Setting the scene: eHealth, Smart Cities, Healthy Cities and Non-Communicable Disease
During the past two decades, the global disease burden has been shifting from infectious to non-communicable diseases (NCDs). The World Health Organization estimates that 70% of the 56.4 million global deaths in 2015 were attributable to NCDs. While several NCD risk factors are associated with individual lifestyle behaviours - such as smoking, low fruit and vegetable consumption, physical inactivity and heavy alcohol consumption - the WHO also views the broader social determinants of health as highly significant to health outcomes:
“The social determinants of health (SDH) are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems.”
What this means is that a myriad of physiological, environmental, genetic and behavioural factors contribute to the development of NCDs. Also known as chronic diseases, these diseases affect people of all age groups, irrespective of country or ethnic origin. Although the geriatric population is most commonly affected by NCDs, growing evidence points at NCD-attributable deaths in the middle-aged population as well. What's interesting is that around 80% of these premature deaths occur in low and middle-income countries. Therefore, it is almost impossible to adopt a one-size-fits-all approach to developing interventions and practices that deal with the global burden of NCDs.
According to the World Health Organization, NCDs can be mainly classified as cardiovascular diseases, cancers, chronic respiratory diseases and diabetes. Risk factors for NCDs are classified into “modifiable behavioral risk factors” which include physical inactivity, unhealthy dietary habits, exposure to tobacco smoke, harmful use of alcohol and “metabolic risk factors” which include raised blood pressure, overweight/obesity, hyperglycemia and hyperlipidemia.
Current public health solutions to combat NCDs target modifiable behavioral risk factors, such as trying to persuade people to eat a healthier diet, quit smoking or get more exercise. While these are lifestyle-based and person-specific, there are some other factors which affect communities and population subgroups as a whole; rapid, unplanned urbanization, unhealthy lifestyles as a globalized trend and ageing populations constitute such examples.
Considering the magnitude of the threat posed by NCDs, we at Young Leaders for Health are on a quest for novel approaches to implement the principles of eHealth, creating sustainable solutions that tackle this global disease burden.
Many of the other terms that we will deal with here have no single, universally accepted definition. eHealth is one of them. The development of sophisticated ways of communicating and storing large amounts of information (information and communications technology, or ICT) has led policymakers to ask how these technologies could be used to make healthcare, disease prevention, diagnosis, treatment, monitoring, conducting research and management more effective and efficient.
In practice, this might mean that patients' health records are stored digitally, enabling them to be shared more easily, or that they could be asked to fill in digital surveys that yield large volumes of useful and accessible health data. In the European Union, for example, EU citizens have the right to work and travel in different member states. If they need medical care in a member state different from the one in which they usually reside, then it is useful for their medical records to be accessible across borders. To this end, the EU has set up an eHealth network, which brings together the Ministries of Health from all EU member states to develop common goals for eHealth.
eHealth is not simply about individual healthcare provision, however. The proliferation of wearable devices, apps and consumer health products to measure health-related information shows how much the private sector has attempted to move into this market in recent years.
Regardless of their potential to improve health, such eHealth interventions often seem to widen already existing health gapsbetween populations that frequently use information and communications technologies (ICT) and those who do not, instead of closing them. For example, "a wearable fitness band isn’t much use if you’re homeless and healthy eating apps aren’t all that practical if you struggle to buy groceries". This is why we feel there is a need to look beyond market-focused approaches to eHealth and consider how it can be harnessed for the sake of public policies in the fields of health promotion and urban planning. The technologies that make eHealth more efficient can also be used to drive forward health improvement at the population level, including in Smart Cities and Healthy Cities.
Since the days of the industrial revolution, cities have been a magnet for job-seekers, immigrant communities and entrepreneurs. This is clearly shown by their continual growth: by 2008, more than half of the global population was living in an urban area. This proportion is expected to rise to 70% by 2050, with some "megacities" projected to grow to 20 million inhabitants and beyond. While cities remain attractive destinations due to their abundance of social, economic and cultural opportunities, the bounty is not equally shared among residents. The lack of clean, piped water and proper sanitation for slum inhabitants means the standard of living for many in megacities is hardly any better than it was in Europe’s unplanned and chaotic industrial centres in the 19th century. Air and noise pollution are increasing and cities are particularly vulnerable to natural and man-made disasters. The safe removal and management of solid waste represent further challenges. The strain of urban growth on both the environment and public health makes the sustainable and efficient design of cities and infrastructure – in a way that reduces, rather than entrenches, urban social inequality – a matter of crucial public policy importance. The Member States of the United Nations have therefore decided to address urban areas in one the Sustainable Development Goals (No. 11) and to “make cities and human settlements inclusive, safe, resilient and sustainable”.
As cities are typically inefficient consumers of resources and require fairly sophisticated public service systems in order to serve the needs of their growing populations, policy makers and urban planners have increasingly turned to technological solutions in order to deliver services at scale. This is where the term “smart city” comes in.
But what is a smart city, and where does the concept come from?
“Smart city” has become something of a buzzword in recent years. As with eHealth, there is no single agreed definition for the term, risking confusion among policymakers about how to actually create a smart city. What commentators broadly agree on is that smart cities share at least one trait: as with eHealth, smart cities try to leverage the power of ICT in ways that improve residents’ lives. Importantly, a city does not simply become smart simply by having high-tech cut and pasted onto it. The true measure of a smart city’s success is not how much technology it uses or “big data” it generates, but what kind of a positive impact it has on its citizens’ safety, health and convenience.
An embryonic version of the smart city concept is thought to have emerged in California in the 1970s, when the little-known public agency, the Los Angeles Community Analysis Bureau, driven by faith in the ability of computers and data analysis to solve big problems, used cluster analysis, infrared aerial photography and computer databases to gather large amounts of neighbourhood data. Their aims were to better understand local poverty demographics and eventually to generate masses of data through an “urban information system”. Likewise, modern smart cities rely on technology to gather large amounts of data that can then be converted into “actionable intelligence for the efficient and sustainable management of the city”.
Contemporary examples of smart cities
Barcelona is an example of a city that has pioneered the use of technology and the Internet of Things (IoT) to provide free WiFi via street lighting, while sensors obtain real-time information about parking spaces and air quality. Since it became clear that some projects have yielded unintended effects, the city has announced its attention to rethink its Smart City strategy in order to focus more on the needs of citizens by taking ownership of its own networks and platform and inviting residents to participate in planning policy-making both in person and through online consultations.
In response to the massive environmental burden created by van journeys delivering parcels to consumers and businesses - increasing due to the popularity of Amazon - the Mayor of London has pledged to reduce the number of large, polluting lorries on London’s roads and phase in the use of zero-emission, electric freight vehicles. In addition, a power and heat project is currently underway which will harness the heat created by the London Underground (if you have ever been in London in the summer, you will know how uncomfortably hot and sticky the Underground gets) and use it to heat public swimming baths as well as people’s homes.
Regularly hit by natural disasters such as flooding - which is deadly for the poorer residents of the city's hillside favelas - the city of Rio de Janeiro has had to develop ways to improve its emergency response system. As a result, the city has implemented a number of strategies. Waste removal trucks have been equipped with GPS, allowing for monitoring and coordination in emergencies when the trucks are required for other purposes. The city has established an Operations Centre which offers a setting for the city's emergency services, including the police and the health department, allowing for better coordination and faster responses to emergencies.
The World Health Organization’s Healthy Cities movement began in 1988 with the aim of putting into practice the principles of the Ottawa Charter for Health Promotion (1986). Originally, just twelve European pilot cities took part. Like Smart Cities, Healthy Cities share the goal of improving residents’ wellbeing and quality of life. Becoming a Healthy City means that a city and its stakeholders proactively address the fact that the roots of (ill) health lie in a city’s physical environment, culture and economy as well as in an individual’s decisions regarding her lifestyle. In other words, the social determinants of health – the conditions in which people are born, grow, work, live and age, and the wider set of forces and systems shaping daily life – all have an impact on an individual’s health status. The complexity of the interplay of these factors means that being a Healthy City should really be understood more as a long-term process, rather than a one-off event. Currently, thousands of cities across all of the WHO’s six regions are members of the Healthy Cities network. But what makes a Healthy City stand out from its not-so-healthy neighbours?
Probably the most celebrated example of a European Healthy City is now Copenhagen. The extensive network of cycle lanes means that 62% of the city’s residents now cycle for convenience – not necessarily because they want to get fit. While the city has abandoned its taxes on fatty foods and sugary drinks and has shied away from a general ban on smoking in public places, it has pushed forward on initiatives such as requiring vegetation to be grown on flat roofs and high taxes on car purchases.
Killing two birds with one stone: how can a city be both healthy and smart?
Singapore recently came out on top as the healthiest city in the world, but it has also been labelled one of the smartest. As a culture that has long placed a high degree of importance of younger generations caring for their elders, the installation of remote monitoring systems enables families to keep an eye on their relatives and alerts them instantly if an incident is detected. Meanwhile, non-emergency healthcare can now be provided by video conferencing for those unable to attend hospital appointments.