causal responsibility and institutional responsibility—the former is descriptive; the latter is prescriptive. All urban stakeholders’ actions have health consequences, and therefore all have some level of causal responsibility for urban health. Typically, urban health outcomes result from competing causal pathways that are difficult to fully visualize or disentangle, making it challenging to attribute responsibility to specific actions or actors—although actions with outcomes that are more proximate or of greater magnitude are easier to characterize. Analyzing, documenting, and educating about the impact of different actors’ decisions on health is an important part of moving beyond siloed practice. In the institutional sense, responsibility for urban health is generally delegated to relevant authoritative bodies. In the absence of specific guidance, formal institutional authority is likely to devolve to the health sector as an aspect of public health. The health sector is indeed the primary actor charged with securing and improving health. It also has a duty to inform, illuminate causal pathways, and make all stakeholders more aware of their health impacts. Yet in the face of urban complexity, it is crucial that urban health activity not be constrained to health sector interventions. In some contexts, the leadership role or locus of control for urban health is allocated to other sectors or to cross-sectoral bodies. This may reflect resource considerations; cultural preferences; the distribution and relationships of local determinants, health outcomes, or stakeholders; or other factors. Although comprehensive plans are rare, cross-sectoral urban health leadership is emerging for some issues. For example, the need to address urban heat-health risks is spurring cities around the world to experiment with cross-sectoral institutional mechanisms—like chief heat officers, tasked with “delivering a unified response to extreme heat … coordinating dispersed efforts both inside city government and across the private sector … [and] break [ing] down silos” ( Atlantic Council Climate Resilience Center, 2024 ). The nature of specific urban health challenges may also suggest—or even dictate—a particular authority structure. Some issues have relatively straightforward, well-understood solutions without strong systemic ramifications that are easily managed by specific sectors or stakeholders. Identifying such issues is an important part of efficient strategic urban health action. No single locus or form of authority structure is ideal for urban health in all contexts, and the best arrangements will depend on local conditions. But purposeful allocation of authority is a critical aspect of urban health action ( WHO, 2023a ). Regardless of how authority is allocated, the practice of urban health necessarily transcends the boundaries of the health sector (see Figure 1 for examples). Traditionally, several specific sectors are associated with and often bear some level of (causal and/or institutional) responsibility for urban health, due to strong, direct, and/or highly visible associations. For example: • Transportation affects air quality, levels of physical activity, and the spatial distribution of people with respect to the determinants of health. • Housing affects exposure to weather extremes, vectors, and toxic pollutants. • Green space affects mental health, levels of physical activity and social interaction, and microclimate. • Water, hygiene, and sanitation affect exposure to infectious pathogens and physical hazards. Similarly, urban health is dependent on actions at multiple scales, implicating actors at these levels with some level of responsibility for outcomes. For example: • Community-level actors implement safety measures, social support, joint advocacy for local interventions, and last-mile solutions for service delivery. • City-level actors have primary responsibility for implementing sectoral infrastructure, delivering services, and allocating local budgets. • Country-level actors are responsible for creating regulatory and legal frameworks, setting budgets, and coordinating financing. Lastly, urban health depends on action across a range of domains: • The public sector has formal charge of urban health action; it also enables and coordinates the participation of other sectors. • The private sector influences the shape of the built environment and the availability and delivery of goods and services. • The civic sector identifies and addresses specific health or equity challenges and can support the public sector in urban health action. The ecumenical nature of responsibility for urban health implies that a common definition should be agnostic about the range or precedence of protagonists. Formal authorities and processes for urban health will be defined locally, yet any actor that ensures the existence of healthy situations and opportunities and/or the resilience and sustainability of health-supporting systems is practicing urban health. What is the scope of urban health action? It is difficult to place conceptual or practical boundaries on urban health, in part because urban systems are extensively interlinked. Every action has both immediate and downstream consequences, and every outcome has both immediate and upstream causes. Likewise, all actions have multiple outcomes, and all outcomes have composite causes. Not having a clear sense of the level or types of actions that should be included makes it difficult to estimate the potential impacts or benefits of urban health action ( Garber et al., 2024 ). For example, while most arbiters would agree that designating cycle lanes falls under the aegis of urban health, it is less clear whether this is true for implementing 15-minute-city strategies that envision a wholesale redesign of the urban fabric—the latter may be seen as beyond the remit of urban health, despite having profound health implications. In the same vein, where should formal urban health strategies draw the line insofar as the actions they consider? Important questions about remit include: • Does urban health action presuppose urban specificity? E.g., do nationwide vaccination campaigns fall outside the remit of urban health because they have no particular urban focus? • Can urban health action take place without the involvement of the health sector? E.g., is the establishment of a health-promoting urban park part of urban health even if no health sector consultation is undertaken? • Does urban health incorporate health-affecting decisions taken for non-health reasons? E.g., are zoning regulations for commercial or industrial activity part of urban health? • Does urban health encompass actions that are significantly upstream from health outcomes—e.g., land use, urban planning, fiscal policy? • Does urban health encompass other broadly indirect pathways mediated via human systems—e.g., economic processes that impact nutrition and thus health; discrimination that impacts labor opportunities and thus the affordability of healthcare; the effects of migration or trade policy? While the answers are not cut-and-dried, the definition proposed here suggests a qualified “yes” to each of the previous questions, in conceptual terms. However, the formal scope of urban health action will vary with different political and institutional contexts and across cities and countries with different risk profiles and resource pools. Three factors tend to determine the definition of formal limits to urban health action in a particular context: • the direct/proximal versus upstream/distal nature of causes, • the magnitude of impacts, and • the availability of resources. Where resources (e.g., financial, human, institutional) are plentiful, the scope of formal urban health action is more likely to be able to encompass determinants that operate less directly or have a lower magnitude of impacts. Where resources are scarce, the focus is likely—unfortunately—to be restricted to the most direct, highest magnitude determinants, even though many upstream determinants have extensive impacts on a range of health outcomes. We stress that this is a descriptive, not a normative, analysis. As a matter of equity, everyone should enjoy access to the highest attainable standards of health, which implies addressing all significant risk factors. Increasing the efficiency or effectiveness of urban health action through strategic approaches allows for the expansion of the horizon of potential action. Meanwhile, assuring the availability of financial and human resources for urban health practice at a level consistent with strategic action is a critical function of governance for urban health ( WHO, 2023a ). In general, urban health action should: • involve those stakeholders whose actions influence health outcomes in cities most directly and/or with the greatest magnitude of impact; • influence those stakeholders whose actions are further upstream of health outcomes or have lesser direct impacts; • inform all urban stakeholders about determinants and outcomes and the form and likely impact of actions. Because all actions that impact urban phenomena have health implications, there is no theoretical limit to the set of activities that could be incorporated under the rubric of urban health. Practically, however, the scope of formal urban health action should not exceed the point where the marginal costs (e.g., of coordinating mechanisms, interventions) exceed the marginal benefits. This limit may not be possible to measure directly, but it can serve as a guiding principle. In defining the scope of urban health action, decision-makers should consider a range of potential intervention points, including: • Actions that directly affect health outcomes, considering their effects both individually and in light of their complex interactions (e.g., separating bicycle lanes to reduce traffic injury risks, while considering how modifying cycling infrastructure affects utilization of parks or other services); • Upstream actions and interactions that impact health indirectly through physical or social systems (e.g., land development policies that have implications for walkability); • Supra-urban actions that create the physical, social, and institutional environment within which urban health impacts emerge (e.g., national migration policy that influences the composition and distribution of urban populations); • Incidental actions by other urban stakeholders that may change the dynamics of urban health impacts (e.g., marketing activities by commercial actors that modify how urban dwellers interact with urban services). The nature of urban health solutions and the need for a strategic approach Even though all urban actions affect health, urban health interventions are often circumscribed, siloed, and fragmented from one another and tend to focus on limited sets of outcomes, sectors, determinants, or targets. Such isolated actions can have positive effects in some contexts. Moreover, not every action has significant systemic impacts, and some urban health challenges can be managed straightforwardly by specific sectors or stakeholders. Identifying such situations is an important aspect of urban health. Nevertheless, a long history of intellectual and programmatic work has recognized the need for cross-cutting action. For example, it is central to the Healthy Cities and Health in all Policies ( The Helsinki Statement on Health in All Policies, 2014 ) approaches. To be optimally effective, urban health must go beyond expanding the range of sectors that implement health-oriented actions and adopt a strategic approach (see Box 2 ), linking actions across sectors, scales, and domains in a coherent strategy that considers how complexity will affect outcomes over time ( WHO, 2024a , 2024b , 2024c , 2023a , 2023b ). The definition proposed here is intended to support the adoption, implementation, and political prioritization of a strategic approach to urban health. Box 2. What are the elements of a strategic approach? The WHO Strategic Guide to Urban Health policy brief series ( WHO, 2024a , 2024b , 2024c , 2023a , 2023b ) lays out a series of elements essential to a strategic approach. Such an approach should be: 1. Integrative: encompassing, involving, and empowering all stakeholders whose actions contribute to urban health; raising collective awareness of risks and opportunities; creating a shared vision prioritizing collaboration toward unified goals; supporting intersectoral connections and joint work; fostering coherence in action, diversity in ideas, and grass roots ownership. 2. Contextualized: tailoring solutions to local conditions, culture, and values; recognizing that social, environmental, economic, and commercial determinants of health vary widely, as do stakeholders and their needs, priorities, capabilities, norms, and resources; using place-based mechanisms to involve local actors in urban health planning, policy, and practice. 3. Complexity-informed: acknowledging the dynamic complexity of cities and their relationships to broader interdependent systems (e.g., climate, global trade); recognizing feedbacks among social, environmental, economic, and commercial determinants of health and health outcomes; avoiding unintended consequences, managing systemic conflicts, and capitalizing on synergies. 4. Equity-oriented: recognizing that populations in situations of vulnerability face heightened health risks, that exclusion exacerbates health inequities, and that these are intersectional and compounding; devoting the effort and resources to rectify injustice and counter the self-perpetuating nature of inequities; leveraging urban health decision-making to prevent and reduce inequities among cities, citizens, neighbourhoods, and population subgroups. 5. Continuously improving: regularly updating situational awareness through formal and informal mapping, assessment, monitoring, and evaluation; always seeking a higher level of health based on best information about present conditions and likely futures; swiftly reacting to changing circumstances; constantly learning from local experience, accumulated evidence, and engagement with peers and other stakeholders. 6. Efficient: taking advantage of cross-sector and cross-scale synergies and avoiding incoherence; pursuing integrated decision-making where appropriate; repurposing existing assets, resources, and mechanisms to mitigate the administrative and financial costs of new policies or structures; improving return-on-investment where feasible. 7. Sufficient: developing and assigning the financial and human resources needed to effectively anticipate, plan for, respond to, and overcome urban health challenges; allocating resources according to needs; investing in capacity building to meet current and future requirements. 8. Forward-looking: ensuring that short- and medium-term actions address immediate needs, yield tangible results, and demonstrate progress, while emphasizing long-term planning to lay strong foundations and sustainable mechanisms for healthy futures; recognizing the impact of current actions on future options (e.g., via path dependency and lock-in). How does urban health relate to other rubrics? Long-standing fields such as public health/healthcare and Healthy Cities share epistemic roots and thematic foundations with urban health. Likewise, in recent decades, several rubrics that encompass similar themes have grown in prominence—these include resilience, planetary health, One Health, and ecohealth. Given broad overlap among all of these with respect to subject matter and practical remit, proponents of a specific approach sometimes claim primacy or exclusivity. These arbiters may see competing rubrics as secondary, redundant, or even counterproductive. However, despite the potential for many of these broad topics to cover similar ground, there are important differences in how they are perceived and applied, which make them valuable complementary perspectives for urban health, rather than competitors. We review a few important distinctions below. Urban health versus public health/healthcare Public health and urban health have similar goals. Both seek to improve the health of populations and recognize a wide range of determinants. Depending on terminological assumptions, each could plausibly be considered an important subcomponent of the other. However, as defined here, urban health is not merely the aspect of public health that deals with urban dwellers. In institutional terms, public health is generally a subdivision of the health sector, whereas urban health, as outlined above, is broader, spanning the boundaries of many sectors. Urban health calls on the service of a broad range of urban experts and actors, and not solely on health actors or other elements of the health sector in urban environments. Urban health likewise covers a wider range of determinants and activities than is usually the case in public health. Conversely, urban health does not necessarily cover every aspect of health in urban populations. Some outcomes are unrelated to urban determinants. For example, for genetic or age-related illnesses, the context is generally coincidental rather than determinative. Urban health, as defined here, deals with impacts arising from causal pathways specific to urban areas. Yet even health issues without clear urban determinants interact with urban phenomena (e.g., health systems; environmental, economic, social, and commercial determinants) to modulate outcomes when they occur in cities. To extend the example above, genetic and age-related illnesses both interact with urban contextual factors, and this interaction is a proper focus for urban health action. One practical concern about subsuming urban health within traditional public health is an overemphasis on health sector-led action. Healthcare systems are but one among many key determinants of health for urban populations. Often, they focus on proximal determinants of health with little engagement with important upstream factors and interactions. Indeed, key opportunities for urban health are often taken up neither by urban health systems nor by other urban sectors (like housing, energy, or transportation). Urban health accordingly aims to enhance engagement, coordination, and integration among these actors to improve health outcomes. Urban health versus Healthy Cities versus healthy cities The term “healthy cities” may be used in at least three different ways, all of which relate to urban health, but with clear differences. First, “Healthy Cities” refers to a movement and a programmatic approach, embodied in the various Healthy City networks and in local implementation at the city scale. Rooted in health promotion and the need for health solutions in cities from beyond the health sector, the Healthy Cities movement arose in Canada and Europe during the 1980s. The movement has continued to grow, with substantial regional and global policy influence ( Barton and Grant, 2013 ; Grant et al., 2024 ; Tsouros, 2015 ). The Healthy Cities approach generally involves city-led action on both specific thematic work and intersectoral governance (see, e.g., Green and Tsouros 2008 ; de Leeuw et al. 2014 ). It often involves municipal health authorities and actors with support from city leaders. In some contexts, these actions are set within a national framework, and they are often supported via local and regional Healthy Cities networks. Healthy Cities is not synonymous with urban health. Rather, it is a modality for the practice of urban health which strives for a higher state of urban health—reflecting the two components of the definition presented here. Yet urban health encompasses a wider set of models for policy and practice than Healthy Cities. The former is urban-focused, encompassing the very broad set of actors and processes at all scales that influence urban phenomena, whereas the latter is city-focused, acting primarily through local governance at the city scale. The second usage of “healthy city” refers to the functioning of the city itself—the ways in which it protects itself, evolves, adapts and grows sustainably. To thrive, cities must promote their own social and economic development; manage security (e.g., avoid political violence, terrorism); sustain good governance (e.g., avoid corruption); foster resilience; coordinate flows of goods, services and people to meet needs; and protect the sustainability of local ecosystems, among other tasks. These actions serve to create and protect assets and livelihoods, improve stability, and promote human and natural capital. This usage is related to urban health because many of the actions taken to foster “healthy” urban functioning can also—if well-designed and managed—yield health benefits. The health of the city (in this sense) and of its population are closely connected, regardless of whether health is the primary aim of city leaders. Urban health seeks to illuminate the links between the health of the city and of its population, paving the way for integrated action, especially seeking to enhance the human health dividend from actions not originally directed at health. A third common usage of “healthy city” refers more generically to a city with a high state of urban health, one that continually seeks to attain this state, and/or one whose processes are designed and managed in such a way as to foster urban health. Each of these is compatible with the proposed definition of urban health. Urban health versus other contemporary rubrics The modern rubrics of resilience, planetary health, One Health, and ecohealth each seek to understand, describe, and address complex societal challenges through broadly integrative approaches. Each is applicable to urban areas, though none is exclusively urban in focus. Resilience is “the capability of a person, structure, or system to withstand shocks or stressors while maintaining or recovering function and continuing to adapt and improve” ( Siri and Indvik, 2022 ). Like urban health itself, it is multifactorial, requiring integrated action and attention to complex interactions. The resilience community tends to focus more on infrastructure and institutions than on health, but resilience is an essential aspect of urban health, as recognized in the proposed definition and in the elements of strategic action (see Box 2 ). Planetary health is “the health of human civilization and the state of the natural systems on which it depends” ( Whitmee et al., 2015 ). It focuses on the relationships between the activities of human societies and earth systems and the ways in which impacts on those systems are threatening the basis for human thriving. The outsized influence of urban areas on earth systems makes them a central concern for planetary health. Likewise, the need to maintain health-supporting natural systems is integral to urban health, as recognized in the proposed definition. Nevertheless, planetary health tends to focus on higher-scale processes than urban health. One Health is “an integrated, unifying approach that aims to sustainably balance and optimize the health of people, animals, and ecosystems” ( One Health High-Level Expert Panel (OHHLEP) et al., 2022 ). It emphasizes the ways in which human and non-human life interact and how these interactions modify health outcomes for both. In practice, One Health often focuses on infectious disease transmission, though the framework is applicable to a broader set of issues. Because urban processes determine many human-animal interactions (e.g., through urban expansion, urban food markets, or the clearing of natural ecosystems for agriculture to feed urban populations), they are a critical consideration within One Health. Conversely, urban health necessarily engages with the dynamics of animal, plant, microbial, vector, and pathogen populations. Ecohealth is “an approach that integrates natural and social sciences to understand and manage ecosystems and the interactions among human, animal, and environmental health” ( Talukder et al., 2024 ). It is founded in the principles of “transdisciplinarity, systems thinking, multi-stakeholder participation, equity, environmental sustainability, and evidence for community-based interventions” ( Charron, 2012 ). As for the other rubrics, the influence of urban areas makes them an important context in ecohealth. As such, ecohealth has strong connections to urban health, but where the former tends to focus on the interactions among ecosystems, human social systems, and health, urban health encompasses a wider range of physical and social determinants and has a more specific urban focus. These are simple descriptions of complex rubrics, and various efforts have been made to more completely describe the differences and similarities among them (see, e.g., Lerner and Berg 2017 ; Talukder et al. 2024 ). Each describes a set of interconnected pathways and determinants of health that is applicable in urban areas. Urban health further defines linkages with and implications for the urban environment, processes, and populations. Discussion Competing paradigms of urban health? Cities have always acted to support the health of citizens—promoting safety, reducing environmental risks, limiting infectious disease spread, and implementing other health-promoting actions. Yet the modern conception of urban health is more recent, as reviewed elsewhere in this collection ( Grant et al., 2024 ). On the one hand, this development was influenced by secular trends that made cities more important, including: growing populations, urban assets, and risks in the context of ongoing urbanization and expanding cities; growing inequities and a greater visibility of slums; growing urban political influence; the evolution of new data sources; and a shift in development financing toward cities. On the other hand, it was also influenced by conceptual shifts, including the inception of a rights-based legal framework for health; recognition of the cross-cutting basis of health determinants and the need for health beyond the health sector; an evolution from siloed to integrated thinking; a newfound emphasis on health equity; growing recognition of the role of complexity; and a shift in perception–from cities as problems to cities as solutions. The breadth of different urban-focused disciplines whose work has helped usher in these conceptual shifts has led different actors to emphasize different aspects of and solutions for urban health challenges. Today, at least four strands of thought or paradigms are active in the urban health space ( Kim et al., 2022 ): • the medical-industrial city paradigm tends to take a biomedical approach focusing on the infrastructure and technologies of healthcare; • the urban health science paradigm emerges from epidemiological practice and complex systems, and seeks to build hard evidence for effective interventions to improve health; • the healthy built environments paradigm originates from urban planning and focuses on spatial considerations and planning policy, often emphasizing quality of life or human flourishing; • the healthy social movements paradigm focuses on health equity and the role of sociopolitical factors and urban governance in health, emphasizing the role of community empowerment. Our proposed definition of urban health is intended to be compatible with each of these paradigms so as to foster strategic action while allowing diverse stakeholders to maintain their unique perspectives. How a common definition can support strategic action Consensus on definitions of urban and other terms and on the remit of urban health are vital preconditions for the successful development and coordination of effective strategic approaches to promote urban health. Common definitions can improve understanding and communication, simplify the process of setting shared goals, make assessment more feasible, and contribute to other objectives. Yet the broad nature of overlapping interests in urban health is a challenge for such definitions because different stakeholders value and emphasize different aspects of urban health. The presentation of a standardized definition, while important for communication, should not be taken as a unilateral endorsement nor as a deprecation of other definitions or traditions, which can offer important insights arising from different ways of thinking about urban health challenges. Moreover, while a common definition is important for effective strategic action, the form of urban health policy, practice, and solutions will differ with local context. We have proposed a definition for urban health intended to support strategic action. This is presented in Box 1 in the six official languages of the United Nations, in recognition of the universal nature of urban health challenges and the value of common understanding. We have also outlined the basic elements of strategic action, reviewed the subjects and scope of urban health practice, and explored the relationship of urban health to public health, Healthy Cities, and a set of contemporary rubrics addressing complex societal challenges. We hope this will bring useful clarity for urban health decision-makers, advocates and practitioners at all scales. Ethics and consent Ethical approval and consent were not required. Data availability statement No data are associated with this article. Acknowledgements We are grateful for the editorial and translation support provided by WHO and the Guangzhou Institute for Urban Innovation. References Atlantic Council Climate Resilience Center: Chief Heat Officers. Chief Heat Officers.2024. (accessed October 8, 2024). Reference Source Barton H, Grant M: Urban Planning for Healthy Cities. J. Urban Health. 2013; 90 : 129–141. 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Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 30 Jan 2025 ADD YOUR COMMENT Comment Author details Author details 1 Urban Health Unit, World Health Organization, Geneva, Switzerland 2 Cities Institute, University of New South Wales, Sydney, Australia 3 Urban Health Collaborative, Drexel University, Philadelphia, PA, USA 4 Université de Montréal, Québec, Canada 5 International Society for Urban Health, Geneva, Switzerland 6 Institute of Urban Environment, Chinese Academy of Sciences, Xiamen, China 7 Manchester Urban Institute, University of Manchester, Manchester, UK 8 Société Francophone de Santé et Environnement, Paris, France 9 Institute of Global Health, University of Geneva, Geneva, Switzerland José Gabriel Siri Roles: Conceptualization, Project Administration, Supervision, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing Jinhee Kim Roles: Conceptualization, Writing – Original Draft Preparation, Writing – Review & Editing Katherine Indvik Roles: Conceptualization, Writing – Original Draft Preparation, Writing – Review & Editing Evelyne de Leeuw Roles: Conceptualization, Writing – Original Draft Preparation, Writing – Review & Editing Carlos Dora Roles: Conceptualization, Writing – Original Draft Preparation, Writing – Review & Editing Franz Gatzweiler Roles: Conceptualization, Writing – Original Draft Preparation, Writing – Review & Editing Elsa Holm Roles: Conceptualization, Writing – Original Draft Preparation, Writing – Review & Editing Deljana Iossifova Roles: Conceptualization, Writing – Original Draft Preparation, Writing – Review & Editing Francisco Obando Roles: Conceptualization, Writing – Original Draft Preparation, Writing – Review & Editing Jean Simos Roles: Conceptualization, Writing – Original Draft Preparation, Writing – Review & Editing Competing interests No competing interests were disclosed. Grant information This work was supported by the World Health Organization Urban Health Unit. Article Versions (1) version 1 Published: 30 Jan 2025, 14:144 https://doi.org/10.12688/f1000research.159970.1 Copyright © 2025 Siri JG 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 Siri JG, Kim J, Indvik K et al. Defining Urban Health for Strategic Action [version 1; peer review: 2 approved with reservations] . 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Reviewer Report For: Defining Urban Health for Strategic Action [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :144 ( https://doi.org/10.5256/f1000research.175768.r390923 ) The direct URL for this report is: https://f1000research.com/articles/14-144/v1#referee-response-390923 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 25 Jul 2025 Trevor Hancock , University of Victoria, Victoria, British Columbia, Canada Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.175768.r390923 This article, by an experienced and well-positioned set of authors, is a thorough and comprehensive review that examines the many different understandings of ‘urban health’ and proposes “a definition of urban health as a shared basis for strategic action”, which ... Continue reading READ ALL This article, by an experienced and well-positioned set of authors, is a thorough and comprehensive review that examines the many different understandings of ‘urban health’ and proposes “a definition of urban health as a shared basis for strategic action”, which is, I agree a worthy endeavour. Their article is a useful and important contribution. I particularly liked one of their key messages: “Any actor that ensures the existence of healthy situations and opportunities and/or the resilience and sustainability of health-supporting systems is practicing urban health”. This has the merit of making it clear that health is not just the business of the health sector, and furthermore that any and all actors can and indeed must play a role in creating the conditions for health in the world’s urban areas. Figure 1 helps make that point effectively. A minor quibble: in the final key message, I would add ‘population health’ to the set of rubrics they consider to be “valuable complementary conceptual frameworks”. (Population health is “The health of the population measured by health status indicators; it is influenced by physical, biological, social, and economic factors in the environment, by personal health behavior, and by access to and effectiveness of health care services” – A Dictionary of Epidemiology , Oxford Reference, 2014) As to the definition itself, as proposed, I think it generally works well. I like that it begins by positioning urban health as an art as well as a science – and in that order. I also like the very sensible point the authors make that: “The intent of this piece is to constructively support strategic action, not to stifle diverse interpretations or permanently settle debates about the conceptual issues involved in urban health.” However, I wonder whether a focus on the health of urban dwellers may miss an important point that is, for me, inherent in the concept of healthy cities: The health of the city system itself – and I take their important distinction between ‘urban area’ and ‘city’ in their useful discussion on what ‘urban’ means. I also find helpful - and broadly agree with - their distinction between Healthy Cities and urban health, with the former being “a modality for the practice of urban health” that is “city- focused, acting primarily through local governance at the city scale.” Moreover, I am glad to see that their second meaning of ‘healthy city’ “refers to the functioning of the city itself”. We must ask how healthy is the built environment, the transportation system, the food system etc. - meaning, do those and the many other elements of the city system itself support the health and health equity of urban dwellers, especially the more disadvantaged and excluded? This speaks to an important point in their definition: “This effort [securing the resilience and sustainability of health-supporting natural and human systems] is a core concern for urban health.” That is why in our original 1986 background paper for the WHO Europe Healthy Cities initiative (Hancock and Duhl, 1988) and elsewhere, Len Duhl and I always argued that a healthy city is not simply the city with the highest overall health status, but one that is striving to become more healthy; this concept is embedded in the definition of a healthy city we proposed - “one that is continually creating and improving . . .”, a point that is also part of the authors’ definition. In that sense, a city with a health-conscious, health-focused governance system but low health status is ‘healthier’ than one that has high health status but pays little or no attention to health and wellbeing and has no health-focused system of governance. Which brings me to the issue of governance, which is a crucial issue in urban health. While the authors mention governance a number of times, it is not defined or discussed in much detail, which is a shame. I favour the 2002 UN Habitat definition: “the sum of the many ways individuals and institutions, public and private, plan and manage the common affairs of the city”. The convening of those many stakeholders - what the authors call “the panoply of actors and institutions—spanning all sectors and scales” - around a common purpose – improving health and health equity for the urban population – is the very essence of a healthy city. Many of these governance issues are discussed in the section on ‘Defining the remit of urban health’ and I agree with them that “recognition of complex interactions is essential to strategic action”. I am also concerned that the authors do not sufficiently emphasise the importance for urban health of the transgression, now, of seven of the nine planetary boundaries identified by Earth scientists ( Planetary Health Check Report 2024 [Caesar, Sakschewski, Andersen et al., 2024] – which is not referenced in this article). While it may be true that “planetary health tends to focus on higher-scale processes than urban health”, those planetary-level changes pose enormous, indeed existential challenges for cities. The future of health in urban areas, especially the health of the disadvantaged and vulnerable, will be enormously impacted, both directly and indirectly by climate change, pollution of all sorts (especially air pollution, plastics and POPs), changes in land and water systems, ocean acidification and the resulting biodiversity loss that stems from these changes. Direct threats that loom over cities in the coming decades include urban heat events, severe weather events, sea-level rise, air pollution and markedly reduced supplies of both fresh water and food. It is particularly troubling that climate change – one of the seven planetary boundaries that have been crossed - receives very little attention, even though it is directly implicated in all the issues identified in my previous sentence. Not only are cities adversely affected by climate change, but they are also important contributors to climate change, being responsible, as they authors point out, for “over 70% of carbon emissions from energy use.” So, both from the point of view of the health of their populations and as ‘healthy cities’, urban areas need to be doing all they can to reduce emissions. Yet the authors make no reference whatsoever to mitigation of climate change through reducing greenhouse gas emissions, even though there are countless opportunities to do so in urban development, housing, transportation and many other policy areas. A minor point: I would add to the list of extramural effects (p 8) the demand for resources (food, water, fuels, materials) that urban areas place on other places, both locally and globally, given that, as the authors note, “cities are responsible for 80% of GDP [and] over 70% of carbon emissions from energy use”. The authors make the important point that “awareness of extra-urban impacts can help urban health actors make decisions that improve health more broadly and avoid decisions that harm health outside of their cities.” A useful approach that they might have mentioned here is the City Portrait approach proposed by the Doughnut Economics Action Lab. Based on a 2 x 2 grid (local/global, social/ecological), cities ask themselves “What would it mean for this city to respect the wellbeing of people worldwide” and “What would it mean for this city to respect the health of the whole planet?” In their discussion of health equity, I would have liked to see a reference to Marmot’s concept of ‘ proportionate universalism’ , which is “the resourcing and delivering of universal services at a scale and intensity proportionate to the degree of need.” For example, low-income populations have less access to quality green space, so they actually need more and better-quality green space than higher-income populations that have more ready access both in their immediate neighbourhood (personal gardens) and by dint of their ability to travel. I found the discussion on both who is responsible for urban health action and the scope of that action helpful, not for the answers the authors provided – they didn’t provide many, and where it did, they were often conditional – but for the important questions they raised. I agree with what amounts to their conclusions: That “Grappling with complexity and grasping its potential impacts is essential to navigating potential actions and managing its consequences”, that “All urban stakeholders’ actions have health consequences, and therefore all have some level of causal responsibility for urban health” and that “the scope of formal urban health action should not exceed the point where the marginal costs”. The text box on the elements of a strategic approach is helpful. With respect to how urban health relates to other rubrics, I agree that “urban health is not merely the aspect of public health that deals with urban dwellers”, any more than it is the aspect of health care that deals with them. I also agree that “Urban health likewise covers a wider range of determinants and activities than is usually the case in public health”, but that is a problem and a challenge for public health, because it should be engaged in some way (not often as the lead sector, but as an ally and supporter) in everything that is of significance for urban health. This means that Ministries of Health must recognise that all aspects of urban health are legitimate areas of work for public health, and should be supported through policy, legislation and funding. I note that some of the references are incomplete, with requests for a reference source. References 1. Caesar, L.; Sakschewski, B.; Andersen, L.S.; Beringer, T.; Braun, J. et al. (2024) Planetary Health Check Report 2024 . 2. 2. Potsdam, Germany: Potsdam Institute for Climate Impact Research. https://www.planetaryhealthcheck.org/planetary- science 2. Hancock, Trevor and Duhl, Len (1988) Healthy Cities: Promoting Health in the Urban Context . WHO Healthy Cities Paper No. 1. Copenhagen: FADL Publications. 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? Yes Competing Interests: No competing interests were disclosed. Reviewer Expertise: Healthy cities and communities, health promotion, planetary health, health and environment, health equity, population 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 Hancock T. Reviewer Report For: Defining Urban Health for Strategic Action [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :144 ( https://doi.org/10.5256/f1000research.175768.r390923 ) The direct URL for this report is: https://f1000research.com/articles/14-144/v1#referee-response-390923 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: Ebenso B. Reviewer Report For: Defining Urban Health for Strategic Action [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :144 ( https://doi.org/10.5256/f1000research.175768.r371348 ) The direct URL for this report is: https://f1000research.com/articles/14-144/v1#referee-response-371348 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 12 May 2025 Bassey Ebenso , University of Leeds, Leeds, UK Approved with Reservations VIEWS 0 https://doi.org/10.5256/f1000research.175768.r371348 This article's findings are important to those with closely related research interests. Readers of F1000 Research will value the proposed common definition of urban health, given the influence that cities exert on national economies, societies, and environments globally ... Continue reading READ ALL This article's findings are important to those with closely related research interests. Readers of F1000 Research will value the proposed common definition of urban health, given the influence that cities exert on national economies, societies, and environments globally The paper’s strengths are: i) its detailed exploration and engagement with diverse conceptual issues and debates that have influenced the evolution of urban health; and ii) its clarification of the meanings of the key elements of the proposed definition that can enhance deeper understanding of the definition itself. I recommend that the authors make the suggested changes below to the manuscript. Minor essential revisions 1. Key messages a) In bullet point 8 (on page 3 of 20) of key messages, the authors state that: “A common definition must also be legible to stakeholders representing the wide variety of disciplinary languages and professional cultures.... Action: Using the term/phrase “ legible ” here can be confusing. Please consider replacing the term legible with alternative words such as accessible and understandable. b) In bullet point 9 (page 3 of 20) of key messages, the authors state that: “Urban health must encompass all social groups and geographical contexts and deliberate efforts are needed to address inequities in knowledge, action, and outcomes. Action: To enhance readers’ understanding of this sentence, I suggest minor edits to the sentence as follows…“Urban health must encompass all social groups and geographical contexts within city boundaries , and deliberate efforts are needed to address inequities in knowledge, action, and outcomes” 2. Introduction section: a) The authors highlighted in paragraph 2 of the introduction (lines 1-2, on page 3 of 20) that urban areas exercised tremendous influence on economies, societies, and environments at all scales. To buttress their point, the authors highlighted that cities are responsible for 80% of GDP, citing a 2011 reference by McKinsey Global Institute. Action: The Executive summary of the reference cited by the authors stated that: cities generated over 80% of the global GDP in 2011 and that by 2025, 600 cities will account for 60% of the global GDP: https://www.mckinsey.com/featured-insights/urbanization/urban-world-mapping-the-economic-power-of-cities To prevent misleading the reader, I recommend that the authors revise the second sentence of paragraph 2 to read: ...To cite just a few examples, cities will be responsible for 60% of global GDP in 2025 (McKinsey Global Institute, 2011). Major Compulsory Revisions a) Discussion: The discussion section of the manuscript is the shortest (<1 page) of the 20-page manuscript and appears to be a work in progress. Compared to the detailed analysis of “meanings of key elements of the proposed definition of urban health” (see pages 5-7 of the manuscript), paragraph 4 of the discussion section is rather short (page 17 of 20). As things currently stand, this paragraph uses bullet points to provide one-line statements to represent the four strands of thought/ paradigms that are active in urban health. This leaves the reader wanting more. Action: The paragraph will benefit from further development to enhance readers’ understanding of the theoretical, methodological and instrumental dimensions of these four strands of thought. The paragraph can be strengthened e.g., by drawing insight from Table 1 on page 4 of the Kim et Al 2022 paper, to shed light on the theoretical, methodological and instrumental dimensions of these schools of thought. b) Conclusion: There is currently no explicit sub-section titled conclusion. The authors should please provide a subsection titled conclusion 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? Partly Competing Interests: No competing interests were disclosed. Reviewer Expertise: Urban Health, Health policy, Health systems strengthening, community engagement, Realist evaluation 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 Ebenso B. Reviewer Report For: Defining Urban Health for Strategic Action [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :144 ( https://doi.org/10.5256/f1000research.175768.r371348 ) The direct URL for this report is: https://f1000research.com/articles/14-144/v1#referee-response-371348 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 Comments on this article Comments (0) Version 1 VERSION 1 PUBLISHED 30 Jan 2025 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 Version 1 30 Jan 25 read read Bassey Ebenso , University of Leeds, Leeds, UK Trevor Hancock , University of Victoria, Victoria, Canada 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 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. 25 Jul 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 (0) 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, by an experienced and well-positioned set of authors, is a thorough and comprehensive review that examines the many different understandings of ‘urban health’ and proposes “a definition of urban health as a shared basis for strategic action”, which is, I agree a worthy endeavour. Their article is a useful and important contribution. I particularly liked one of their key messages: “Any actor that ensures the existence of healthy situations and opportunities and/or the resilience and sustainability of health-supporting systems is practicing urban health”. This has the merit of making it clear that health is not just the business of the health sector, and furthermore that any and all actors can and indeed must play a role in creating the conditions for health in the world’s urban areas. Figure 1 helps make that point effectively. A minor quibble: in the final key message, I would add ‘population health’ to the set of rubrics they consider to be “valuable complementary conceptual frameworks”. (Population health is “The health of the population measured by health status indicators; it is influenced by physical, biological, social, and economic factors in the environment, by personal health behavior, and by access to and effectiveness of health care services” – A Dictionary of Epidemiology , Oxford Reference, 2014) As to the definition itself, as proposed, I think it generally works well. I like that it begins by positioning urban health as an art as well as a science – and in that order. I also like the very sensible point the authors make that: “The intent of this piece is to constructively support strategic action, not to stifle diverse interpretations or permanently settle debates about the conceptual issues involved in urban health.” However, I wonder whether a focus on the health of urban dwellers may miss an important point that is, for me, inherent in the concept of healthy cities: The health of the city system itself – and I take their important distinction between ‘urban area’ and ‘city’ in their useful discussion on what ‘urban’ means. I also find helpful - and broadly agree with - their distinction between Healthy Cities and urban health, with the former being “a modality for the practice of urban health” that is “city- focused, acting primarily through local governance at the city scale.” Moreover, I am glad to see that their second meaning of ‘healthy city’ “refers to the functioning of the city itself”. We must ask how healthy is the built environment, the transportation system, the food system etc. - meaning, do those and the many other elements of the city system itself support the health and health equity of urban dwellers, especially the more disadvantaged and excluded? This speaks to an important point in their definition: “This effort [securing the resilience and sustainability of health-supporting natural and human systems] is a core concern for urban health.” That is why in our original 1986 background paper for the WHO Europe Healthy Cities initiative (Hancock and Duhl, 1988) and elsewhere, Len Duhl and I always argued that a healthy city is not simply the city with the highest overall health status, but one that is striving to become more healthy; this concept is embedded in the definition of a healthy city we proposed - “one that is continually creating and improving . . .”, a point that is also part of the authors’ definition. In that sense, a city with a health-conscious, health-focused governance system but low health status is ‘healthier’ than one that has high health status but pays little or no attention to health and wellbeing and has no health-focused system of governance. Which brings me to the issue of governance, which is a crucial issue in urban health. While the authors mention governance a number of times, it is not defined or discussed in much detail, which is a shame. I favour the 2002 UN Habitat definition: “the sum of the many ways individuals and institutions, public and private, plan and manage the common affairs of the city”. The convening of those many stakeholders - what the authors call “the panoply of actors and institutions—spanning all sectors and scales” - around a common purpose – improving health and health equity for the urban population – is the very essence of a healthy city. Many of these governance issues are discussed in the section on ‘Defining the remit of urban health’ and I agree with them that “recognition of complex interactions is essential to strategic action”. I am also concerned that the authors do not sufficiently emphasise the importance for urban health of the transgression, now, of seven of the nine planetary boundaries identified by Earth scientists ( Planetary Health Check Report 2024 [Caesar, Sakschewski, Andersen et al., 2024] – which is not referenced in this article). While it may be true that “planetary health tends to focus on higher-scale processes than urban health”, those planetary-level changes pose enormous, indeed existential challenges for cities. The future of health in urban areas, especially the health of the disadvantaged and vulnerable, will be enormously impacted, both directly and indirectly by climate change, pollution of all sorts (especially air pollution, plastics and POPs), changes in land and water systems, ocean acidification and the resulting biodiversity loss that stems from these changes. Direct threats that loom over cities in the coming decades include urban heat events, severe weather events, sea-level rise, air pollution and markedly reduced supplies of both fresh water and food. It is particularly troubling that climate change – one of the seven planetary boundaries that have been crossed - receives very little attention, even though it is directly implicated in all the issues identified in my previous sentence. Not only are cities adversely affected by climate change, but they are also important contributors to climate change, being responsible, as they authors point out, for “over 70% of carbon emissions from energy use.” So, both from the point of view of the health of their populations and as ‘healthy cities’, urban areas need to be doing all they can to reduce emissions. Yet the authors make no reference whatsoever to mitigation of climate change through reducing greenhouse gas emissions, even though there are countless opportunities to do so in urban development, housing, transportation and many other policy areas. A minor point: I would add to the list of extramural effects (p 8) the demand for resources (food, water, fuels, materials) that urban areas place on other places, both locally and globally, given that, as the authors note, “cities are responsible for 80% of GDP [and] over 70% of carbon emissions from energy use”. The authors make the important point that “awareness of extra-urban impacts can help urban health actors make decisions that improve health more broadly and avoid decisions that harm health outside of their cities.” A useful approach that they might have mentioned here is the City Portrait approach proposed by the Doughnut Economics Action Lab. Based on a 2 x 2 grid (local/global, social/ecological), cities ask themselves “What would it mean for this city to respect the wellbeing of people worldwide” and “What would it mean for this city to respect the health of the whole planet?” In their discussion of health equity, I would have liked to see a reference to Marmot’s concept of ‘ proportionate universalism’ , which is “the resourcing and delivering of universal services at a scale and intensity proportionate to the degree of need.” For example, low-income populations have less access to quality green space, so they actually need more and better-quality green space than higher-income populations that have more ready access both in their immediate neighbourhood (personal gardens) and by dint of their ability to travel. I found the discussion on both who is responsible for urban health action and the scope of that action helpful, not for the answers the authors provided – they didn’t provide many, and where it did, they were often conditional – but for the important questions they raised. I agree with what amounts to their conclusions: That “Grappling with complexity and grasping its potential impacts is essential to navigating potential actions and managing its consequences”, that “All urban stakeholders’ actions have health consequences, and therefore all have some level of causal responsibility for urban health” and that “the scope of formal urban health action should not exceed the point where the marginal costs”. The text box on the elements of a strategic approach is helpful. With respect to how urban health relates to other rubrics, I agree that “urban health is not merely the aspect of public health that deals with urban dwellers”, any more than it is the aspect of health care that deals with them. I also agree that “Urban health likewise covers a wider range of determinants and activities than is usually the case in public health”, but that is a problem and a challenge for public health, because it should be engaged in some way (not often as the lead sector, but as an ally and supporter) in everything that is of significance for urban health. This means that Ministries of Health must recognise that all aspects of urban health are legitimate areas of work for public health, and should be supported through policy, legislation and funding. I note that some of the references are incomplete, with requests for a reference source. References 1. Caesar, L.; Sakschewski, B.; Andersen, L.S.; Beringer, T.; Braun, J. et al. (2024) Planetary Health Check Report 2024 . 2. 2. Potsdam, Germany: Potsdam Institute for Climate Impact Research. https://www.planetaryhealthcheck.org/planetary- science 2. Hancock, Trevor and Duhl, Len (1988) Healthy Cities: Promoting Health in the Urban Context . WHO Healthy Cities Paper No. 1. Copenhagen: FADL Publications. 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? Yes Competing Interests No competing interests were disclosed. Reviewer Expertise Healthy cities and communities, health promotion, planetary health, health and environment, health equity, population 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 (0) Hancock T. Peer Review Report For: Defining Urban Health for Strategic Action [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :144 ( https://doi.org/10.5256/f1000research.175768.r390923) 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/14-144/v1#referee-response-390923 keyboard_arrow_left Back to all reports Reviewer Report 0 Views copyright © 2025 Ebenso B. 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. 12 May 2025 | for Version 1 Bassey Ebenso , University of Leeds, Leeds, UK 0 Views copyright © 2025 Ebenso B. 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 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's findings are important to those with closely related research interests. Readers of F1000 Research will value the proposed common definition of urban health, given the influence that cities exert on national economies, societies, and environments globally The paper’s strengths are: i) its detailed exploration and engagement with diverse conceptual issues and debates that have influenced the evolution of urban health; and ii) its clarification of the meanings of the key elements of the proposed definition that can enhance deeper understanding of the definition itself. I recommend that the authors make the suggested changes below to the manuscript. Minor essential revisions 1. Key messages a) In bullet point 8 (on page 3 of 20) of key messages, the authors state that: “A common definition must also be legible to stakeholders representing the wide variety of disciplinary languages and professional cultures.... Action: Using the term/phrase “ legible ” here can be confusing. Please consider replacing the term legible with alternative words such as accessible and understandable. b) In bullet point 9 (page 3 of 20) of key messages, the authors state that: “Urban health must encompass all social groups and geographical contexts and deliberate efforts are needed to address inequities in knowledge, action, and outcomes. Action: To enhance readers’ understanding of this sentence, I suggest minor edits to the sentence as follows…“Urban health must encompass all social groups and geographical contexts within city boundaries , and deliberate efforts are needed to address inequities in knowledge, action, and outcomes” 2. Introduction section: a) The authors highlighted in paragraph 2 of the introduction (lines 1-2, on page 3 of 20) that urban areas exercised tremendous influence on economies, societies, and environments at all scales. To buttress their point, the authors highlighted that cities are responsible for 80% of GDP, citing a 2011 reference by McKinsey Global Institute. Action: The Executive summary of the reference cited by the authors stated that: cities generated over 80% of the global GDP in 2011 and that by 2025, 600 cities will account for 60% of the global GDP: https://www.mckinsey.com/featured-insights/urbanization/urban-world-mapping-the-economic-power-of-cities To prevent misleading the reader, I recommend that the authors revise the second sentence of paragraph 2 to read: ...To cite just a few examples, cities will be responsible for 60% of global GDP in 2025 (McKinsey Global Institute, 2011). Major Compulsory Revisions a) Discussion: The discussion section of the manuscript is the shortest (<1 page) of the 20-page manuscript and appears to be a work in progress. Compared to the detailed analysis of “meanings of key elements of the proposed definition of urban health” (see pages 5-7 of the manuscript), paragraph 4 of the discussion section is rather short (page 17 of 20). As things currently stand, this paragraph uses bullet points to provide one-line statements to represent the four strands of thought/ paradigms that are active in urban health. This leaves the reader wanting more. Action: The paragraph will benefit from further development to enhance readers’ understanding of the theoretical, methodological and instrumental dimensions of these four strands of thought. The paragraph can be strengthened e.g., by drawing insight from Table 1 on page 4 of the Kim et Al 2022 paper, to shed light on the theoretical, methodological and instrumental dimensions of these schools of thought. b) Conclusion: There is currently no explicit sub-section titled conclusion. The authors should please provide a subsection titled conclusion 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? Partly Competing Interests No competing interests were disclosed. Reviewer Expertise Urban Health, Health policy, Health systems strengthening, community engagement, Realist evaluation 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 (0) Ebenso B. Peer Review Report For: Defining Urban Health for Strategic Action [version 1; peer review: 2 approved with reservations] . F1000Research 2025, 14 :144 ( https://doi.org/10.5256/f1000research.175768.r371348) 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/14-144/v1#referee-response-371348 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. 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