Science meets imagination – cities and health in the twenty-first century

Abstract

Urbanism will be a dominant concern of policy-makers, planners, investors, researchers, businesses, governments and communities across the globe in coming decades. It has been projected that by 2050, up to 70% of the global population will live in urban areas. Cities and urban governance are being pushed to the forefront of both human and planetary health. Whether health and equity will be prioritised as a basis for decision-making is an open debate. Decisions – made or neglected today – will have impacts over time on human life and ecology, cities and health. Yet the processes of setting directions and making decisions are fraught. Life in urban contexts is complex and replete with uncertainties; the pace of change is rapid; values and long-range goals are contested; and information is incomplete or embodies various forms of bias. A new form of literacy is needed that can help us make decisions and act. Approaches to futures thinking are increasingly used at all levels and in diverse sectors to support decision-making, especially under conditions characterised by complexity. Methods are qualitative, quantitative or hybrid. They include visioning, Delphi studies, horizon scanning, scenarios, trend projection, modelling and backcasting. In combination, they often offer a systematic examination of alternative futures. This article explores the field of futures thinking in relation to cities and health. Importantly, it proposes a set of themes that will be the focus of a special issue of Cities & Health in 2019. These include the use of futures studies and foresight, the prospect of strengthening futures literacy, and the nature of policy-making and governance for improved population health within the developing global urban context.

Keywords:

• Urban futures
• health futures
• urban health
• foresight
• futures thinking

Predictions about how we will be born, live and die half a century from now litter the literature and social media. Ideas and images are sometimes reassuring, sometimes curious, frightening or shocking. Many are capable of triggering emotional responses ahead of logical appraisals. Existing phenomena seed these ideas and images of futures, such as ‘wearable computing’ or ‘smart environments’ and the numerous changes as a result of AI (artificial intelligence). While we cannot, of course, know what the world of 2070 will actually look, sound, smell and be like, we do know that in around 50 years from now, decisions made or neglected today will be having observable and measurable impacts on human life and ecology, cities and health.

This article has two main purposes. It stands on its own in exploring futures thinking in relation to cities and health in the twenty-first century and the interrelatedness of cities and health and science and imagination. It also acts as a scene-setting introduction to the broader topic of urban and health futures, the use of futures studies and foresight, the prospect of strengthening futures literacy, and the nature of policy-making and governance for improved population health outcomes within the developing global urban context. These themes will be the focus of a special issue of Cities & Health in 2019.

While we will not delve into the myriad of terms and definitions associated with futures thinking, it is appropriate to provide working definitions of two concepts that are used in this paper – futures studies and foresight. Futures studies are often referred to as an academic field of endeavour covering ‘any kind of study focusing on what the future might be like’ (European Commission Joint Research Centre 2008). Foresight has a stronger focus on participation and action, and has been defined as a ‘systematic participatory, future intelligence gathering and medium- to long-term vision building process aimed at present-day decisions and mobilising joint actions’ (European Commission Joint Research Centre 2008). Gaining a systemic perspective on a theme (such as urban health) through the integration of insights from various disciplines is a hallmark of foresight.

What do we need to think about?

As we start to think about the topic of this paper, a number of questions quickly emerge which we need to acknowledge and address before we move to the deeper content of foresight for urban health.

What is the relationship between the city and the health and wellbeing of its communities?

Perhaps put more simply what is the healthy city? In trying to answer these questions, we are beginning to engage in futures thinking and probably more explicitly about visioning, applications of imagination, experimentation, learning and attempting to mainstream this range of processes into policy and practice.

What time span makes sense when exploring urban futures?

Those working with approaches to futures thinking often refer to imminent or short-term futures as the next three to five-year period (which may relate to government election cycles in some countries), the medium term as five to 20 years and the long-term as 20–30 years or beyond. Notably, the longer the timeframe the more uncertainty there will be about conditions, situations and events. Despite the uncertainty associated with long-range futures thinking, these processes may still help us to collectively analyse, imagine and anticipate interactions, changes and impacts (positive, negative and neutral) and factor these into today’s decision-making.

Should we consider one urban health future or many?

We have a tendency to discuss ‘the’ future, as if there is a singular or ‘most likely’ future and direct our efforts to revealing its contours and messages. In strategic planning exercises, for example, we undertake analytical activities to reduce uncertainty and boost control and clarity. These goals may pull us towards adopting a somewhat rational and linear thinking process, concluding with one serious future and set of options, perhaps accompanied by some contingencies. However, as the information that is available to inform decisions and actions is always imperfect and incomplete, and a vast range of known, unknown and unknowable factors shape a limitless array of potential conditions, situations and events, it is folly to rely too much on one image of the future.

Practitioners and theorists who work with futures studies and foresight often refer to multiple types of futures. Henchey (1978) put forward the idea of ‘possible’, ‘plausible’, ‘probable’ and ‘preferable’ futures. This framework has for many years been serving the interests of those exploring the use of futures in the fields of public health and health (medical) care (Bezold and Hancock, 1993). Whether these futures are perceived as positive, negative or neutral may be based on a subjective assessment. Taylor (1990) elaborated on the idea of plausible futures and represented futures that lie outside the realms of what may be conceivable in a ‘cone of plausibility’. These explore not only the positive trends and events but those that are catastrophic, disruptive, aberrant or anomalous, pushing us to confront uncomfortable or undesirable futures and ‘wildcards’. Miller (2011) refers to three types of futures – contingency futures, optimisation futures and emergent futures – that vary in their role in strategy development and openness to new possibilities. Overall, in trying to discern multiple and different types of futures, we are drawn into gaining deeper understanding of the characteristics and behaviour of systems underpinning observable patterns of health and equity in urban contexts.

Finally, in the field of urban health, what does the nexus between futures thinking and governance, policy-making, implementation and adaptation look like?

This question invites us to consider how futures thinking is connected to the processes that steer decision-making, define priorities, support effective action and stimulate responsiveness in the urban health field. While there seems to be limited contemporary empirical evidence on this specific issue, research in political science and related fields is evolving our insights and understanding (Barrett and Fudge 1981). What seems to be apparent is that the variables of governance, policy-making and implementation tend to be thought of as fixed. The evolving reality is that traditional policy models cannot easily meet the demands of rapid ‘transitions’ and ‘splintered urbanism’ (Graham and Marvin 2001). As Horne and Fudge (2016) remind us, ‘there is a growing urban transitions literature (Geels 2004). Often referred to as the “multi-level perspective”, with some proponents arguing that modern tools of reflexive governance can and could support sociotechnical transitions (Kemp and Loorbach 2006)’ such as urban health. ‘While the transitions literature is contested on the grounds that “steering” and outcomes for consumption are unpredictable (Shove and Walker 2007), the notion of systemic change requires in any event a collective, bi-partisan vision and long term strategy’ (Horne and Fudge 2016). This is equally true for urban and health policy and practice.

Perhaps one of the most important aspects of futures thinking is that it helps to realise cross-sectoral interactions featuring multidisciplinary contributions and engagement of the public. In so doing, this work is subjecting some commonly held theories of governance and policy-making to new scrutiny, and encouraging the exploration of how these theories are ‘espoused’ and actually ‘used’ (Argyris and Schön 1974, Schön 1983), what policy actors’ ‘assumptive worlds’ tell us (Young and Mills 1980) and how they are changing and being adapted to reflect the rapid change of the contemporary world.

What issues are we facing in the next 10? 30? 50 years?

It is well established that the shift in human habitat from rural to urban is continuing apace. Interacting trends in economics, politics, technology, social change, culture and environment are powering this shift. Urbanism will be a dominant concern of policy-makers, planners, investors, researchers, businesses and communities across the globe in coming decades. It has been projected that by 2050, up to 70% of the global population will live in urban areas (Fudge et al. 1996, UN 1998, 2015, UN Habitat 2016). Cities and urban governance are being pushed to the forefront of both human and planetary health (Grant et al. 2017). However, the extent to which health and its promotion will be prioritised as a basis for decision-making is an open debate. Health has struggled to be seen as a vital dimension of the global urban agenda (Singh and Beagley 2017), but is more firmly on the agenda than ever before (World Health Organization 2016).

A reading of projected trends by authoritative institutions and research teams indicates a diverse range of complex urban issues that are not only highly significant for health but enmeshed. These issues tend to be firmly anchored in natural and social sciences and include impacts of climate change on ecological systems; management of finite natural resources and waste in the context of increasing consumerism; protection of air, soil and water; quality and sustainability of urban infrastructure including roads, housing, green spaces, energy supplies, sewerage; food systems; inequalities in wealth and health; adequacy of services and environments to support liveability; and environments supporting physical activity and mental health and wellbeing.

Why use foresight in the urban health field?

The complexity of forces driving urbanisation in countries, within regions and globally is unparalleled in human history. The shape of cities – their form, design and environments – are changing apace and in many places, in a highly uncontrolled manner (Fudge et al. 1996, UN Habitat 2016). Discerning policy priorities and options that will generate urban health and health equity is thus a profoundly difficult and demanding technical and social exercise for actors at all levels. Moreover, so the city can continually respond to achievements and failures and adapt to changing conditions, policy improvisation will be necessary. Richer insights into driving forces, how they interact over time, and their implications for urban health will be needed, creating demand for foresight. Work over 15 years by the European Commission, the EU Urban Environment Expert Group, local authorities and the WHO Healthy Cities initiative attempted to explore through a combination of foresight and practice innovations improved urban health as part of a wider sustainability agenda. These explorations were achieved through their collaborative engagement within the European Sustainable Cities and Towns Campaign.

Foresight, in its broadest sense, is used to produce such insights and help decision-makers to anticipate, prepare and act. It has been referred to as a process that operates like ‘a canary in the mind’ (Wilkinson and Ramirez 2010). Undertaking a foresight initiative involves the careful selection and use of futures methods and tools. Evolving toolkits incorporating these methods and tools are being used around the world by national, subnational and local governments, statutory authorities, businesses, NGOs, citizen organisations, consulting firms and other entities to gain insight into complex issues such as urbanisation and optimising population health. Visioning, Delphi studies, horizon scanning, scenarios, trend projection or extrapolation, modelling, and backcasting are examples of commonly used methods and the focus of academic research in many countries. These have often been integrated with more conventional policy analysis techniques, assisting analysts to detect and calculate trends, scope and quantify risks, depict alternative scenarios, surface worldviews and perspectives of groups and teams, and define plausible, possible, probable, preferred and emergent futures.

The value of foresight does not primarily rest in its potential to produce definitive point predictions or direct us to the most strategic decision. Rather, foresight can generate constructed knowledge and put into perspective what we know, do not know and cannot know. Depending on the methods and tools used, it can open spaces for policy deliberation to inform today’s thinking and decision-making and support policy improvisation. Thus, foresight can foster a social process that strengthens shared understanding and commitment, and mobilise action (Fawkes 2009).

Miller (2011) argues that our experience with foresight over time can help to develop the competency of ‘futures literacy’ among professional and citizen groups alike, and a stronger capacity to use the future in the present.

We act in the present and we perceive in the present, and the way we act and perceive are deeply influenced by the way we imagine the future. So what I am interested in is developing the story telling capacity, the narrative capacity to invent alternative worlds, to understand system boundaries … what we are doing when we extrapolate … and what we are doing when we think we can impose our views, our hopes, on the future…. This question of how to use the future effectively is something I think we need to be developing as a competence.

This is viewed as a competence that provides the capability of activating our anticipatory systems – being conscious of imagining the future.

What methods are needed?

Diverse futures methods and tools have been applied in the urban health field, each with specific functions. Many of these, while known to policy-makers, may be underused or not used for maximum effect or relied on too heavily.

Quantitative futures methods such as trend projections and forms of statistical modelling are being turbo-charged by rapidly developing techniques in the field of predictive analytics underpinned by a level of ‘smart’ data collection unimagineable a few years ago. This field aims to predict future outcomes by uncovering deep patterns of interaction between entities. Historical and present-day data are both essential. The appeal of predictive analytics to those with strategy development, planning and sustainability interests, at all levels, includes the reduction of uncertainty and illumination of possibilities.

Despite its appeal, predictive analytics is limited in its ability to produce the range of knowledge needed to make policy and to stimulate action for healthy urbanisation. Instead, methods that may be particularly useful in the field of urban health have a bias towards the production of qualitative data and hosting social processes. Established methods such as community visioning are based on social engagement and consensus building. They can enable the construction of collective intelligence, shared perspectives, and understanding and acceptance of differences between groups. They may stimulate commitment to action. Exciting methodological innovations are also developing. We are seeing anthropologists bringing qualitative and ethnographic approaches together and combining them with quantitative methods and ‘big data’ analytics. This contemporary form of ethnography provides new insights into and understandings of the everyday experience of the digital on our lives and the potential impacts of digital futures on society (Pink 2012, Pink et al. 2015). As well, it has value for the health field in terms of translational research and user involvement in research and policy development (Fudge et al. 2008, 2016).

A foresight initiative or exercise typically combines methods and tools in a way that serve a particular objective. For example, a community or organisational visioning exercise might include a technical analysis of STEEPL-V trend projections (covering social, technological, economic, environmental, political, legal, values), a scenario development activity that surfaces tacit knowledge and makes it available for debate and reframing, and a collective visioning exercise. There is no single model that can be used for all foresight initiatives, or even a ‘best practice’ model. Indeed, prototyping foresight approaches is a rich field of activity in corporate, government and intergovernmental contexts.

The practical experience of national and subnational governments, NGOs and the private sector in applying futures methods and tools is an important and instructive source of inspiration for designing foresight approaches. Accessing this experience can be difficult however, where commercial-in-confidence and other protections reduce access.

So where is practice across the globe?

Foresight initiatives focused on urban settings and health are in progress in many parts of the world. These illustrate the potential contribution of methods, tools and capacity building to developing strategic approaches to prevailing ‘wicked’ problems and those on the horizon. These initiatives demonstrate how futures studies methods and tools may be deployed, the potential value of framing a project around the concept of futures, and the knowledge assets that can be generated for use in policy-making and action.

In the last few years, several interesting initiatives have emerged that are concerned with urban health and utilise futures studies and foresight as central features. These include the U.K. Foresight ‘Future of Cities’ Project that engaged several cities in the U.K; work by World Health Organization Western Pacific Regional Office that is developing futures literacy among Asian and Pacific stakeholders to advance action on urban health; the Cities Changing Diabetes initiative that is activating cities across the globe to ask ‘what will it take to bend the curve on diabetes in our city?’; and several city foresight initiatives in Australia and elsewhere. Evaluations of these initiatives as well as data, know-how and tools will be important outcomes for wider dissemination and discussion.

A scan of foresight initiatives related to cities and health will be the focus for one of the Special Issue papers.

What are the implications for policy and practice?

There are several potential implications for policy and practice from using foresight in urban health policy efforts.

•	New and expanded connections may form between a diverse range of actors representing multiple disciplines and interests, broadening ongoing participation in policy and practice. Relevant disciplines for urban health foresight include psychology, sociology, economics, law, engineering, anthropology, architecture, and planning and management.
•	Engagement of community members or representatives in foresight activities may strengthen the relevance of policy and practice to communities that remain in rural areas, those who are making the transition to urban settlements, those who are settled in cities and also those for whom mobility has become the norm.
•	In using foresight, cities will typically move beyond developing a single preferred future, which is often the focus of strategy development, to consider alternative futures such as possible, plausible and probable futures, including unpopular, unacceptable or threatening futures.
•	The scope of policy analysis and planning in cities may expand beyond the conventional through the use of futures methods, offering more diverse insights and options, and revealing biases and gaps in evidence used for policy-making.
•	The basis for priority-setting and decision-making in relation to key urban health issues may be made more robust with new forms of data, information, knowledge and social engagement resulting from foresight work.
•	The locus of leadership may shift and opportunities to develop healthier urban futures may expand as more actors take part in collective foresight activities.
•	Policy and practice may be served by new types of partnerships with universities and other centres of learning, set up to support the development of the futures literacy of urban health actors involved in policy-making. While skills in trend projections and other methods that have been available for some time may be well distributed within and across sectors, skills development may be needed in detecting weak signals of new drivers of change and trends, or using ‘black swans’, ‘wildcards’ and other disrupters in policy-making and policy improvisation processes.
•	Ideally, population groups with diverse perspectives on urban living and health will be supported to participate in or contribute to foresight processes – children, youth and the ‘old old’ as well as people with lived experiences of disadvantage, stigma and marginalisation. Step changes in the use of digital (social media) and in social innovations may result from engaging the public in foresight initiatives.

Beyond cities themselves, the systematic use of futures methods and tools by institutions involved in urban health (parliaments and national governments, private sector, NGOs, citizen bodies, UN, UNDP, WHO) may shift their orientation to future generations, and influence policy priorities.

Concluding comments

As indicated at the outset, this article has had two purposes. It has explored futures thinking in relation to cities and health in the twenty-first century. It has also hopefully provided an introduction to broader urban and health futures which will be the focus of a Special Issue of Cities & Health in 2019.

Systematic exploration of alternative futures and collective imagining, combined with the best use of science and scientific innovation, may help us perceive and act in ways that take us towards health-enhancing and sustainable urban environments and living patterns.

We wish to conclude this article with an invitation to contribute to the Special Issue we will be editing and publishing next year. Some possibilities and agendas that we hope may further stimulate your thinking and your practice about healthy urban futures might include:

•	the interrelatedness of science and imagination
•	the nature of contemporary policy-making, implementation and governance and how it is changing
•	the policy and practice of designing and redesigning cities to create positive health outcomes
•	the bringing together of climate change, urban development and health
•	the evaluation, transmission, learning and scaling up from local practice innovations to different levels of government – district, city, regional and national and the mainstreaming of these ‘islands of innovation’ to wider policy and practice.

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes on contributors

Colin Fudge is a professor of Urban Futures and Design at Chalmers University, Sweden; Senior Adviser to the EU Climate KIC; Global Adviser for the UN Global Compact: Cities Program and for UN Habitat and is Royal Professor of Environmental Science, Sweden. He is Emeritus Professor in RMIT, Australia and in Bristol, U.K. He has worked in universities at president and vice-president levels in Europe and Australia and at Deputy Secretary and Director levels in government and cities in the U.K., Sweden, Australia and the European Commission.

Sally Fawkes is a senior academic at La Trobe University in Melbourne, Australia. Sally holds a Master of Business Administration (Monash) and PhD in health policy (La Trobe). Her research, professional leadership and consulting activities are at the nexus of foresight, health promotion, health system reform, and urban health and healthy cities. Sally is a long-standing technical advisor to World Health Organization, contributing to leadership development and health policy and practice innovation in Asia, the Pacific and Middle East.