Future of healthcare: cities are the most powerful tools we have

April 2020

Words by Katie Puckett

Prevention is better than cure, and smart technologies can only go so far. The only realistic solution for the future of healthcare is to keep people well for longer — which means reshaping the urban environment in a way that promotes health rather than hindering it.

“Regardless of the country, the evidence about what shapes the health of the population is pretty consistent, and healthcare isn’t the biggest determinant”

Chris Naylor, The King’s Fund

“Cities concentrate people and resources in one place, which creates hazards but also very real opportunities for improving health,” says Chris Naylor, senior policy fellow at UK health charity The King’s Fund. Naylor, who has researched the role that cities play in health around the world, says that more than half of the variation in population health is down to three key determinants: the environmental and social conditions in the places where we live, our economic situation, and our behaviour and lifestyle.[29] “Cities play a really important role because they influence all three. We should be creating compact, walkable, mixed-use developments that encourage social interaction and make it easier for people to be active. We should be doing everything we can to inspire and enable healthy eating, and to create places for play and leisure for all ages.”

Are successful cities inherently unhealthy? In The Economist’s latest index of the most liveable cities, Tokyo is the only large city ranked in the top ten — the rest are small or medium-sized, led by the Austrian capital Vienna.[30]

Cities taking a stand

City leaders are playing an increasingly influential role, often ahead of national governments. Polluting vehicles, unhealthy foods and smoking may be legal, but they are being made unwelcome in various forms at city level.

  • In Paris, the most polluting vehicles are banned from entry and whole areas are car-free on Sundays
  • New York’s introduction of mandatory calorie labelling in 2008 helped pave the way for federal adoption later on; its 2002 ban on smoking in public places has yet to reach federal level
  • In Berlin, every year the amount of space given to cars decreases and the cycle network increases
  • Amsterdam’s Healthy Weight programme prohibited advertising of unhealthy food targeted at children, and only tap water and healthy packed lunches are allowed in primary schools

Neither is there any crossover at all with the 20 most dynamic cities in JLL’s City Momentum Index, which is dominated by India and China.[31] But there must be an intersection between health and success, says Naylor — “If you have a really unhealthy population, that’s bad economically in terms of reduced productivity, absence from work and welfare expenditure.” The global depression looming as an indirect result of COVID-19 is ample evidence of the economic importance of good health.

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The emerging science of wellness is starting to yield an evidence base on the relationship between health and environment. Building standards such as WELL and Fitwel monitor aspects such as biophilia, ergonomics and whether a building nurtures mental health. Studies in office environments have found that good ventilation can increase cognitive scores by 101%, for example, or that workers seated next to windows sleep for 46 minutes longer at night.[32] The WELL Community standard, launched in 2017, applies these principles across whole districts. As cities become smarter, urban designers will have many more tools to improve outcomes. “Once we have high-speed wireless networks, and people are wearing devices tracking their health data, we will be able to use AI and rich data sets to promote health and wellness,” says Kevin Cassidy at WSP.

In Copenhagen, city authorities have collected data on pedestrian and cyclist movements for years, providing quantitative evidence for policy making. “In many cities, this kind of detailed data is simply unavailable,” says Naylor. “If cities are to reorient planning and other activities to place greater emphasis on population health, this must be reflected in the types of data they collect — what matters must be measured.”

Planners and designers should prioritize the social determinants of health as they develop tomorrow’s smart cities, says Howard University’s Michael Crawford, addressing factors such as transportation, food security, job opportunities, affordable housing and safety. “If you do not have access to nutritious food, diabetes medication alone will not help you effectively manage your condition. If you have a prescription but no pharmacy within your community, what good is that prescription? Technology can help address some of these barriers.”

Doctors are prescribing walks in nature for patients suffering from chronic conditions. The Park Rx America platform lists 10,000 parks and has 500 registered “prescribers”, who can set the frequency of visits, text reminders and check how often the patient has “filled” their prescription.[33] Photo: jzajic/Adobe Stock

“There is a massive body of evidence showing how the design of our buildings and neighbourhoods affects public health. Everyone in the built environment has a role to play”

Joanna Frank, Center for Active Design

Independent cities: Better for older people, better for everyone

Older people will be a much larger group in future cities, and so we will have to design places that support them to remain healthy and independent. But it’s not only older people who need a sense of community, to rest occasionally or use a public convenience. Narrow pavements, fast-moving traffic and air pollution can make any of us reluctant to walk, let alone cycle, and poor signage or obstructions make it hard for everyone to navigate urban environments. By analyzing how the most vulnerable members of society navigate a city, it can reveal important design lessons that would benefit us all.

“No matter how beautifully we’ve designed a hospital, it’s still a hospital,” says Vivien Mak at P&T in Hong Kong. “If people can stay in the community, they are socially engaged and more active, and that slows down the deterioration and hopefully keeps them healthier.” In Hong Kong, the proportion of the population aged over 65 is expected to increase from 16.6% in 2016 to 36.6% by 2066. Mak’s office was commissioned by the government to produce the Elderly-friendly Design Guidelines, to inform decision-making on new developments. These are structured around four overarching principles: environments that are safe; that foster independence and confidence; that support cognitive ability and reduce anxiety; and that promote wellbeing and contentment.

“If older people find it difficult to find a place or they don’t enjoy the experience, they won’t go out,” Mak points out. “If the walk from their home to the grocery store takes half an hour, they probably have to take a rest a few times during the journey. If you provide sheltered seating spaces where they can chat with their friends, they may be happy to do so.” Some features of the urban environment can make it all but impossible for anyone less able to get around. “In Hong Kong, we have a lot of elevated crossings, but if they don’t come with an elevator, it’s hard for older people to climb those flights of stairs.” Other examples include pedestrian crossings that don’t leave enough time for older people to reach the opposite side, or level changes that can trip them up. Unclear signage or bland places that all look the same can leave them confused, she adds. “For example, an all-white floor, with white walls and white ceiling may be confusing because they can’t see where the floor ends and the wall begins. If it’s the other way round, with very strong floor patterns and big contrasts that young people like, that can make older people feel dizzy.”

From The Possible Issue 06

Read the magazine

This article appeared in The Possible issue 06, as part of a longer feature on the future of healthcare

 

Notes [29] The King’s Fund, June 2018 [30] Global Liveability Index, Economist Intelligence Unit, 2019 [31] JLL City Momentum Index 2020 [32] World Green Building Council, October 2016 [33] parkrxamerica.org

 

 

 

 

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