Secondary cities in today’s West Africa were rural villages thirty years ago, so their housing, water, sanitation, and public health infrastructures are often very poor or nonexistent. Addressing issues of secondary cities requires new vision, policies, and approaches. Governments must work with local and traditional management systems and structures already in place. This paper describes the concept of environmental health and the related preconditions for disease prevention in secondary cities. It analyzes the institutional, economic, and social dynamics and conditions in secondary cities and their impact on the environmental health of populations. Several country experiences are presented as examples where effective relationships were created between government and client communities to address— in a sustainable fashion—the environmental health conditions. The paper gives policy recommendations to improve and implement more effective development programs in secondary cities in West Africa with the ultimate goal of improving people’s lives. Public authorities often just wait for the arrival of another “project,” with very little awareness of or skills to focus on these projects to address community needs and life patterns. Since environmental health requires attention from both the ministries of health and environment—along with the ministries of planning, education, interior, and others—a cross-sectoral approach must be used.