In the early stages of the COVID-19 pandemic, dubious assertions that population density increased spread of the virus led to premature and dangerous recommendations promoting suburban sprawl. In 2020, we published a commentary in Cities & Health to refute these recommendations. We hypothesized that features of activity-supportive environments, including high density, would be protective from severe COVID-19 outcomes. The goal of the present commentary is to examine evidence that has emerged during the pandemic to evaluate veracity of the predictions and recommendations we made in 2020. An updated analysis of cities from each continent supports our 2020 analysis that population density is not associated with COVID-19 mortality. Our earlier recommendations to promote activity-supportive environments to benefit both infectious and non-communicable diseases, and to ensure equity of access to such environments, are now supported by empirical studies. Evidence related to public transport shows mitigation of risk could be achieved by limiting riders, travelling during off-peak hours, enforcing physical distancing, requiring face coverings, and implementing strict cleaning protocols. There is substantial evidence that environmental features and interventions that support COVID-19 mitigation strategies also have additional health, environmental sustainability, and economic benefits.@en

Creating healthy and sustainable cities should be a global priority. Some cities prioritize 15-minute cities as a planning approach with co-benefits for health, climate change mitigation, equity, and economic recovery from COVID-19. Yet, as our recent Lancet Global Health series on “Urban Design, Transport, and Health” showed, many cities have a long way to go to achieve this vision. This policy guideline summarizes the main findings of the series, which assessed health and sustainability indicators for 25 cities in 19 countries. We then outline steps governments can take to strengthen policy frameworks and deliver more healthy, equitable, and sustainable built environments.

The Lancet Global Health series provided clear evidence that cities need to transform urban governance to enable integrated planning for health and sustainability and commit to policy implementation. Evidence-informed indicators should be used to benchmark and monitor progress. Cities need policy frameworks that are comprehensive and consistent with evidence, with measurable policy targets to support implementation and accountability. The series provided evidence-informed thresholds for some key urban design and transport features, which can be embedded as policy targets. Policies and interventions must prioritize identifying and reducing inequities in access to health-supportive environments. Governments should also invest in open data and promote citizen-science programmes, to support indicator development and research for public benefit. We provide tools to replicate our indicators and an invitation to join our 1000 Cities Challenge via the Global Observatory of Healthy and Sustainable Cities.@en

An essential characteristic of a healthy and sustainable city is a physically active population. Effective policies for healthy and sustainable cities require evidence-informed quantitative targets. We aimed to identify the minimum thresholds for urban design and transport features associated with two physical activity criteria: at least 80% probability of engaging in any walking for transport and WHO's target of at least 15% relative reduction in insufficient physical activity through walking. The International Physical Activity and the Environment Network Adult (known as IPEN) study (N=11 615; 14 cities across ten countries) provided data on local urban design and transport features linked to walking. Associations of these features with the probability of engaging in any walking for transport and sufficient physical activity (≥150 min/week) by walking were estimated, and thresholds associated with the physical activity criteria were determined. Curvilinear associations of population, street intersection, and public transport densities with walking were found. Neighbourhoods exceeding around 5700 people per km², 100 intersections per km², and 25 public transport stops per km² were associated with meeting one or both physical activity criteria. Shorter distances to the nearest park were associated with more physical activity. We use the results to suggest specific target values for each feature as benchmarks for progression towards creating healthy and sustainable cities.

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Benchmarking and monitoring of urban design and transport features is crucial to achieving local and international health and sustainability goals. However, most urban indicator frameworks use coarse spatial scales that either only allow between-city comparisons, or require expensive, technical, local spatial analyses for within-city comparisons. This study developed a reusable, open-source urban indicator computational framework using open data to enable consistent local and global comparative analyses. We show this framework by calculating spatial indicators—for 25 diverse cities in 19 countries—of urban design and transport features that support health and sustainability. We link these indicators to cities’ policy contexts, and identify populations living above and below critical thresholds for physical activity through walking. Efforts to broaden participation in crowdsourcing data and to calculate globally consistent indicators are essential for planning evidence-informed urban interventions, monitoring policy effects, and learning lessons from peer cities to achieve health, equity, and sustainability goals.

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City planning policies influence urban lifestyles, health, and sustainability. We assessed policy frameworks for city planning for 25 cities across 19 lower-middle-income countries, upper-middle-income countries, and high-income countries to identify whether these policies supported the creation of healthy and sustainable cities. We systematically collected policy data for evidence-informed indicators related to integrated city planning, air pollution, destination accessibility, distribution of employment, demand management, design, density, distance to public transport, and transport infrastructure investment. Content analysis identified strengths, limitations, and gaps in policies, allowing us to draw comparisons between cities. We found that despite common policy rhetoric endorsing healthy and sustainable cities, there was a paucity of measurable policy targets in place to achieve these aspirations. Some policies were inconsistent with public health evidence, which sets up barriers to achieving healthy and sustainable urban environments. There is an urgent need to build capacity for health-enhancing city planning policy and governance, particularly in low-income and middle-income countries.

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Walkable, activity-friendly neighbourhoods are recommended for their benefits for non-communicable diseases, environmental sustainability, and economic performance. But how do activity-friendly neighbourhoods function during infectious disease pandemics like COVID-19? The spread of COVID-19 in some of the world’s dense cities has raised concerns about the risks of urban density and public transit. However, there are several pathways by which dense, mixed-use neighbourhoods with transit access and recreation facilities can reduce the risk of both infectious diseases and non-communicable diseases. Reducing health inequities is a core value for public health, and we comment on strategies for equitably creating activity-friendly communities.

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What if there was a single therapy available with strong evidence that it: a) boosts immune function and reduces inflammation (the most important physiological mechanisms determining the severity of COVID-19 infections); b) prevents and treats most of the chronic diseases that increase risk of severe COVID-19 infections; and c) can reduce anxiety and depression produced by the health, economic, and social isolation stress of the pandemic? Every health care professional would demand urgent production of that agent to be prescribed to every patient infected with the coronavirus, and the world would demand that agent be given prophylactically to everyone.@en

Few studies assess built environment correlates of active commuting in low-and-middle-income countries (LMICs), but the different context could yield distinct findings. Policies and investments to promote active commuting remain under-developed in LMICs like India, which grapples with traffic congestion, lack of activity-supportive infrastructure, poor enforcement of traffic rules and regulations, air pollution, and overcrowding. This cross-sectional study investigated associations between home neighborhood environment characteristics and active commuting in Chennai, India. Adults (N = 370, 47.2% female, mean age = 37.9 years) were recruited from 155 wards in the metropolitan area of Chennai in southern India between January and June 2015. Participants self-reported their usual mode of commute to work, with responses recoded into three categories: (1) multi-modal or active commuting (walking and bicycling; n = 56); (2) public transit (n = 52); and (3) private transport (n = 111). Environmental attributes around participants’ homes were assessed using the Neighborhood Environment Walkability Scale for India (NEWS-India). Associations between environmental characteristics and likelihood of active commuting and public transit use were modeled using logistic regression with private transport (driving alone or carpool) as the reference category, adjusting for age, gender, and household car ownership. Consistent with other international studies, participants living in neighborhoods with a mix of land uses and a transit stop within a 10-minute walk from home were more likely to use active commuting (both p < 0.01). Land-use mix was significantly associated with the use of public transit compared to private transport (adjusted odds ratio (aOR) = 5.2, p = 0.002). Contrary to findings in high-income countries, the odds of active commuting were reduced with improved safety from crime (aOR = 0.2, p = 0.003), aesthetics (aOR = 0.2, p = 0.05), and street connectivity (aOR = 0.2, p = 0.003). Different environmental attributes were associated with active commuting, suggesting that these relationships are complex and may distinctly differ from those in high-income countries. Unexpected inverse associations of perceived safety from crime and aesthetics with active commuting emphasize the need for high-quality epidemiologic studies with greater context specificity in the study of physical activity in LMICs. Findings have public health implications for India and suggest that caution should be taken when translating evidence across countries.@en