By Bingyu Luo
Illustration selected from Shutterstock by Lia Bote
Healthcare is an important component of public welfare but is under huge pressure from public health challenges. A surging number of patients during recent pandemics (such as the Covid-19 pandemic) have exhausted medical resources and exceeded the admission capacity of medical institutions. In addition, the increasingly ageing population demands more medical facilities. As contemporary challenges in public health arise, ‘smart city’, a trending strategy that reinforces urban management with advanced institutional instruments and revolutionised technology, is framed as a solution that helps people tackle these problems. However, it is very unlikely that the existing limitations of the smart city solution can be justified as the proper answer to public health. Specifically, this article suggests that (1) smart health can only serve as a technological complement rather than a well-rounded solution to public health for the time being; (2) while smart healthcare services have empowered people in New York City, Chicago and Louisville with hope to enhance efficiency and promote wellbeing, there are constraints due to a lack of connection to a wider smart city plan, potential subjective and unreliable data sources, as well as the narrow range of application and limited impact; (3) the concerns around data security and privacy can impede smart health from being implemented, and smart health requires multi-disciplinary and multi-agent coordination. This article reveals the gap between existing proposed strategy and regional practices- taking New York City, Chicago and Louisville as case studies. Furthermore, it provides an evaluation of smart health, covering advantages, limitations, and possible directions for improvement.
Science to Policy Statement
This article highlights the disparity between the suggested smart city approach and the actual methods employed at the regional level, using New York City, Chicago, and Louisville as examples. It argues that smart health can solely serve as a technological complement to public health for the time being, due to a lack of connection to a wider smart city plan as well as undependable data sources. Concerns about data security and multi-agent coordination are also raised to help understand why those policies may not work as expected.
Smart City, healthcare, Information and Communication Technology (ICT)
The development of smart health in the United States has been marked by significant
advancements in healthcare technology, digital innovation, and data-driven solutions. Given the fact that the United States has been in the leading position to develop the applications of smart health in the past decade and cases in the U.S. are worth exploring, this article analyses three regional practices in the U.S. from New York, Chicago and Louisville to display the gap between existing proposed strategy and reality.
Before delving into the discussion of smart health, it would be useful to distinguish smart health from smart healthcare. Smart health refers to the use of data analytics and digital tools such as to empower individuals to manage their own health and well-being with the help of data collected from the surrounding environment, considering itself as an extension and crucial component of a smart city initiative to promote public health with technology. In contrast, smart healthcare focuses on enhancing the efficiency, quality, and delivery of medical services within the healthcare system, making a far less strong connection with the wider environment.
Case Study 1: the New York State Diabetes Prevention Program
Since 2020, New York State (NYS) has targeted consumer-centric health and launched the New York State Diabetes Prevention Program (NDPP) for “adults with diagnosed prediabetes or who are at high risk of developing Type 2 diabetes (Department of Health, 2021)”. Compared with other health models, consumer-centric health empowers patients to actively participate in making informed decisions about their well-being, which shifts the healthcare system from a provider-driven model to one that prioritizes the individual’s needs and preferences. To meet medical needs during Covid-19, NYS Medicaid expanded the services via telehealth to deliver services to members remotely where face-toface visits were not recommended. Distance Learning sessions provided through telehealth may be accomplished via digital technology such as bluetooth-enabled weightscales. This programme enhances convenience while allowing participants to use virtual monitoring and communicate often with fellow participants and life coaches.
The incorporation of consumercentric technology makes NDPP a qualified example that demonstrates the progress in establishing smart health communities, but that is far from enough for smart city solutions to solve the problem in public health. First, preventive care is only a portion of medical care, and the prevention of Type 2 diabetes is an even smaller portion of the medical care system. It is true that attempts such as NDPP are beneficial, but it may still take a long time to transfer the technology to preventive care for other diseases and other dimensions such as palliative care. Wider applications in medical services, not just adapting to the emergency during pandemics, are needed for efficient solutions to public health in the long term. Second, as NDPP offers suggestive and instructional guidance and resources rather than data that can be monitored, it may not be easy to evaluate how this program has taken into effect. More feedback from the users’ perspective may be helpful to inform whether this program is digitally inclusive, i.e. whether it is equally accessible to users from different geographical regions and ethnic groups. New York City is a strong case to illustrate that compared with smart healthcare, traditional medical care may be more accessible and irreplaceable, which makes smart healthcare a technological complement for now.
Case Study 2: Healthy Chicago 2025
In September 2020, Healthy Chicago 2025 was launched to develop approaches that strengthen neighbourhood vitality and system coordination. It was Chicago’s fiveyear community plan to improve health, focusing on racial and health equity to reduce the gap of Black-White life expectancy. Compared with the plan launched in New York City, Chicago explored further into a series of well-rounded health issues. The priority areas and guiding principles include (1) Community Themes and Strengths, (2) Forces of Change, (3) Community Health Status, and (4) Local Public Health System/Health Equity Capacity. Chicago is another powerful case exemplifying smart health as a set of complementary toolkits: these guiding principles rely heavily on social determinants of health and residents’ personal perceptions, equally or more important than the perspectives of smart health services.
The main advantage of Healthy Chicago 2025 lies in the fact that it is one of the very few city plans in the United States that specifically focuses on improving health conditions and reducing health disparity from different dimensions, but there are drawbacks as well. The lamp post sensors have been used in data mining, collecting information about the city’s road surface and detecting environmental data such as air quality, light intensity, noise levels, temperature and wind speed. However, there are no clear mention of smart sensors in the municipal government’s official report; therefore, the application of sensors in Healthy Chicago 2025 remains unknown, and the reliability of data in this program can be hardly proved.
Case Study 3: AIR Louisville: Applying ICT to identify asthma triggers
Mobile Information and Communication Technology (ICT) refers to the integration and utilisation of technology, specifically related to information and communication, including mobile devices, wireless communication, location-based services and mobile health. As living with lung diseases such as asthma and chronic obstructive pulmonary disease (COPD) can be challenging, in Louisville, KY, mobile ICT was incorporated into citizen sensing, a scenario where individuals take an active role in monitoring their own health and the health of their communities through digital tools. This can help the city to react to asthma triggers such as allergens, air quality, and tobacco smoke, preventing its residents from experiencing potential chronic conditions in the long term. In 2014, Louisville was ranked the 16th most challenging city in the U.S. for people with asthma . To identify possible locations of asthma triggers within the region, researchers distributed medication sensor-enabled inhalers from Propeller Health to asthma sufferers in Jefferson County. When residents used inhalers, location of the usage was recorded automatically via an app on smartphone and transmitted the information to servers; then, the sensor monitored the air nearby for particulates that might trigger an episode; without smartphones, participants may receive wireless hub devices to collect and transmit sensor data [2,3].
Figure 1. Map of asthma hotspots collected by Propeller inhaler sensor and smartphone app (Serchuk, 2015).
Fig. 1 illustrates the asthma hotspots that were located in Jefferson County using the mobile ICT. As  has noted, the sensor data spotlighted one particular road where inhaler use was three times as high as throughout the rest of the city. The city then responded to this information offered by ICT and planted trees that separate residential neighbourhoods from the congested road. According to the latest information on the program’s official website, the digital health platform produced satisfying clinical results, including an average of 82% reduction in rescue inhaler use and 29% of uncontrolled participants gained control of their asthma. Although this program helped Louisville learn what causes asthma and COPD symptoms for citizens, there are still concerns around digital exclusion for the elders, over-reliance on technology, and sustainability due to the stability of funding.
While AIR Louisville has some meaningful implications, such as improving individual-level outcomes, building relationships across silos and rebuilding trust in local government, the benefits are still constrained to Jefferson County. It was because of the strong support from former city mayor Greg Fischer that this project worked, but the experience cannot be transferred to other regions easily: both the multidisciplinary coordination and support from the local government are unstable.
Table 1. Comparison between New York City, Chicago and Louisville on practices in smart healthcare services.
Table 1 includes a brief comparison between New York City, Chicago and Louisville on practices in smart healthcare services. Overall, smart healthcare services still face barriers to becoming mainstream solutions and have restrictions in data coverage, collection and application, therefore can only be regarded as a technological complement. Based on the demonstration of smart health as well as the comparison between case studies in New York City, Chicago and Louisville, the evaluation will focus on (1) opportunities and risks, and (2) policy implications and social environment to support smart health services.
First, the opportunities and risks smart healthcare services entail are worth mentioning. A high demand for technologies in healthcare and popularisation of digital infrastructure leads to endless potential of smart health, including (1) the innovative data collection, presentation, and analysis, (2) the data-driven preventive actions and administration of critical incidents, (3) the development of a well-rounded evaluation system, (4) the creative approaches to engage patients and families in managing their health, (5) the possibility to improve policy decisions, and (6) personalised healthcare and prevention. Besides opportunities, there are two main types of challenges, which are (1) multidisciplinary research and interaction as well as (2) security and privacy. Implementing research in smart health requires scholars, government officers and practitioners to closely collaborate throughout the projects to avoid redundant procedures and wasted data collection, and forming consensus from the very beginning would be time-efficient. Also, extensive research has stressed the need to protect users’ privacy and data security – treating them with the highest priority [4-6]. As smart healthcare services entail data that is likely to disclose users’ daily habits, social status and other extremely personal information, it should be utilised in a highly confidential manner. Although Healthy Chicago 2025 argues that the lamp post sensor does not invade privacy according to the City of Chicago’s Information Technology Commission, and does not record the MAC and Bluetooth addresses of mobile devices, other practices may not guarantee this at the same level. Other concerns worth noting include accessibility and usability, as well as connection with other smart city services.
As for policy implications, the most important lessons are (1) taking the public need in medical resources as guidance and ensuring the digital infrastructure is well established, (2) highlighting priorities for each city or region and formulating a phased action plan for implementation, and (3) emphasising reconstruction standardisation of working procedure and application integration, achieving integrated management of services. Redefining smart cities and choosing the direction for future development demand participation of many stakeholders, including the government, the public and enterprises, so as to achieve a highly participatory, inclusive and autonomous urban development mode. The majority of policy recommendations involve the multi-disciplinary and multi-agent coordination that enables the entire mechanism to run smoothly [7,8].
In conclusion, this article critically evaluates smart healthcare services based on three case studies from the United States, arguing that smart healthcare solutions can promote citizens’ health to some extent depending on the context under which it is examined. Although they only serve as technological complements rather than perfect answers for the timebeing, it would
be unfair to simply claim that they are the castles in the air.
 Serchuk, D. (2015). Louisville using high-tech inhalers, smartphones to track asthma. Insider Louisville. https://insiderlouisville.com/metro/communities/louisville-using-hightech-inhalers-smartphones-trackasthma/
 Cook, D. J., Duncan, G., Sprint, G., & Fritz, R. L. (2018). Using Smart City Technology to Make Healthcare Smarter. Proceedings of the IEEE, 106(4), 708–722. https://doi.org/10.1109/jproc.2017.2787688
 Barrett, M., Combs, V., Su, J. G., Henderson, K., & Tuffli, M. (2018). AIR Louisville: Addressing Asthma With Technology, Crowdsourcing, Cross-Sector Collaboration, And Policy. Health Affairs, 37(4), 525–534. https://doi.org/10.1377/hlthaff.2017.1315
 Vattapparamban, E., Guvenc, I., Yurekli, A. I., Akkaya, K., & Uluagac, S. (2016). Drones for smart cities: Issues in cybersecurity, privacy, and public safety. 2016 International Wireless Communications and Mobile Computing Conference (IWCMC). https://doi.org/10.1109/iwcmc.2016.7577060
 Yang, F., & Xu, J. (2018). Privacy concerns in China’s smart city campaign: The deficit of China’s Cybersecurity Law. Asia &Amp; the Pacific Policy Studies, 5(3), 533–543. https://doi.org/10.1002/app5.246
 Ramos, L. F. M., & Silva, J. M. C. (2019). Privacy and Data Protection Concerns Regarding the Use of Blockchains in Smart Cities. Proceedings of the 12th International Conference on Theory and Practice of Electronic Governance. https://doi.org/10.1145/3326365.3326410
 Meijer, A., & Bolívar, M. P. R. (2015). Governing the smart city: a review of the literature on smart urban governance. International Review of Administrative Sciences, 82(2), 392–408. https://doi.org/10.1177/0020852314564308
 Ruhlandt, R. W. S. (2018). The governance of smart cities: A systematic literature review. Cities, 81, 1–23. https://doi.org/10.1016/j.cities.2018.02.014
About the Author
Bingyu is an MPhil candidate studying Planning, Growth, and Regeneration at the Department of Land Economy and a member of St. John’s College. She is interested in exploring the intersection of economics and geography, as well as smart city policies and urban analytics from an interdisciplinary perspective, especially how technology promotes urban vitality and innovation. Originally from Xiamen, China, Bingyu holds a Bachelor’s degree from the University of Michigan, Ann Arbor with an Economics major and Urban Studies minor. She used to be a research assistant at the Poverty Solutions Initiative, University of Michigan.
Corresponding address: firstname.lastname@example.org
Conflict of interest: The author declares no conflict of interest.