Illustration Giacomo Bagnara
Urban health is in a bind. Governments spend billions healing people, but then send them back to the source of the problem. Chronic conditions such as obesity, type 2 diabetes and asthma are perpetuated by cities that encourage driving over walking, where junk food is available on every street corner, and where deaths from air pollution are on the rise.
In the UK, long-term illnesses account for 70% of spending on health and social care, according to a 2018 RICS insight paper Cities health and well-being. In the US, the Center for Disease Control says 90% of the nation's $3.3tr annual healthcare budget is spent on chronic and mental health conditions.
Many of these conditions are strongly influenced by the way we design and build our environments. Many more could be monitored using sensors, allowing patients to spend more time at home, relieving some of the burden on hospitals. Where even a 1% improvement in urban health could save billions, the sector is ripe for disruption as cities get smarter.
Michael Chang, programme manager for planning and health at Public Health England, says that "appropriate smart planning concepts that improve neighbourhood design can play a significant role in positively shaping our health behaviours." Research by the UK's National Institute for Health and Care Excellence reveals that "high standard" spatial planning saves money, too: for every £1 spent on the planning process to promote walking, cycling and insulating homes, the health service could save £50, £168 and £50 respectively from a resultant drop in demand for treatments of conditions caused by unhealthy lifestyles.
Many of these ideas are being trialled in England, says Chang as part of an NHS initiative to apply a place-based approach to health at 10 "Healthy New Towns". Land use and infrastructure investment are coordinated in ways that promote healthy behaviours and active communities, as reducing social isolation has significant potential to delay the onset of many long-term conditions. A UCL-led study published in August this year, for example, found that 60-year-olds who spend more time socialising face a lower risk of dementia.
"Smart planning concepts that improve neighbourhood design can play a significant role in positively shaping our health behaviours! Michael Chang, Public Health England
Dr Helen Pineo, lecturer in sustainable and healthy built environments at UCL, and co-author of the RICS insight paper, says there is great potential to use data from smart technologies such as the internet of things (IoT) to help us understand how people use the built environment and how this relates to health. "If we have better knowledge of noise or air pollution exposures, for example, we can develop urban and building designs to reduce them. Better monitoring of these exposures also would allow us to identify and remedy design or technical solutions that aren't working," she explains.
The International Data Corporation forecasts that $95.8bn will be spent on smart city initiatives in 2019, up 17.7% on last year. Most of the funding, it says, will go on fixed visual surveillance, advanced public transit, smart outdoor lighting, intelligent traffic management and connected back office. Singapore, New York, Tokyo and London will have each invested more than $1bn on smart city programmes this year. Many of these investments will have spillover effects, providing city-wide connectivity and data-driven networks via IoT that can be leveraged to achieve positive health outcomes.
The RICS insight paper suggests that strategies to reduce exposure to air pollution within buildings and improve urban air quality are "highly impactful" – and urgent: UK air pollution is linked to 36,000 deaths per year; in China, poor air quality is associated with an estimated 4,000 deaths per day. City governments want diagnostic tools able to model the concentration of pollutants from the street to the megacity scale.
One such tool is RapidAir. Developed by Ricardo over the past five years following the company's work with 200 city authorities globally. RapidAir can calculate in minutes what previously took hours or days of data crunching. "If we had a now-cast of live traffic data, we could display a model of what happened an hour ago [in terms of air quality]," says Dr Stuart Sneddon, business manager air quality and environment at Ricardo. "Or if you're looking at bus emissions, we can model the impact of making changes to the fleet in days not months."
RapidAir has been supporting scenario modelling for four Clean Air Zone studies across the UK, and is used by the Department for Environment, Food and Rural Affairs and the Scottish Government as a planning support tool to understand the effects of industrial facilities and infrastructure and transport developments on air quality. In future, the benefit won't just be fast processing times: "As more sensors able to measure ambient air pollution are integrated into the city, we're trying to link to living and live systems," says Sneddon, explaining that this would enable the real-time management of traffic-related pollution.
"If you're looking at bus emissions, we can model the impact of making changes to the fleet in days not months" Dr Stuart Sneddon, Ricardo
One of the risks of using data to identify and manage urban health issues, warns Pineo, is that we may focus our attention too much on the problems for which we have data – such as air pollution – and disregard harder-to-measure exposures. "We have to ask what information we need, rather than focusing on what we can measure easily," she says.
In Boston, US, a team at MIT's Senseable City Lab is attempting to do just that by exploring what flows underneath cities: sewage. The Underworlds project is working on the premise that you can tell a lot about a person's health by sampling their microbiome. As this "information" is flushed down the toilet, it lives on in our sewage as a kind of collective microbiome. By tapping into this – via small robots that collect samples from sewers – the project aims to speed up detection rates for viruses, bacteria and chemicals. "Hopefully, we can use this information to help healthcare providers and the general population to prepare and proactively respond to outbreaks," says the lab's director, Professor Carlo Ratti.
To date, the project's two robots – named Mario and Luigi after Nintendo's moustachioed plumbers – have taken samples in Boston, Kuwait City and Seoul. It is the first attempt to sample sewage "upstream" at a neighbourhood level, and the goal is for cities to deploy the samplers according to where and what they want to test. "We have detected epidemics such as influenza before people became aware of them," says Ratti. "We have also been able to track dietary habits in different cities, and detect the consumption of drugs in certain areas."
The lab also hopes to help in the fight against antibiotic resistance. Ratti says that sewage can not only shed light on resistance levels, but could also help provide alternative treatments for bacterial infections in the form of phages – viruses that attack and kill bacteria.
Hard-to-capture data like this reveals the dramatic potential for the smart city to impact population health– but some of the most practical interventions are focused on wellbeing at the building scale. "It's a real wakeup call to most of my medical colleagues when I point out that the average person spends about 90% of their life indoors," says Dr Brent Bauer, medical director at the Well Living Lab in Minnesota, referring to the US Environmental Protection Agency's findings on indoor air quality. While he acknowledges that healthier homes and offices will be more likely in communities that are also pursuing similar health goals, "the indoors needs to be optimised to promote health and wellness."
"The average person spends 90% of their life indoors, so it needs to be optimised to promote health" Dr Brent Bauer, Well Living Lab
Bauer says that the more these changes can happen with minimal or no effort on the part of the individual the more likely they are to be successful. The potential of smart tech here is transformative: I dont see a lot of changes in the near future that are not critically dependent on tech he says. Its one of the reasons our Well Living Lab staff has several technology experts working side-by-side with the building and medical scientists.
The Well Living Lab is currently investigating how factors such as light, sound, air quality, temperature, ergonomics and biophilia influence our wellbeing. Studies have revealed optimum temperatures for open-plan offices (21.7oC), as well as the impact of lighting on cognitive performance – task switching improved when office staff were exposed to blue-enriched LED lighting compared to fluorescent lighting, for example, and they also reported sleeping better at night. The past three decades of sleep research has shown that there are real health and cognitive penalties for routinely sleeping less, Bauer says," so anything a designer or manager can do to optimise sleeping conditions is going to have a major impact, especially over the long term."
What does the future indoor environment look like? Bauer paints the picture: a connected platform of sensors and actuators that can optimally control light, sound, temperature and humidity for each room depending on the needs of the individual occupying the space; built-in cues to encourage movement; real-time biomarkers to detect stress, as well as routine assessment of overall health via analysis of urine and faeces; and all of that data collected and delivered to a local care team.
"The more we learn, the more convinced I become that there isn't going to be one or two major interventions," says Bauer. "Bringing all of the components together is where the real magic is going to happen."
When the UK government's £98bn Healthy Ageing Challenge Fund was announced in January 2019, then prime minister Theresa May said adaptive technology could give everyone five more years of healthy living at home. While investment in smart technology is welcome, research by Agile Ageing Alliance (AAA) founder Ian Spero suggests that 85% of European housing stock is not fit for an ageing population. Key accessibility features – level access flush thresholds wide doors and circulation space and entrance-level toilets – are found in only 5% of homes
While Spero is in no doubt that digital technology is a key enabler, he believes that local authorities need to take a holistic approach to healthcare from the design stage and best-practice standards for retrofit – "otherwise technology is like putting a plaster on a dam."
The AAA's Neighbourhoods of the Future 2017 report Better Homes for Older Adults coined the term "cognitive home", predicting that modern methods of construction will enable smart technologies to be built into the membrane of new-build homes and connected to the NHS. Care could then be calibrated with tiers dependent on the level the user needs over time.