BEYOND URBAN PENALTY AND URBAN SPRAWL: BACK TO LIVING CONDITIONS AS THE FOCUS OF URBAN HEALTH Nicholas Freudenberg, DrPH; Sandro Galea, MD, DrPH; David Vlahov, PhD ABSTRACT: Researchers have long studied urban health, both to describe the consequences of urban living and to design interventions to promote the health of people living in cities. Two approaches to understanding the impact of cities on health have been dominant, namely, urban health penalty and urban sprawl. The urban penalty approach posits that cities concentrate poor people and expose them to unhealthy physical and social environments. Urban sprawl focuses on the adverse health and environmental effects of urban growth into outlying areas. We propose a model that integrates these approaches and emphasizes urban living conditions as the primary determinant of health. The aim of the model is to move beyond describing the health- related characteristics of various urban populations towards identifying opportunities for intervention. Such a shift in framework enables mean- ingful comparisons that can inform public health activities at the appro- priate level and evaluate their effectiveness in improving the health of urban populations. The model is illustrated with two examples from current urban public health practice. KEY WORDS: urban health; social determinants of health; public health inter- ventions. INTRODUCTION Increasingly, the world’s ability to meet its health goals will depend on our success in improving the well-being of people living in cit- ies. For the past 200 years, urbanization, the concentration of people and resources in cities, has been a dominant influence on health. By 2007, more than half the world’s population will live in cities, and countries in Nicholas Freudenberg, DrPH, is Distinguished Professor Public Health, Hunter College, City University of New York; Sandro Galea, MD, DrPH, is Associate Director, Center for Urban Epide- miological Studies, New York Academy of Medicine; and David Vlahov, PhD, is Director, Center for Urban Epidemiological Studies, New York Academy of Medicine. Requests for reprints should be addressed to Nicholas Freudenberg, DrPH, Program in Urban Public Health, Hunter College, City University of New York, 425 East 25th Street, New York, New York 10010; e-mail: nfreuden@hunter.cuny.edu. Journal of Community Health, Vol. 30, No. 1, February 2005 (Ó 2005) DOI: 10.1007/s10900-004-6091-4 1 0094-5145/05/0200-0001/0 Ó 2005 Springer Science+Business Media, Inc.