The aim of this study was to evaluate the amount and quality of water in the Magdalena-Eslava river system and to propose alternatives for sustainable water use. The system is the last urban river in the vicinity of Mexico City that supplies surface water to the urban area. Historical flow data were analyzed (1973–2010), along with the physicochemical and bacteriological attributes, documenting the evolution of these variables over the course of five years (2008–2012) in both dry and rainy seasons. The analyses show that the flow regime has been significantly altered. The physicochemical variables show significant differences between the natural area, where the river originates, and the urban area, where the river receives untreated wastewater. Nutrient and conductivity concentrations in the river were equivalent to domestic wastewater. Fecal pollution indicators and various pathogens were present in elevated densities, demonstrating a threat to the population living near the river. Estimates of the value of the water lost as a result of mixing clean and contaminated water are presented. This urban river should be rehabilitated as a sustainability practice, and if possible, these efforts should be replicated in other areas. Because of the public health issues and in view of the population exposure where the river flows through the city, the river should be improved aesthetically and should be treated to allow its ecosystem services to recover. This river represents an iconic case for Mexico City because it connects the natural and urban areas in a socio-ecological system that can potentially provide clean water for human consumption. Contaminated water could be treated and reused for irrigation in one of the green areas of the city. Wastewater treatment plants and the operation of the existing purification plants are urgent priorities that could lead to better, more sustainable water use practices in Mexico City.