Looking beyond the hospital: public health in smart cities

An example of smart technology and public health combining for the public good: Governments around Europe have worked to implement COVID-19 contact tracing apps, such as the Corona-Warn-App in Germany. Participation is voluntary and the app has already been downloaded by close to 23 million people. More information on the app can be found here. [Photo Source: Photo by Cedrik Wesche on Unsplash]

Often the best public health work goes unseen and it is not until a crisis like the current pandemic that the full scope of public health is recognised.

2020 has been an eventful year, with the COVID-19 pandemic most notably finding itself the topic of headlines on a daily, hourly and even minute-by-minute basis. The pandemic has wreaked havoc not only on the physical health of those afflicted but also on the mental and social well-being of many people at all levels of society, with already vulnerable populations being disproportionately impacted. From new routines and ways of working to managing stress, family obligations and ongoing physical implications, being ‘healthy’ is in some ways more challenging than ever.

To many, ‘health’ is something that lies within the walls of a hospital or a doctor’s office, but as COVID-19 has demonstrated, health applies to and is impacted by all layers of urban society. For instance, studies now link long-term exposure to air pollution to an increased risk of dying from COVID-19. The actions in response to COVID-19 have been some of the most visible aspects of public health, but often the best public health work goes unseen and it is not until a crisis like the current pandemic that the full scope of public health is recognised.

So, if ‘health’ is not merely determined by the clinical space and ‘public health’ means more than just controlling infectious diseases and responding to pandemics, how then are these concepts defined? And why and how are these terms relevant to those engaged in the field of smart cities?

‘Health’ and ‘public health’: beyond the walls of clinical medicine and into the wall-less bounds of cities

To set the stage in our understanding, let’s turn to two important definitions and related principles, as proposed by the World Health Organization (WHO):

Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. It is a core WHO principle that ‘the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition’.

Public health is the art and science of preventing disease, prolonging life and promoting health through the organized efforts of society. Public health focuses on the entire spectrum of health and wellbeing, not only the eradication of particular diseases.

One way of understanding the social determinants of health is through their grouping into five overarching domains: 1) Education Access and Quality, 2) Health Care Access and Quality, 3) Neighbourhood and Built Environment, 4) Social and Community Context and 5) Economic Stability. [Image Source: U.S. Centers for Disease Control and Prevention]

Considering these definitions, it becomes clear that the responsibility for creating a healthy community rests with all sectors of society, not merely with those engaged in direct healthcare services. The ways that cities prioritise and respond to needs and challenges can directly influence health, either positively or negatively and intentionally or unintentionally. Even when targeting a specific health outcome (e.g. cardiovascular disease) is not the explicit focus of a project, an implementation — and how it is implemented — can have significant impacts on the health of a population by influencing the social determinants of health, i.e. 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.

Simply living in cities should not be exposing people to unnecessary health risks, but the scientific evidence clearly suggests that urban living can negatively impact health, e.g. through air pollution. However, the ‘silver lining’ to this evidence is that most of these impacts are completely preventable. For instance, with a topic such as air quality, implementations like urban air quality platforms can track data that inform meaningful policy changes to reduce air pollution, while innovative last-mile delivery systems can reduce local emissions caused by standard door-to-door deliveries.

Those working both within and with cities not only need to recognise how implementations like these can impact health but should also maximise the potential for positive health impacts for the greatest number of people.

These are two examples of real smart city implementations that can impact health even when — at least for a solution like last-mile delivery — improving health may not be the primary focus. As cities work to improve urban quality of life for all of their residents, those working both within and with cities not only need to recognise how implementations like these can impact health but should also maximise the potential for positive health impacts for the greatest number of people.

Embedding public health principles and (health) equity into smart city implementations

Equality and equity do not necessarily imply that justice has been achieved. [Image Source]

Aside from the COVID-19 pandemic, 2020 has also been an eventful year for racial and social justice reform, both of which also have direct relevance to smart cities. Actions aimed towards furthering justice have highlighted that some of those doing work that they consider to be beneficial for communities are not always considering everyone in the community or listening to the community members’ needs. This underscores that not only is it important for cities to consider what they are implementing but also how what they are implementing is being implemented.

There are many ways in which those working with smart city solutions should try to bring these questions into consideration, but a few key areas include focusing on removing unconscious bias, promoting inclusion and addressing social and environmental justice in implementations. Just looking at one of these areas — for instance, promoting inclusion — those driving urban change can ask themselves questions including:

· Does the implementation involve citizens in the ideation, creation and evaluation phases?

· Which citizens are involved? Why?

· Who is empowered and informed to participate?

· Is anyone who wants to participate unable to do so due to limitations including transportation access, childcare availability, etc.?

· Are those participating representative of the entire population of the city?

· Are specific efforts made to involve and benefit marginalised and vulnerable groups?

· And importantly, after the previous questions have been taken into account: who is still not represented, and why?

Each of these areas honestly deserves more than just a mention in a Medium article, as they are areas in which improvements — or negative consequences — can dramatically impact not only health and health equity (‘the absence of unfair and avoidable or remediable differences in health among population groups defined socially, economically, demographically or geographically’) but also overall urban quality of life, both on a population-level and individual-level.

Looking ahead

Cities need to consider how these implementations can incorporate public health best practices around inclusion and justice to ensure the most vulnerable groups are not adversely impacted, intentionally or unintentionally.

From counting mask wearers on public transport with AI to using cameras to enforce social distancing guidelines, we are likely to continue seeing smart implementations geared towards preventing COVID-19 spread. However, looking both within and beyond the pandemic, cities need to consider how these implementations can incorporate public health best practices around inclusion and justice to ensure the most vulnerable groups are not adversely impacted, intentionally or unintentionally. Even before the pandemic, it was inspiring to see cities like Madrid, Spain, implementing mobility management strategies for vulnerable populations and others such as Munich, Germany, considering how systems like e-bike sharing can include more vulnerable users, e.g. by developing an e-trike prototype to make bike share more accessible for the elderly and physically impaired people.

Hopefully, within both pandemic-directed implementations and beyond, we will continue to see this type of thought and care being put into smart city planning and execution. The scope of ‘smart cities’ does not fit neatly into a box or set limitations, and neither does the world of public health — it therefore seems natural that the work of both fields towards improving and ensuring a high quality of life and high standards of living for all should be increasingly combined to maximise the potential positive benefits for all members of our communities.

The Municipality of Madrid aims at developing meaningful policy guidelines to address mobility management for vulnerable groups (elderly and children), thus shifting urban mobility in the outskirts from the dominance of car use to active trips and increasing safety in the outskirts of the city. [Photo Source: Photo by Robert Tjalondo on Unsplash]