Around the world it is reported that over 1000 official ‘smart city’ pilot projects have been launched, with more than half reported to be based in China. With an estimation that 60% of China’s whopping 1.4 Billion people will be living in an urban setting by 2030, this pole position on the smart cities front is hardly surprising. But, to what extent can they truly address the complexities of social determinants of health (SDOH); what is currently happening in terms of smart cities in China and what are the associated realities and concerns?
The Urban Health Penalty & the Chinese Commitment
Growing urbanization in China has been linked to overburden on public health services, increased air pollution and other negative health implications associated with a boom in urban expansion such as increased rates of non-communicable diseases and mental health conditions. In order to tackle this urban sprawl head-first smart cities are emerging as a potential way for private and public enterprises to work together to address public health concerns and their associated social determinants of health.
Clearly, there are much deeper levels of complexity at play when it comes to addressing population health globally and in the Chinese context. However, for any urban decision makers to ignore the role that these environments have to play in determining health outcomes would be foolhardy, with a torrent of research examining what has been dubbed the ‘urban health penalty’ - the exposure to unhealthy physical, environmental and social environments and their profound impact on health outcomes and quality of life.
So, what is a smart city? At its core, a smart city can be seen as a tech enabled and interconnected infrastructure that is aimed at improving the lived urban experience of those residing in it. Enabled Smart cities are intended to be capable of monitoring, analyzing and supporting optimal interactions with the urban environment and guiding residents towards a better quality of life while maintaining the development and economic prosperity of the region.
In 2016 the ‘Healthy China 2030’ commitment highlighted China's response to the UN Sustainable Development Goals (SDGs) and willingness to put public health at the forefront of national policies. Physical environment is a core element of the social determinants of health and something that governments are beginning to take greater ownership of, and action with the help of private enterprise, as it is time and time again proven to be a worthwhile investment into public and population level health.
It has been reported that there were 47 pilot smart cities in China from 2009 to 2017 including Beijing, Shanghai, Ningbo, Hangzhou, Guangzhou, Shenzhen, and Wuhan. In 2018 it was reported that this number had increased to over 500 active smart city pilots.
PATH - Big Tech and Big Moves
Naturally Big Tech have had their role to play in the Chinese smart city movement, oftentimes taking advantage of their strongholds to launch pilots, for example Tencent for Shenzhen and Guangdong and Alibaba in Hangzhou. China’s tech giants Ping An, Alibaba, Tencent and Huawei (PATH) have come together to launch a smart city initiative reportedly working together to contribute their varied expertise in communications, hardware, mobile payments and beyond. Notably Ping An released a white paper on Smart Cities last year in which it documents it’s audacious goal to offer a “Smart City Cloud” leveraging blockchain, biometrics monitoring, cloud computing and AI, and appears to be taking the reins on the initiative.
Another effort within the PATH group Alibaba Hangzhou City Brain aimed at reduced traffic congestion with the help of AI. In addition to reducing access times these efforts may also have a positive adjacent impact in terms of reduced air pollution resulting from the minimized commute times - not to mention the mental health implications and other more severe health outcome impacts that may result otherwise. Hangzhou was once ranked fifth among China's most congested cities, but it has now dropped to 57th on the list with some of this being attributed to the AI efforts. The City Brain project tracks over 100 routes in real time by collating data on traffic flow, weather and other variables. In addition to the adjacent public health knock-on effects there are more concrete impacts on Chinese healthcare through the identification and guidance on the best routes to be taken by ambulances attending emergency cases.
China Mobile has also been making waves with their 5G efforts recently, launching a pilot investigation in Fangshan last year exploring the options for optimized connectivity with autonomous vehicles. The allure of 5G, being pioneered in the Chinese context, is that it promises to let varied devices and data points interact with each other, something that is clearly appealing in smart city push and the wider IoT movement. 5G is thought to be more than 500 times faster than fiber and 20 times faster than 4G flagging new frontiers for remote diagnosis and access to connected health solutions.
Connecting the Dots - Hubs and Drivers
Public health in China has been long seen as overly fragmented and hospital centered, something that cannot be sustained with the internal flux of population migrating to urban hubs. One example of how cities are responding to this need is the city of Guangzhou that has started to roll-out a consolidated regional health record hub as a way to address fragmentation and lack of streamlined access for patients seeking care. As a part of these regional records consumers and patients can make payments for healthcare services and streamline booking through the associated app enabled by Tencent’s WeChat. Varioushospitals in the Guangzhou region are said to be actively exploring the integration of AI into their services beyond initial access and training, with facial recognition identification (such as Face++ and Yitu, an AI and facial recognition Unicorn).
Many of these moves towards making cities smarter have been leading to a growing skepticism around the ‘big brother’ element of the increasingly connected Chinese urban landscape. Concern has been voiced around the lack of privacy law that would meaningful work in conjunction with the new smart infrastructure that seems to be at odds with the aggressive support and roll out of smart city efforts highlighted in various policy moves such as the National Smart City Pilot and the 500 smart city pilots active in 2018.
“The Luohu model in Shenzhen offers a good look at the future of urban health in China. It's based on a report from the World Health Organization, and includes several pillars that mirror reform efforts in the US and other countries: greater focus on primary care as opposed to hospital care, integration of electronic records throughout the region, emphasis on community based care and referrals (e.g. pharmacist or psychologists).
Beyond that there's a tremendous opportunity for China to think about the environmental and economic determinants of health as facets of their rapid urban growth. Air quality, daily commuting routes into and out of the city, as well as wages and working conditions all correlate with the demographic trends of China's core workforce. These underlying drivers of population health will have less to do with being able to access a doctor, and more to do with day to day quality of life, sleep, diet, stress, and other determinants that are being compromised in the urban boom happening throughout the country.”
Naveen Rao, Managing Partner @ Patchwise Labs
As the world's largest CO2 emitter, it goes without saying that environmental pollution issues loom large in urban health reality in China. To date the environmental state of the country has remained at odds with their booming economic development. This is something that authorities and tech players are now attempting to attend to with the help of digital health solutions and infrastructure investment.
Chongqing, a central city facing heavy industrialization and air pollution paired up with China Mobile To improve the monitoring of air quality with the support of IoT sensors, camera and a bespoke monitoring platform. This collated information is then transmitted to the Ministry of Environmental Protection for decision making around the best plan of action.
It's clear that tech is going to be a key catalyst in enabling green environmental efforts and allowing economic growth to flourish, however this will not happen in isolation. An honest appraisal of whether these solutions are simply offsetting environmental impact produced by industrial efforts or actually creating an incrementally healthy environment for people to live is something that should be kept firmly in focus.
As defined by the WHO, the social determinants of health are “the conditions in which people are born, grow, live, work and age.” The realization of the influence of these determinants on health is not new, but the mechanisms with which we can collect data and understand their underlying dynamics in addition to the ways in which we can address certain facets of them, such as optimized access, are.
Naturally as AI implementation and widespread data collection becomes more ingrained in public life there are growing concerns around privacy, something that public and private sector players will have to work together to define and reinforce.
While public health in China has been experiencing dedicated attention in recent years resulting in increased life expectancy these improvements have occurred unevenly in different settings with the life expectancy in Shanghai for example being more than 10 years greater than other regions. This flags a point of pause for continued smart city effort - progress must be more evenly distributed—through urban and rural.
Socio-demographic, psychological, and behavioral information are not data points that are routinely collected by formal health system actors to provide a more holistic insight into a patient's health. With the careful implementation of biometric measures and tech enabled interactions in urban environments this seems to be a new horizon and one that will require new and improved regulation and privacy standards.
It will be imperative for policy makers and innovators to share their honest findings around the measurable impact of these investments. Similar to how we expect startups or new pharmaceutical drugs to produce evidence of measurable impact on health outcomes we need to evaluate these collective smart city efforts with the same objective lens.
Interested in learning more about health innovation efforts in China? On September 25th we will partner with Frontiers Health, Healthware, and Bayer to shine a light on the growing Chinese digital health ecosystem and distill what the world can learn from it. Learn more about the speakers and apply to attend HERE