Re-Thinking the Environment, Cities, and Living Spaces for Public Health Purposes, According with the COVID-19 Lesson: The LVII Erice Charter

Abstract

Background. Urban planning is a key tool to promote health in cities. The COVID-19 emergency accelerated several social, environmental, and digital challenges, stressing the importance of some issues regarding housing, urban mobility, green areas, and health service networks, urban health policies, and actions. These issues were the subject of an intensive residential course (the 57th) held in Erice, Sicily, in June 2021 in the “International School of Epidemiology and Preventive Medicine G. D’Alessandro”, and the main findings are described here. Methods. Lectures presented the topics, subsequently developed them, and argued them in parallel practical sessions using the World Café technique, since it is well suited for the interaction of participants and the involvement of groups. Results. The World Café provides new insights into how to improve the livability and health of urban spaces, and a set of strategies and actions were proposed for each topic. Discussion and Conclusions. All attendees agreed on the importance of participation in the planning processes, but also on the need for strong political support to ensure the resources needed and a full integration of health with other local policies. A multidisciplinary approach to developing systemic operational capacities and health literacy is considered pivotal to raising awareness and participation.

1. Introduction

During the last few years, the international debate about urban health has increased, also at the United Nations, World Health Organization (WHO) level, as demonstrated by the Sustainable Development Goals (SDGs) proposed in the 2030 Agenda and by the large number of documents produced [1,2,3,4]. In fact, considering the increasing trend of urbanization, these organizations underline the need to address the development of more sustainable lifestyles to reduce the urban ecological footprint and climate changes, but also the spread of diseases [1].

As many of the social, environmental, and economic determinants of health have origins outside health scope and health policies (nostro 1a carta erice), the strategy “Health in All Policies” (HiAP), a collaborative approach aiming to ensure policymaking outside the health sector, is increasingly being recognized [5]. To guarantee health and equity, the HiAP approach aims to integrate and articulate health issues into policymaking across sectors with a view to accountability, transparency, access to information, participation, sustainability, and multi-sectoral collaboration.

Therefore, to design salutogenic urban environments and accessible healthy housing, the HiAP strategy is pivotal, since these objectives are achievable only if all relevant sectors, including social welfare, urban planning, housing, and public health, contribute to that [6]. Obviously, HiAP must move in a “social accountability” framework to integrate equity considerations into the agendas of policymakers, especially for those who have never previously considered health as one of their responsibilities [5].

The shortages in housing, especially in the suburbs of large cities, are an example of emphasizing the health relevance and priority of this issue for the definition of local policies. Thus, a transversal training open to all professional profiles involved is crucial, aiming to acquire shared knowledge baggage, to provide health evidence, where available, regarding the role of living environments in health, as well as good building practices to obtain safe and healthy homes [6]. One last important point to underline concerns health literacy and the importance of investing in campaigns to raise awareness and knowledge around these topics in the population and among public opinion in order to empower them and increase their ability to participate in local policy choices [7,8].

In the last few years, the scientific international debate on urban health increased [1,2,3,4], and some Italian researchers participated in that by elaborating several addressing documents [4,9,10,11,12,13,14,15].

The first paper [9], in agreement with other international documents (WHO), reports some strategic goals for Italian cities, aimed at realizing healthy environments—in terms of accessibility, inclusiveness, resilience, and sustainability—through local governments’ actions. To achieve these goals, a sort of “co-production” is required, intended as a participatory process where different stakeholders come together to achieve joint goals. In fact, as previously reported, greater inclusion can lead to improved interactions of citizens with decision-makers and to novel solutions delivering interesting elements of transformation [5]. This approach is also well-aligned with the 2030 Agenda, since it drives more equity and inclusiveness [16].

The second paper [4] aimed to provide indications for designers and other involved bodies on the requirements of “Salutogenic cities”, capable of promoting health because of their layout, and integrated the previously defined strategic objectives [9] with the emerging environmental issues, like the urban adaptation to climatic changes and the new related housing needs.

It was also emphasized that they need to apply an interdisciplinary approach to develop skills to work with the system in order to cope with difficulties, since joint action is required to involve communities, starting from the professionals themselves [16].

Since the WHO declared the COVID-19 outbreak a pandemic, severe lockdown measures were adopted by the Italian Government. In particular, the mandatory mass quarantine impacted people’s daily lives, with negative psychological effects compounded by the fears of infection, frustration and boredom, inadequate supplies and information, financial loss, and decreased daily physical activity, with the growth of non-communicable diseases as a consequence.

In the literature, several studies published immediately after the lockdown and over the next few years highlighted the physical and mental long-term consequences of COVID-19 [15,17,18,19]. Other studies focused on the impacts on the built environment, rethinking the urban priorities under the lens of the pandemic challenge [10,11,20,21]. All these factors, to date, represent a growing concern for public health.

The urban priority discussed in many papers [10,11,20] led to a list of immediate, medium, and long-term actions to be implemented, urged by the multifaced health, environmental, social, and economic criticalities, due to this worldwide emergency. The discussion has also been focused on housing design strategies, underlining the need for larger and more livable spaces, possibly facing green areas. In fact, built environment restructuring can improve public health through increased opportunities for active healthy behaviors [10,11,20,21]. Behavioral science targets individual health behaviors within a place, suggesting the potential to integrate these approaches [22].

In 2021, the “International School of Epidemiology and Preventive Medicine G. D’Alessandro” organized an intensive residential course (the 57th) devoted to “Re-think cities and living spaces for public health purposes, according to the COVID-19 lesson”, held in Erice, Sicily, from 24 June to 28 June 2021.

The aim of the course was to share knowledge and views on this topic to enrich the strategies and actions already suggested for Italy [4,9,10,11,14], with further ideas and proposals, also considering international experiences [20,21,23]. Therefore, a multidisciplinary team of speakers, from the European Public Health Association, the Italian Ministry of Health, the Regions and Local Health Units, and university teachers of different disciplines (Urban Planning, Transportation, Public Health, etc.) were invited.

The course participants were public health physicians, epidemiologists, hygiene and [reventive medicine residents, architectural planners, and engineers, i.e., all those who could be involved in public health and strategies for healthy urban planning. The training program provided participants with operating tools recognized at national and international levels for the assessment and planning of an urban environment capable of encouraging the adoption of correct and healthy lifestyles.

As part of the course, during the practical sessions, teachers and attendees discussed some criticalities and changes in urban living observed in Italy and in other countries following the COVID-19 pandemic [20,24]. To facilitate the discussion, a creative participation technique was used [25,26].

The aim of this article is to report the results of this multidisciplinary comparison.

2. Materials and Methods

As previously reported, several discussion sessions with participants took place during the course. Such sessions were correctly defined as “practical sessions” intended to exploit those moments as an element of direct confrontation through the participation of all the attendees on the main topics covered during the course and articulated in 7 thematic tables:

• Housing and indoor environment;
• Urban mobility and walkable environment;
• Urban green spaces and ecosystem services’ assessment;
• Healthcare services network;
• Design for all;
• Urban health policies;
• Urban health actions.

To achieve these goals, the World Café technique was chosen [25], because this creative technique is well-suited for the interaction of participants and the involvement of groups, so that everyone could bring their own contribution following the collective reasoning that some facilitators managed by using questions and insights. Figure 1 summarizes its phases: the World Café’s scope was to make available the power of informal conversations to creatively develop thoughts and resources, realize an indirect learning experience, share knowledge, and generate change. A facilitator was assigned to each table, selected from the teachers of the course previously trained on this technique, whose tasks were to involve and moderate the intervention of all participants, to record and summarize the discussion for the next group, to favor the contamination and exchange of ideas between one group and another, and to present what emerged from the various groups during the final session. The multidisciplinarity of the experience was guaranteed, when forming the groups, by merging together designers and public health experts into the different groups according to the skills available among the participants. The main benefit of this technique is its versatility, as it can be proposed in different contexts (e.g., alone, during meetings or courses, etc.); further, it allows the sharing of knowledge, development of innovative ideas, and extending the dialogue process to even larger groups of people. In addition to the exchange of ideas, it allows the deepening of relationships.

The evolution of ideas in a World Café is achieved through the invitation for all participants to move within a rather short time from one discussion group to another [25,26,27]. For this particularity, the World Café tool was used and compared with other participation techniques, for example, brainstorming, which does not involve alternating participants. Using the World Café allows one to creatively expand and mobilize thoughts and resources and manage any “dominant” interlocutors who could monopolize the discussion. At the same time, it shows some limitations: it needs spaces and equipment, depending on the purpose, and it can require quite a few facilitators [25,26,27].

The intimate and welcoming setting of a café was recreated with a common space useful for hosting the involved people. The participants were divided into groups, each made up of 9–10 people, with a couple of them connected remotely. When forming each group, an effort was made to include people with different geographical backgrounds and work experience. Materials for notes, drawing, and writing were laid out on the central table to consolidate ideas.

3. Results

The World Café technique immediately proved itself to be a facilitatory and welcoming process useful for bringing out reflections, thoughts, and insights following the theme of the table and trying to develop and enrich it. The friendly approach, typical for a conversation in a café, immediately became a key element of the atmosphere created during the Erice courses. Each group was involved in participating in at least two discussion tables for a total of about 3 h. Interaction was achieved through the invitation extended to all participants to illustrate the experience gained during the lessons, along with the participants’ personal experience, in a short time to summarize the contents. By using Post-Its and brief notes, an attempt was made to summarize and order the main reflections by putting together the contributions of the participants and fixing the contents to a poster (See Figure 1). The result was the realization of an in-depth proposal of the seven thematic tables with the realization of a common piece of work to which the young participants were able to contribute by increasing the theoretical basis achieved during the week of the course with experiential elements derived from the comparison and multiple skills present at the various tables.

Overall, 66 participants, followed by 14 trainers and 3 supervisors, actively contributed to the seven tables of the World Café.

Figure 2 outlines the strategies/actions proposed for each thematic area and, based on the evidence from the literature [4,9,10,11,20,24], proposes a mutual relationship for the expected impacts of these strategies on the urban built environment and the health of the population. In the following, the main insights that emerged during the discussions are briefly reported, which can be included in three main topics: (1) re-thinking the urban environment, particularly focusing on housing, mobility, and urban green space; (2) re-thinking community services, with particular attention to healthcare services and inclusive design; and (3) re-thinking policy-making and acting in relation to the COVID-19 lessons.

3.1. Rethinking the Urban Environment

The availability and quality of housing are pivotal questions for public health. It is known that the pandemic exacerbated the detrimental effects of the housing crisis the health, showing the urgent need to increase and ensure that the supply of shelters is adequate [28,29]. Recent studies have proven that living in overcrowded homes may be an important risk factor for COVID-19 mortality [30], so housing sizes are an issue that several researchers are thinking about, producing an indication to review the current standards [28,29].

At the same time, poor indoor air quality (IAQ) and thermal discomfort are another source of concern [31,32,33,34]. The need for reducing energy consumption in buildings requires the correct balance with air change [35,36,37,38,39], but this balance is often not achieved. During the lockdown, scarce indoor ventilation caused concern due to the increased risk of contracting the disease [10,37], especially for people living in overcrowded houses. An improvement in IAQ has the potential to reduce not only infections with SARS-CoV-2, but also other respiratory infections, reactive airway diseases (e.g., asthma), toxic effects due to the inhalation of volatile organic compounds, and other pulmonary and cardiovascular diseases. Therefore, identifying solutions able to ensure adequate levels of IAQ is a priority, especially considering the increasing trend in energy efficiency interventions for buildings.

Some studies have shown that living in more spacious apartments or in neighborhoods with higher levels of urban greenness was associated with lower COVID-19 infection rates [40]. The lockdown period has changed people’s ways of living, working, and interacting in their living environments. The WGs emphasized the need to re-think housing standards to make these places resilient, designing flexible, adaptable, and shared spaces [5,6,7,8,9], and visible and accessible green spaces or elements [10,11]. In particular, the discussion has focused on the flexibility of ground floors and basements, which could become shared spaces available to all tenants, providing temporary quiet workstations and maintaining social distancing in case of a new lockdown [10,11].

To respond to the new housing needs (e.g., home automation and telemedicine) and to assure the control and management of the home, including IAQ, a technological and digital transition should be considered [10]. In this field, COVID-19 has boosted smart city development, as evidenced by the increase in teleworking, telemedicine, surveillance systems, and online commerce and education [41]. The current market offers several solutions, like, for example, user-friendly wearable devices with sensors that detect some environmental and health parameters, which could provide useful support for raising people’s awareness of IAQ, as well as their own health [42,43]. It is important to evaluate their implications (e.g., privacy issues) well before an extensive application by raising citizen awareness about their correct use [20].

In general, in addition to buildings, green infrastructure, especially that with proximity, shows a positive impact on air quality in urban areas, mitigating adverse climatic phenomena [44,45,46], beneficially affecting physical and mental health [44,46,47,48,49,50], social cohesion, and resilience to climate change [51]. Such infrastructure includes green roofs and walls, gardens, and condominium spaces, as well as the presence of balconies or terraces in which there are plants or small gardens and, obviously, proximity gardens. During the early phase of the COVID-19 pandemic, these spaces had a strategic role, being one of the few recreational places accessible during lockdown periods, even with different levels of restriction between countries.

The use of urban green space (UGS) may depend on individual choices, but also on access issues, due to different distributions between neighborhoods. UGS represents an important part of the public spaces and common services of a city, and they should have a proper territorial distribution [52], assuring their accessibility for all population groups [53] for greater environmental justice and inclusiveness, improving urban salutogenesis. At the same time, the population should be aware of all the benefits of greenery to promote wider and cultured use of it and to develop a sense of belonging, perceiving greenery as a “common good” that deserves respect. Improving the safety and maintenance of green areas through passive surveillance should also be included, for example, having an accessible reporting system for any malfunction or risk (e.g., through an app with the geolocation of the report). Schools, GPs, local health services, and other official channels could provide valid support to reach these objectives.

However, an overall vision of UGS is currently unavailable. Italy has various municipal tools for mapping and managing UGS [54,55], but they are not widespread and often contain partial and non-comparable information [56]. Today, UGS includes a diversity of structures that combine to provide multiple ecosystem services (ESs), namely provisioning services, regulating services, and cultural services [57]. These services, as highlighted by the European Commission [58], should be integrated into a comprehensive vision of green infrastructure, also including the perceptions and preferences of citizens in planning proposals and management [59].

The use of integrated methodologies to evaluate the relationship between natural resources, artificial habitats, and human well-being, like the ESs evaluation, can support the development of urban projects in which benefits are optimized [60,61]. It possible since they are built taking into account several services, returning both tangible and intangible effects on multidimensional and multiscale levels. Some examples are carbon sequestration, climate and water regulation, nutrient cycling, users’ perceptions visiting a place, and spiritual and religious value or aesthetic value.

Some tools (INVEST, ITree, and SimulSoil) and evaluation frameworks [62] attempt to measure both quantitative and qualitative aspects for various purposes [63,64,65,66,67] to encourage public administration to adopt “green” measures and promote “green and sustainable cities”. These interventions do not provide a direct economic return, but the benefits can be tangible for the population and cities, contributing to improving the quality of the urban environment [68] and the economic value of building heritage.

Another important factor of urban living is mobility. The pandemic and anti-spread public health policies have affected many aspects of everyday mobility in cities, with different results. Several measures were gradually put into effect to meet the requirements of social distancing, which indicated the poor preparedness of operators. At the same time, mobility decision-makers opted for easing existing restrictions and regulations for passenger cars [69], as well as for other solutions (e.g., pop-up bike lanes, recently questioned [70], or micro-mobility fostering traveling alone). All the above does not agree with what has been postulated in the policy of sustainable transport development since time, that is, with the promotion of active modes of transport and transit, and the reduction of the use of private vehicles [71].

The WGs considered the development of knowledge and communication as factors contributing to the restoration of urban transport sustainability. The low preparedness of transit operators was caused by the severity, scale, and speed of the pandemic. At the same time the uncertainty is often compounded by poor access to specific data on the impact of urban mobility policies and best practices on health. The need for knowledge goes hand in hand with appropriate communication to inform and educate citizens on correct behaviors and safe and sustainable mobility options.

Among the emergency solutions developed to cope with social distancing, some cities have promptly put in place measures, such as temporary bike lanes, and enlarged sidewalks to adapt to increased pedestrian flows [72] and improve the walkable environment [11,73,74]. Although it is unclear whether all the above are slated to become permanent, these solutions were considered leverage to increase the active modes of transport and to redesign the built environment to attract more people after the pandemic. More specifically, these solutions were associated with the 15 min city [75], highlighting that this concept poses some practical difficulties in its implementation, mostly in terms of equity, resources, and preparedness. Furthermore, it raises one more issue, considering the post-pandemic observed massive revamping of private traffic, i.e., the need to educate citizens to be more environmentally conscious about their travel options.

Finally, the WGs suggest some solutions to reduce the use of passenger cars. They include designing a more walkable built environment, providing more co-working opportunities, increasing the use of remote work within corporate culture, and promoting more creative solutions (e.g., cashback or other types of reward associated with transit passes or tickets for regular home-to-work commuting).

3.2. Re-Thinking Community Services

Social, political, and economic transformations, including the disruptions caused by the COVID-19 pandemic, affect the spaces of care and all urban environments hosting public functions [14]. The Architectures for Health—as urban services—have become an active part of a city’s public life for health prevention and promotion, as well as an opportunity for urban regeneration, citizen awareness, and sensitization. Today, such facilities have a new identity value and familiar characteristics for neighborhoods and communities, renewing the relationship between disease treatment, health, and well-being promotion [68,76,77,78].

The pandemic emergency has highlighted the weakness of the health system, placing a heavy burden on hospital centers and especially on emergency departments; therefore, it is pivotal to achieve more extensive and homogeneous levels of service, reduce hospitalization demand, and use digitalization and telemedicine tools, where applicable, to monitor the health of citizens. This change will not be able to disregard the management of an efficient network of places intended for other forms of assistance and the concrete involvement of home care, increases in rehabilitation hospitalization facilities, health residences, and territorial outpatient clinics, and the careful management of services that precede rapid and targeted therapeutic interventions in hospitals [79,80].

The participants agreed with the importance of these social and health facilities, and the community hospitals and community houses envisaged by the Italian Recovery Fund (PNRR) are particularly considered as premises for preventive, educational, cultural, and community services (i.e., associations and schools) with counseling and social services, outpatient clinics, screening activities, and basic diagnostics (i.e., RX, echo, etc.). Responding to these needs could, therefore, be an opportunity to restore an identity to urban voids with new attractive models dedicated to neighborhoods, but also to hard-to-reach or cross-border territories.

At the same time, the COVID-19 pandemic has enlarged the barriers for people with disabilities of all ages. Many of them face difficult challenges, such as a lack of accessible spaces or adequate equipment. The social distancing and government-imposed social restrictions have been additional barriers, especially challenging for those who need personal aides or caregivers.

The increased opportunity for high- and low-technology solutions in the pandemic could be an opportunity and benefit the disabled community to transform daily living places to be more accessible and inclusive.

Design for all (DfA) is the design for inclusion that aims to meet the needs of different people, regardless of age, gender, background, culture, ability, or disability [53,81,82,83]. DfA is promoted by the UN Convention on the Rights of Persons with Disabilities [68] and the recent Strategy EU 2021–2030 [84]. Currently, European legislation has integrated the DfA strategy within standards, such as EN 17210 [85], defining inclusive design requirements for all EU Countries. In Italy, the PNRR also promotes and provides funding for social inclusion [86].

As an inclusive environment implies physical accessibility, sensory, cognitive, and social inclusiveness, like gender equity and cultural specificities [87], the spaces of facilities should be adapted according to all the different users’ needs. Wayfinding should use different methods (visual, tactile, and auditory) and be flexible in case changes need to be made in accordance with emergency situations. Inclusion also means the possibility of equitable access to health services with accessible facilities located throughout the territory (e.g., community-based healthcare), where the availability of information services is also guaranteed [14].

DfA will require specific training considering the needs of both customers and staff, also aimed at decision-makers and technicians.

Finally, the WGs stressed the importance of quantifying the impact of DfA on health outcomes, providing scientific data on topics such as social inclusion, but also of quantifying costs and benefits to drive investments. Therefore, assessment tools are needed that can measure the quality of inclusive design in existing buildings, as well as methods to support the design of new facilities [88,89].

3.3. Re-Think Policy-Making and Acting

As each city and even each district differs by needs and population groups, policy-making needs to engage the community, and this participative approach is included in many regulations and projects for which it is a fundamental requirement. To be effective, it requires the involvement of policy-makers and different stakeholders (e.g., citizen subgroups, trade associations, social cooperatives, schools, etc.), depending on the issue’s content.

The introduction of health issues into planning processes requires strong political support to ensure the resources needed and a full integration of it with other local policies. Health is a powerful motivator, and the COVID-19 pandemic clearly demonstrated this, but frequently, it is necessary to strengthen the awareness of citizens and policy-makers of its real value. For this reason, the health objectives followed in each intervention have to be explicit, measurable, and quantified through an evaluation of the produced changes in the quality-of-life, in the health level, in environmental justice, and so on [90].

After these general considerations, three macro areas emerged during the discussion. The first assessed topic involved the structural problems of the cities touching various issues, such as urban heat islands (UHIs), lack of green spaces [91], the presence of unused or misused buildings, and neglected suburbs. As for UHIs, since a rebuilding policy is too costly, to empower citizens, incentivizing the creation of privately owned and community-managed exposed gardens, both in front of houses and in common areas, was proposed. The valorization of green spaces, especially those that are abandoned, could also be addressed by promoting vegetable gardens managed by locals. Regarding unused buildings and degraded suburbs, WGs believe that citizen-empowered solutions are limited, since they require policy-making, such as revisiting regulations on buildings. A proposal concerns the reformation of the rental policies instead, by regulating, for instance, fees and promoting centralized control over the maximum number of people who are allowed to rent an apartment. This is a critical issue, especially for poor and foreign people [6,29], but also for university students. Therefore, its importance should be highlighted, considering the concern it caused during the COVID-19 pandemic and the related lockdown period and that it could cause if future emergencies occur.

The second topic involved urban mobility. The discussion mainly focused on the need to improve the accessibility of public transportation and re-evaluate mobility plans to ensure that everyone’s needs are met (e.g., circular routes from suburbs to suburbs and not only radial, from suburbs to city centers). Apart from public transportation systems, the need to put in place or implement policies to promote private sustainable transport, not only by economic incentives, but also by improving safer bicycle lanes and routes to increase the safety perception of the citizens, was underlined.

The third topic involved community problems, mainly focusing on the lack of citizens’ involvement in environmental issues, such as waste sorting, low acceptance of local waste-to-energy plants, and resistance to using tap water as a primary source of drinkable water [92,93,94]. In all those cases, the proposed solution was to better inform citizens about the value of said activities and plants, although, in certain cases, a structural intervention would be required.

Today, urban regeneration projects can be an opportunity to re-think the way of living in neighborhoods, to develop healthy places able to promote health, and to fit the real needs of inhabitants.

In fact, urban health is a lens to guide dialogue between people with different backgrounds (health and social science professionals, urban planners, designers, and citizens) to pursue health promotion and disease prevention, but also involves applying models for healthy environments that can clash with local contexts not culturally ready to accept radical changes.

The “practices of urban living” [95], understood as collective actions, habits, and choices, are the starting point for health promotion. As discussed before, the COVID-19 pandemic changed the use of urban spaces and the ways of interacting and socializing, causing significant upheavals in residents’ daily ways of living and, consequently, their moods [88] and their priorities.

For the participants, the relevance of urban action consisted of the advancement of new and accessible social spaces intended to cultivate the social, cultural, and human capital in the city and aimed at building social networks that go “beyond the time of the aperitif”. This includes, but is not limited to, green spaces, vital elements of urban habitats, and the provision of personal and collective regeneration, while acting as a social determinant of health.

What is described above is influential for a second theme, that of choosing where to live. Large cities offer opportunities, mediated by the mobility networks of public transport, ride/bike sharing, large pedestrian areas, and cycling paths, which also facilitate certain lifestyles, but social networks are created by the contexts of one’s living environment. It has to be argued that changes, such as relocation to other places, are complex choices and their long-term implications are unclear [21].

As of today, many public health departments do not have sufficient resources to handle the complexities and realities of health in urban spaces. As the Italian Ministry of Health has recognized Urban Health as a strategic direction for the improvement of public health [96], the development of more skills and guidelines in this field is pivotal. Some national guidelines on this theme have already been produced [97] and offer indications on how to implement the National Health Plan objectives, representing a good starting point for the development of good practices at local levels.

4. Discussion and Conclusions

As mentioned in the introduction, the aim of this article was to report the results of a multidisciplinary discussion on how to re-think salutogenic cities after the COVID-19 pandemic, to enrich the strategies and actions already suggested or active in Italy [4,9,10,11,14].

This aim is in line with the Urban Health Research Agenda for 2022–2032, recently developed by the WHO, which is expected to identify gaps in the urban health field, develop global research priorities that address them, and strengthen the methodologies, but also provide evidence for the development of multisectoral interventions to promote urban health [98].

The World Café results, although reiterating several themes largely described in the literature [10,11,14,20,21,23,24,29], add new insights on how to improve the livability and health of urban spaces, suggesting strategies, policies, and actions. Some indications were proposed on re-thinking the built environment, taking into account the quality and availability of housing, green spaces, and urban mobility, all themes widely debated in the literature [10,11,20,21,23,29]. The different places of origin of the WGs’ participants, distinct not only by physical distances, but also by dissimilar cultural and social situations, created a richness of different urban experiences. This perspective was maintained throughout the discussions, emphasizing the fundamental role that direct experience has in the contextualization of projects.

One of the most stressed points was the importance of using participatory approaches to the decision processes regarding urban health has been underlined, even if they can clash with local contexts that are not culturally ready to negotiate “inflexible” proposals, like those regarding health. Consequently, adequate training for all actors is pivotal, also considering the expected introduction of new digital technologies (e.g., home automation, telemedicine, etc.) and integration of methodologies of analysis (e.g., ecosystem services, safe mobility, design for inclusion, etc.). Actually, many new surveillance and governance instruments are available today, for the use of which the development of appropriate competencies is needed in order to exploit the opportunities science and technology offer in the best way. Knowledge can also contribute to reducing injustices and inequalities, favoring higher consciousness and participation in community activities and decision processes [99].

In fact, despite the evident advances in public health, many health inequalities persist, especially in cities, indicating that much remains to be done to achieve equity. The COVID-19 pandemic, hitting mainly the most vulnerable groups, severely exacerbated the pre-existing inequalities, but offered, on the other hand, the opportunity for a critical reflection on the importance of urban health policies.

One of the priorities of the WHO Agenda 2022–2032 [99] is to explore how urban inequities can compound neighborhood risks, and how addressing them can improve health equity and outcomes. As mentioned above, the post-COVID-19 response can be an opportunity, if aimed at ensuring dignity in the living conditions of all of the population, to prepare the population for other future global crises [11,21,23].

Knowledge can contribute to this preparation, increasing cities’ and populations’ resilience to emergencies, which is a crucial issue for Italy too, since, like other countries, it always faces many types of threats, such as those induced by climate change, like floods, earthquakes, etc. [11].

The WHO, together with the European Program “United Action for Better Health”, set priorities for 2020–2025 starting from what citizens in the region expect from their health authorities, including universal access to quality care without fear of financial hardship, effective protection against health emergencies, and healthy communities, where public health actions and policies secure a better life in an economy of well-being [100].

As in the past, the pandemic generated debate and a lot of ideas and suggestions about the future of cities, and it was the source of several lessons, which will continue to emerge for years [10,11,101,102]. Today, in Italy, the National Reprise and Resilience Plan offers several opportunities to regenerate cities under new perspectives, in which health, equity, and sustainability can walk together. It is to be hoped that planners, local authorities, and policy-makers will be able to seize this extraordinary development opportunity to identify and realize effective actions to satisfy human needs, regarding sustainable development in its broad sense.