Healthier Cities for a Healthier Future

Over the course of my career, I’ve had the privilege to call many cities my home, including Little Rock, Chicago, and Baltimore. Now, at Stanford Medicine, I live among several, including Palo Alto, San Francisco, and San Jose. While immensely rewarding, this experience has also given me a firsthand look at the extremes of urban settings — particularly when it comes to patient health.

In a span of blocks, the life expectancy of residents can rise or fall by as much as a decade, proof of the powerful effect social determinants have on our well-being: from the air we breathe to the food on our tables to the roofs over our heads. Today, more than half of the world’s population lives in an urban center, and that number is expected to reach 68% in the next 25 years. At the same time, 75% of the world’s cities are more unequal now compared to two decades ago. As urban populations keep expanding and as the gaps grow wider, the need to reimagine urban health and address disparities is more urgent than ever.

Cities as Social Determinants of Health

Where a person lives is critical to their health. Biology, habits, and family history are important. But these factors pale in comparison to the combined impact of their physical environment, social supports, economic status, and access to quality medical care. In short, where we are born, live, learn, work, play, worship, and age. Worldwide, cities are distinct places. Centers of culture and community, industry and infrastructure, they have a lot to offer the increasing number of people who live in them. What’s more, compared to people in rural areas, urban dwellers tend to have better health and better access to health care.

However, city living has its own pitfalls and risks. Green spaces can be scarce, and urban environments have more air pollution, transportation noise, and pockets of high temperature from heat absorbed by buildings, roads, and other man-made infrastructure. Long histories of segregation and recent spurts of urbanization create vast divides in quality of life and long-term health for residents living in the same urban area. Needless to say, there is abundant room for improvement. According to the McKinsey Health Institute, a broad city-level focus on enhancing health could add as much as five years of higher-quality life for each city dweller around the world — a staggering total of 20 billion years or more.

Mental Health Struggles in Urban Environments

One area of urgency is mental health. Research has found that the more time a person spends in an urban environment as a child, the more likely they are to develop mental illness as an adult. People living in cities are more likely than their rural counterparts to develop depression and anxiety, and risk of both schizophrenia and psychosis are strongly increased in people who are born and raised in cities. To better understand the association, one study used magnetic resonance imaging to evaluate the brain activity of urban dwellers. The researchers found that living in a city is associated with increased brain activity linked to processing fear and stress, and growing up in an urban environment can affect how well we regulate emotions and manage stress.

What might be causing this activity? The physical environment seems to play a role. It’s well known that spending time in natural outdoor spaces has mental health benefits, but these green spaces are less prevalent in cityscapes. Additionally, poor air quality has been associated with depression and other mental health conditions, and other toxins are likely to have an impact. Researchers also point to social factors, such as loneliness, crime and social inequalities, increased noise and sensory overload. Within cities, marginalized groups are disproportionately affected by poor mental health, with income, education, housing, and social support influencing mental health outcomes.

In recent years, as people around the globe increasingly struggle with their mental health, challenges in cities have only grown more pressing. Last year, the United States Conference of Mayors surveyed 117 leaders about the mental and behavioral health needs of their cities. Nearly nine out of 10 said their cities lacked necessary resources for addressing the mental health crisis their residents were facing.

To advance solutions for these pressing challenges facing our urban centers, I’m proud of a new collaboration between Stanford Medicine, McKinsey Health Institute and Google Health to shape healthier cities and communities and improve health outcomes for their billions of residents.?

Combining our strengths in analytics, technology, research, and convening power, I believe we can make an important contribution. Working alongside a broad network of stakeholders and regional leaders, our three organizations will actively explore opportunities to create new resources and learnings that can scale and work in many different contexts. Among other key priorities, an initial focus of this collaboration is mental health and investigating how the responsible use of AI can potentially close gaps in care—in alignment with existing city-level health initiatives, population health strategies, and clinical applications.

It is a bold aspiration?but a worthy one. Lifting the health of our cities lifts the health of us all. I look forward to partnering with city and community leaders around the globe and sharing more of what we learn in the months to come.

These resources provide further information about the social determinants of health and their impact on mental health in urban environments.

Cities as catalysts: Unlocking up to 25 billion healthier years of life (McKinsey Health Institute). This article explores the potential for adding 20 billion to 25 billion additional years of higher-quality life across the globe through interventions that improve health and address health disparities in cities.

City life damages mental health in ways we’re just starting to understand (Popular Science). This article explores research—both new and old—that highlights the ways that urban environments can impact mental health.

The social determinants of mental health and disorder: evidence, prevention and recommendations (World Psychiatry). This study discusses structural conditions that cause mental illness and provides recommendations for strategies and interventions to address these social determinants.

The Mental Health Crisis in America’s Cities and Their Responses to It (The United States Conference of Mayors). This 2023 survey explores the state of mental health and well-being in 117 U.S. cities and how regional leaders are responding to a growing need for support.

Image by Mongkol