Editorials Christmas 2011: Editorial

Recognising the potential of cities

BMJ 2011; 343 doi: https://doi.org/10.1136/bmj.d7979 (Published 19 December 2011) Cite this as: BMJ 2011;343:d7979
  1. David Satterthwaite, senior fellow1,
  2. Diana Mitlin, principal researcher1
  1. 1International Institute for Environment and Development (IIED), London WC1X 8NH, UK
  1. david{at}iied.org

Cities can contribute to, rather than threaten, a healthier and more ecologically sustainable future

Cities have never enjoyed a good reputation for health. In many African and Asian cities, health problems and life expectancies are still as bad as in 19th century cities in Europe and North America. Yet other cities have some of the world’s highest life expectancies.

Most of the world’s cities are now in Africa, Asia, and Latin America. But in Africa and Asia most governments and aid agencies ignore city problems. They fail to notice how many people now live in cities and how bad conditions are for much of the population—in hundreds of cities, a third or more of the population lives in illegal settlements that lack basic services. But it is increasingly evident that well functioning cities are key to wealthier more resilient economies. Rapid economic growth in Brazil, India, and China has been underpinned by successful cities. Cities attract new investment because of economies of agglomeration, including infrastructure and service provision, a large diverse labour force, and sizeable consumer markets.

There is some recognition of how much urban poverty has grown—a large proportion of those who are malnourished and hungry; have poor living conditions; and have high infant, child, and maternal mortality live in cities. But cities also have great potential for the public good. The unit costs of providing piped water, good sanitation, healthcare, and emergency services are lowered by density and large population numbers. So too are the costs of providing good schools and the rule of law.

Just as cities provide potential for good health, they also provide opportunities to tackle climate change. Cities are often blamed for being the main drivers of growing greenhouse gas emissions. Yet many cities have low emissions per person, sometimes as little as 1% of that of the largest (mainly North American) emitters.1 Low emissions are usually a result of weak economies, but some cities with a high quality of life—such as Porto Alegre and Barcelona—have relatively low emissions.1 Well governed cities where low density urban sprawl is discouraged provide opportunities to reduce emissions and maintain a high quality of life—for example, by people choosing to walk, bicycle, or travel by public transport rather than use private cars.2 Many of those with the highest consumption and high emitting lifestyles do not live in cities.

Many cities are in locations at high risk from climate change—on the coast, places often hit by hurricanes, areas with very high temperatures, and particular districts (mostly low income) that are heat islands. But again agglomeration economies can also help build resilience to these effects. Well governed cities build on a base of existing infrastructure and services and capacities for risk reduction, especially for vulnerable populations.

But the benefits of concentrating people and enterprises can be realised only by competent and accountable city governments and national governments that share resources between richer and poorer areas. Latin America provides evidence for this. Over the past three decades, the proportion of city dwellers with piped water, sewers, and drains has increased dramatically. Although many city dwellers still live in informal settlements, it is much less common for these to be bulldozed. The acceptance of these people as equal citizens has been underpinned by more fundamental political change—the return to democracy, real decentralisation, the introduction of elected city governments, and more participatory governments (including participatory budgeting), all of which are underpinned by pressure from citizens and grassroots organisations. Such experiences are key to social progress and democratic transformation. From the Middle Ages onwards, cities have enabled citizens to come together and define more equitable outcomes and more democratic choices.

Progress is also evident in Asia and Africa. The Thai government’s Community Organizations Development Institute has shown that living conditions in informal settlements can be transformed by supporting residents to design and implement improvements.3 Across hundreds of cities in Africa and Asia, grassroots organisations including federations of “slum” and shack dwellers are finding new ways to satisfy their own needs, such as developing their own savings schemes, building or upgrading their homes, and improving sanitation. These federations also offer partnerships to local governments, and where local governments respond positively—as in cities in the Philippines, India, South Africa, Zimbabwe, Malawi, Kenya, Uganda, and Namibia—the scale and scope of what can be done increases.4

So we have examples of cities where the potential for health and for delinking a high quality of life from high greenhouse gas emissions is acted on. Some cities also have more inclusive and participatory local governments that work with their low income populations, and this could also help improve health and build resilience to climate change. Success in development, health, and climate change adaptation and mitigation depends on a much wider recognition of these potentials, together with the political will to act on them within nations and within each city.


Cite this as: BMJ 2011;343:d7979


  • Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.

  • Provenance and peer review: Commissioned; not externally peer reviewed.


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