Bridging Bilbao and Burgas through One Urban Health: Policy Pathways for Europe

Background

The One Health approach is increasingly applied in urban settings (One Urban Health), linking human health with ecosystems and governance. Bilbao (Spain) and Burgas (Bulgaria), two coastal cities at different stages of transformation, illustrate how urban development trajectories shape health outcomes and equity. This comparative analysis draws on Eurostat and urban policy data to examine how long-term governance and investment strategies influence population health.

Results

Bilbao and Burgas face similar public health challenges, such as ageing (∼24% aged 65+) and climate risks, but Bilbao began addressing them decades earlier. Bilbao (∼345,000 inhabitants) started its transformation in the late 1980s after industrial decline. The “Bilbao effect”, driven by political commitment and urban regeneration, shows how integrated policies combining environmental clean-up and cultural investment improve urban health. These efforts are linked to better air quality and outcomes, contributing to Spain’s higher life expectancy (∼83 years) and lower avoidable mortality. Burgas (∼200,000 inhabitants), historically an industrial hub during the socialist period, still reflects the legacy of past environmental and demographic policies, with lower life expectancy (∼75 years) and higher disease burden, particularly cardiovascular. Over the past decade, Burgas has been advancing along a Bilbao-like pathway. An emerging “Burgas effect” is visible, driven by EU-funded regeneration, circular economy initiatives, digital, educational and cultural investments.

Policy implications

The Bilbao effect shows that integrated urban investments can reduce health inequalities. Burgas demonstrates this pathway is transferable and can be accelerated through EU cohesion policies aligned with One Urban Health.

Conclusions

Cities can translate One Health into action. Learning between Bilbao and Burgas shows that even historically burdened settings can become healthier and more resilient.

Key messages

• Urban settings are where One Health becomes actionable, linking environment, governance and population health in real time. One Urban Health enables cities to address public health challenges.

• The “Bilbao effect” shows that sustained urban policies can improve health; emerging cities like Burgas demonstrate that this pathway is transferable.