Healthy cities

Polluted air: Photo by Holger Link on Unsplash

During the last century and even during the last decades health within cities has improved significantly. Between 1990 and 2015, the worldwide mortality rate of children below the age of 5 dropped from 90 deaths per 1,000 live births to 43. Which still means that globally a child dies every five seconds. Child mortality is the main cause for (regional) variations in life expectancy.


Healthy Cities is the first of a series of short essays on how we can make our cities more humane. That means finding
a balance between sustainability, social justice and quality of life. This requires far-reaching choices. Once these choices have been made, it goes without saying that we should use smart technologies to realize them.

Child mortality is lowest in the most prosperous families in developed countries. Health and wealth are related tightly. The figure below illustrates the differences in child mortality in urban and rural regions in several parts of the world.

Under 5-year child mortality rate – Source: The Urban Disadvantage, 2015.

As a consequence, improving health implies improving the availability and affordability of care and fighting poverty as well. Many diseases are directly related to living conditions, which in turn are related to wealth. Therefore, a humane city will focus on providing adequate care and for all its citizens, and work on the disappearance of the causes of illness. In both respects digital technology can play a supporting role. The technological solutions presented below are selected from the Smart City Solution Database, a comprehensive collection of smart city applications, tools and policies. The recent report of the McKinsey Global Institute, Smart Cities: Digital solutions for a more livable future also offers a wealth of inspiring cases.

Cities: Unhealthy places

Despite the aforementioned improvements in living conditions and medical care, cities are unhealthy places, particularly in developing and emerging countries and in a less degree in developed countries too. According to the Global Burden of Diseases Study of the World Health Organization, 4.2 million deaths worldwide every year are caused by particulate pollution.

Take India for example, where economic growth results in unprecedented urban development. Air pollution is seen as the direct cause of 627.000 deaths annually. Moreover, an official study of 1,405 cities reveals that only 50% of urban areas have water supply connections and that water is supplied on an average for only three hours a day. Waste disposal and sewage treatment plants are missing in most Indian cities: 30% of the households have no toilets, the coverage of the sewage network is merely 12% while the treatment of sewage is even lower at 3%. Most of the untreated sewage is discharged into rivers, ponds or lakes, which are also the main source of potable water.

A billion city dwellers worldwide live in slums, on sidewalks or below bridges. Nearly all of them lack drinking water and sanitation.

In the past, cities in now developed countries where extremely unhealthy places too, characterized by frequent outbreaks of epidemics that regularly killed large sections of the population. Living conditions have improved considerably in the last century. The same applies to sanitation, clean drinking water and medical care. The air has become cleaner but air pollution still is a major problem. Near the main roads, the concentration of particulate matter is irresponsibly high, especially on warm, windless days.

More than 26 million people in the U.S. have asthma, and therefore difficulties with breathing. Many chronic diseases in the country are associated with the air quality. African-American residents die three times more from asthma than whites. They often live in segregated communities with poor housing, near heavy industry, transportation centers and other sources of air pollution.

Whether cities are healthy or not depends on their location on earth and the neighbourhood within a city. However, infectious diseases are widespread. In developing countries, they are associated with the lack of sanitation, the presence of mosquitos and water and air pollution. In developed countries, infectious diseases are primarily related to polluted air.

Filtering air
fortunately, it will take many years to eliminate particulate matter. Therefore, sucking ambient air into a filter system, collect and agglomerate fine dust and Nano plastics particles and releasing clean air a necessary alternative. Recently, ETE, EmTechEngineering has developed a filter system that does not use fossil resources, and is available for a low price.
(Figure: Filtering particulate matter – by ETE)

The occurrence of infectious diseases in developing countries is decreasing – apart from polluted air – due to better but very basial medical care, more breastfeeding, measles vaccination, vitamin A supplementation, and the use of impregnated mosquito nets. At the same time, the AIDS epidemic threatens to reverse the progress made, in particular in eastern and southern Africa.

The growing prosperity of city-dwellers worldwide comes with health problems related to lifestyle and air pollution. Their solution requires major changes in the design of cities and the behaviour of citizens, and include the provision of parks and other green spaces, making cities more walkable, a general reduction of cars, the transition to electric vehicles, and changing food and moving habits. The role of life-style related physical efforts (at least 2,5 hours walking a week at brisk speed) is increasingly emphasized and supported by medical research.

The solution to make America physically active
Radbonus is a smartphone application that promotes cycling by commuters in partnership with  municipalities and enterprises. It is tracking the distances covered by bicycle and for every certain number of kilometers there is a bonus, for example a shop discount. So far, participants have been cycling for 6.000.000 kilometers, an equivalent of 21,400 tonnes of CO2 emissions.
Photo: Cyclist – by Victor Kern on Unsplash

A substantial number of mental health problems is also related to the occasionally tough characteristics of the modern life-style, the abuse of alcohol and drugs, and subsequent homelessness included.

Measuring health threats

For years, city-governments started measuring the quality of the air by a sensor-networks as one of their first smart city features. Measurement focused on pollution by ozone, nitric oxide, nitrogen dioxide, particulate matter and black carbon (soot), as the main causes of health problems that can be attributed to pollution.

Barcelona is generally praised as one of the first towns that placed sensors citywide to measure particulate pollution. The results have confirmed the strong relation between air quality and the intensity of the traffic. The general complaint nowadays is that action has stayed behind and the level of pollution did not change.

In Amsterdam too, air quality has been measured for years, and although cars have become less-polluting, the intensity of the traffic has increased. As a consequence, last year the level of pollution from particulate matter and nitrogen dioxide (NO2) exceeded the standards of the World Health Organization (WHO) in many Amsterdam streets. The city government stated that the life of an average citizen of Amsterdam is shortened with one year due to pollution. The Amsterdam Community Health Service (GGD) estimates that 4.5% of the loss of healthy years is the result of exposure to dirty air. To put this outcome in context: the percentage is less than the damage to public health caused by smoking (13.1%) and overweight (5.0%), but more than the damage caused by lack of movement (3.5%) and excess drinking (2.8%).

In spite of the abundance of data that is already available, the recently installed left-sided city government surprisingly asked Google to measure the air quality during one year. Probably to create support for the upcoming ban of cars from the entire city centre. Google – by means of its Street-view cars – did the same in London, Copenhagen, and in some American towns.

Breeze technologies
There is a wide range of devises that measure air quality. The start-up Breeze technologies produces cheap sensors and at the same time presents the results in public maps of the local environment. Socially responsible companies sponsor the sensors that feed data to this portal. They are being installed either in the companies’ own buildings, or co-located with interested citizens.
Map: Breeze technologies

Measuring air quality as a community activity: the AiREAS project in Eindhoven
Effective solutions for air pollution vary from planting trees, electrifying busses, reducing traffic, or even filtering the air. Since the intensity of the traffic is a good indication of the level of pollution, reduction of traffic is obvious. This measure often encounters resistance from citizens who are not involved directly. For this reason, groups of citizens who are involved start projects to measure the quality of the air. The AiREAS-project in the Dutch city of Eindhoven is a very professional initiative. An innovative measuring system has been developed together with knowledge institutes and the government. The 35 sensors are distributed over the areas of the town and the system offers real-time information. The AiREAS-group regularly discusses the results with other citizens and with the city-government, which has taken some measures and anticipates the expected level of air pollution when developing plans. The measurement of the quality of the air is supplemented by medical research. This research has confirmed that citizens in the vicinity of main roads and the airport have an increased risk of death, reduced lung function and asthma.

The project recently reached an important milestone. The municipality of Eindhoven has stated that it will be one of its main goals to be a healthy place to live.

The AiREAS-project is linked to comparable initiatives in other European cities. Occasionally, data are exchanged. For instance, the short video below, reveals the quality of the air at New Year’s Eve. See what happens at 23.30 PM! The violet colour means that the air is approximately toxic!

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Projects such as AiREAS prove that sensing alone is not enough to improve the health of a city. On the contrary, the installation of sensors and the intention to take measurements over a longer period might be part of a strategy to postpone actions. On the other hand, sensing as a part of a thorough, well-informed and persistent citizen’s initiative often leads to direct actions and is usually much cheaper too.

As the example below illustrates, the use of sensors is not restricted to measuring the quality of the air and water. They also can be used to detect the presence of infectious insects.

Measuring the risk of infectious diseases
Health agencies use traps to check the presence of infectious mosquitos. These traps are inspected manually and are therefore labor-intensive and expensive. Irideon has developed a sensor that automatically counts insects, identifies the species and gender, and determines age. The data is available in real-time to City Heath Agencies.
Photo: Mosquito sensor by Irideon


For years, it has been predicted that healthcare will change drastically due to technology, computerization, robotization and artificial intelligence.

There have indeed been major changes, especially in affluent places where technology is used in diagnostics, for instance the use of AI and treatment, for instance the automation of certain forms of surgery. The pharmaceutical industry has developed many new medicines, albeit often at fabulous prices. Many of these changes are commercially driven and their impact on the quality of care cannot be taken for granted. At the same time, automation can help keep healthcare affordable. Healthcare in the Netherlands already uses 14% of the GNP.

Below I discuss a number of technological developments in healthcare and their significance for making cities humane.

Information, self-diagnoses and self-treatment
The Internet has at least 325.000 health sites and apps, which provide comprehensive information about diseases, options for diagnosis and self-treatments. Many use gamifications, such as exercises to improve memory. Others have more impact and require remote monitoring.

The Integrated Medical Information and Analytical System (IMIAS) in Moscow
This program is designed for patients, doctors and the health care administration. Patients can schedule their appointments online. Doctors have an overview of the patient’s medical history. The health care administration can manage the workload of outpatient clinics. The program is designed to serve at country level. It is fully operational and new services are added stepwise. So far it is functioning in Moscow and 8,200,000 unique patients are registered in the system, that is about 66% of all Muscovites. 200,000 city residents make appointments with a doctor through IMIAS every day. Because of the efficiency gains, waiting times to see a specialist have been cut in half and doctors save up to 2 million working hours a year (over 30%) thanks to the electronic forms.
Photo: Patient logs in in IMIAS by Commune of Moscow

Elsewhere, for example at the Taipei Medical University Hospital, the use of blockchain technology has proved effective in addressing privacy concerns.

Monitoring patients at distance (at home) will increase in the coming years – especially in Western countries. General practitioners have already started telemedicine at various locations: In that case, consultations take place remotely, sometimes with simple test equipment for home use.

The same applies to automated digital observations, for example in the elderly’s homes. Patients for whom this is useful can receive timely alerts about vaccinations, use of the toilet, compliance with therapies or the use of devices. Sensors attached to asthma inhalers, can, for example, check that it is being used properly.

The animation below shows how a doctor can conduct a digital consultation.

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Given the ample availability of general practitioners in developed countries, telemedicine will mainly be used in less populated regions and in regions where general practitioners are not widely available.

Cisco’s connected health children
Cisco’s TelePresence system can connect people from different locations via video and audio and allow them to collaborate remotely. The Cisco Extended Care is a browser-based platform for patients and their parents to access health services from any location.  Appointments and unplanned consultations can be made easily. It also supports instant messaging, video conferencing and information sharing. The system is used in Brazil, among others, where specialists from a clinic offer consultations that can be attended in local clinics[1].
Photo: remote consultation with TelePresence by Cisco

Monitoring at distance: The next major step forward?
The solutions discussed above are generally suitable for the best educated and digital skilled people. The wide availability of medical information, the possibility of diagnosis and self-treatment even makes some people obsessively concerned with symptoms of possible illness.

Could the future not be that we are doing the obvious things for our health, such as walking, cycling, eating good food and having fun, and that the early symptoms of emerging diseases are permanently watched in the background thanks to wearables, without us being aware of this?

Therefore, real progress will be the result from unobtrusive checking of our physical condition by wearable devices, occasionally supplemented by self-tests. The local health center will monitor and analyse all patients’ data using artificial intelligence. By analyzing data from common disease cases, health services can identify groups of people with elevated risk profiles and targeted interventions. With the resulting pattern, illness can be predicted, followed by automated suggestions for self-treatment or an advice to consult the general practitioner, while we probably have not experienced anything but vague symptoms up to that point.

The same idea could fundamentally improve the care for older people who live alone. Probably more data will be collected then and the district nurse will be informed prior to her daily visit. People for whom this is useful can receive timely alerts about vaccinations and compliance with certain therapies or the use of certain devices.

Needless to say, such a system can only be implemented step by step in order to evaluate its effectivity and especially its impact on human health. A growing number of remote monitoring applications makes it possible to gain experience.

Smart Service Power
Smart Service Power enables the elderly to live in their familiar environment as long as possible. Digital technology ensures proper care in the event of incidents or in the event of non-compliance with prescribed behavior. The system includes a fall/collapse detection module that automatically notifies the district nurse.  In addition, clients wear sensors that check the hydration level and remind them to drink if they forget this. An intelligent tablet dispenser ensures that medication is used correctly and a digital assistant supports people in their daily life. This short video explains the Smart Service Power project and its implementation in Germany.

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Health in the humane city

This short essay has shown that health is improving worldwide, thanks to increasing medical care. At the same time, diseases are increasingly linked to conditions of human origin. In addition, these conditions hit poor people harder than the rich. After the fight against mosquitoes in the prevention of infectious diseases seems to be won, there are still poor sanitation, lack of clean drinking water, and unhealthy housing. Air pollution also takes its toll. A growing number of diseases due to life-style must be added too.

As a consequence, improving health is not a primarily a medical problem. For developing countries, improving living conditions, sanitation, providing drinking water and medical care, especially for young children and their mothers – birth control included – are priorities. For all cities, the improvement of air quality is mandatory, which requires a major redesign of the city and the reduction the role of motorized traffic. A healthier life-style requires more and more attention and the same applies to the treatment of people with mental health, alcohol and drugs problems, especially younger people. Since health and wealth are strongly correlated, a viable income, decent housing and social life are the ultimate health recipe for the underprivileged around the world.

Given this background, a plea in our part of the world for even more medical technology, e-health included, is somewhat embarrassing. The growth in healthy years as a result of healthcare investments in developing countries far exceeds the impact of the same investment in our part of the world. However, most developing countries are on the right track and we can even learn of the effectiveness of their approach.

Finally, I will summarize the essence of a humane approach to health in our cities, taking into account the relationship between urban policy, wealth and health. Many actors are involved in this approach and certainly not only the city council.

Actions for a humane approach to health in cities

  1. Health of citizens, including the increase of healthy years for all citizens, is a cornerstone of urban policy, in particular with regard to affordable housing, income, urban design and traffic.
  2. The city council guarantees the availability of first-line medical assistance in well-equipped medical centers that are easily accessible, including telemedicine.
  3. For elderly people living alone, adequate personal assistance supported by electronic aids is available. These aids are being developed in close collaboration with general practitioners and district nurses.
  4. Instead of people with mental problems getting lost in countless organizations and clinics, a personal counsellor will be assigned who will put them in contact with specialized caregivers and municipal services if necessary.
  5. People are enabled to participate in a project that monitors their health remotely, giving timely advice, and warns them if they should contact their doctor. Such a system can become standard in the long term.
  6. Health education is aimed at a healthy lifestyle, where possible based on scientific research, and which distances itself from dogmatic dependence on specific doctrines or hypes.
  7. Bureaucracy is banned from all types of medical care. Teams are self-organizing and the time available for patients is maximized.
  8. An advisory body at the national level will prioritize investments in medical and pharmaceutical research to prevent these investments from being driven by a technology or commercial push.


*) This article was brought to you by Professor Herman van den Bosch, Professor at Open University of The Netherlands.