Advancing health and wellbeing through
the smart city agenda
For special edition on Smart Cities in Local Environment
Unedited. See journal website for final version.
Gregory Trencher1 Andrew Karvonen2
1 Tohoku University: Graduate School of Environmental Studies (corresponding author)
2 KTH Royal Institute of Technology, Stockholm, Sweden
Contemporary smart cities have largely mirrored the sustainable development agenda by
embracing an ecological modernization approach to urban development. There is a strong
focus on stimulating economic activity and environmental protection with little emphasis
on social equity and the human experience. The health and wellbeing agenda has potential
to shift the focus of smart cities to center on social aims. Through the systematic and
widespread application of technologies such as wearable health monitors, the creation of
open data platforms for health parameters, and the development of virtual communication
between patients and health professionals, the smart city can serve as a means to improve
the lives of urban residents.
In this article, we present a case study of smart health in Kashiwanoha Smart City in Japan.
We explore how the pursuit of greater health and wellbeing has stretched smart city
activities beyond technological innovation to directly impact resident lifestyles and become
more socially relevant. Smart health strategies examined include a combination of
experiments in monitoring and visualization, education through information provision, and
enticement for behavioral change. Findings suggest that smart cities have great potential
to be designed and executed to tackle social problems and realize more sustainable,
equitable, and livable cities.
Visions and efforts to realize sustainable cities over the past three decades have largely
focused on the simultaneous pursuit of economic development and environmental
protection (Hodson and Marvin 2017). The current smart city agenda has embraced this
ecological modernization approach to urban development. By weaving “smart” information
communication technologies (ICT) into the urban landscape, smart cities promise to
improve environmental and economic performance through data collection, analysis, and
evidence-based policymaking (Goodspeed 2015, March in press). This can enable more
intelligent planning and optimized or novel service delivery by municipalities and industry
(Saujot and Erard 2015). In parallel, real-time data from smart devices can guide citizen
behaviors and choices regarding matters such as home energy use. Meanwhile, empirical
studies of smart city projects reveal that that vast majority of projects are overwhelmingly
fixated on driving physical environment and infrastructure improvements and fostering
innovation in service of economic growth (Albino et al. 2015, Alizadeh 2017). Largely
ignored, on the other hand, is the human experience and the possibility of contributing to
improved wellbeing and urban livelihoods through application of smart technologies.
The process of urban development represents an important opportunity to pursue the
social dimensions of city life such as health and wellbeing. Health is a longstanding urban
agenda. Nowhere is this exemplified better than the Sanitary City movement of the late
nineteenth and early twentieth centuries (Melosi 2000, Pincetl 2010, Karvonen 2011). Faced
with countless deaths from transmissible diseases such as cholera and tuberculosis, city
planners and engineers significantly improved human health in modern cities by
introducing systems of water supply, wastewater treatment, and solid waste collection. In
recent times, the link between health and the urban environment has taken on a renewed
light through emerging scholarship. Söderström (2016) has documented interesting cause-
and-effect linkages between dense and chaotic urban environments and mental health
while Thomas and colleagues (2014) argue that wellbeing benefits can flow from positive
mental health in cities.
Propelled by breakthroughs in technology and data science, the agenda of health and
wellbeing is increasingly becoming an attractive target for digital innovation. The
development of digital health records, the introduction of remote doctor visits and the rise
of wearable consumer devices (e.g. FitBit, Apple Watch) herald an emerging digital age for
medical services. Moreover, health care is a costly but essential public service. Many
governments around the world are therefore keen to leverage ICT to improve the health of
citizens and boost the effectiveness of health related services to reduce the burden of
healthcare expenditures on the public purse (Goodspeed 2015). Cognizant of such trends,
scholars have recently highlighted a yet to be fulfilled potential for the smart city agenda to
contribute to the enhancement of health and wellbeing of citizens (Haarstad 2016, March
and Ribera-Fumaz 2016, Meijer and Bolívar 2016, Bibri and Krogstie 2017). However, as
highlighted by Haarstad (2016), empirical scholarship to demonstrate this potential is
lacking. A stretched smart city agenda exploiting digital technologies to improve resident
health and wellbeing represents a stark contrast to the techno-utopian agendas of Masdar
City, Songdo, and other exemplar smart cities around the world. Scholars have critiqued
such projects for their narrow pursuit of technological innovation in service of economic
growth and selected corporate interests and their failure to tie the trial and diffusion of
technologies to messy social issues and concrete goals of improving resident livelihoods
(Hollands, 2015). The potential for an expanded conception and execution of the smart city
thereby points to the possibility of using technologies not as ends in themselves—as is
most often the case (Glasmeier and Nebiolo 2016) —but rather, as a means to improve the
social aspects of urban living.
Whilst scholarship on the adoption of ICT to pursue greater health and wellbeing through
smart city development is nascent, Japan is rapidly emerging as a global frontrunner in this
field. Prompted by an accelerating transition to an aging population, private, public and
third sector actors in a handful of urban development projects are ambitiously stretching
dominating conceptions of smart cities by actively experimenting with ICT and smart
planning to advance societal health and longevity. Addressing this trend, this study
examines on-the-ground experiences and accumulated learning in Kashiwanoha, a national
(and possibly global) pioneer of smart city health strategies. Through a case study
approach, the primary objective of this article is to increase understanding around the
potential for smart cities to move beyond conventional environmental and economic
agendas to tackle a social challenge such as the pursuit of healthier lifestyles and greater
wellbeing. This paper contributes to the emerging social agenda in smart city discourse
( Glasmeier and Christopherson 2015, Goodspeed 2015, Stollmann et al. 2015, Glasmeier
and Nebiolo 2016, Bibri and Krogstie 2017) and addresses the following research questions:
l How is health envisioned in the smart city and how is it connected to other
l What approaches are used to advance health and wellbeing of residents and what
outcomes, challenges, and learning have resulted?
The following background section provides an overview of the current smart city agenda
and its failure to address social issues. We then introduce digital health and wellbeing as an
approach to address this gap by focusing on social welfare, resident wellbeing and
lifestyles. Our case study of Kashiwanoha then demonstrates how in practice a smart city
can envision and implement an array of technology- and people-centered measures to
guide residents towards greater health and wellbeing. Findings demonstrate an array of
top-down and bottom-up approaches including experiments in monitoring and
visualization, public education through digital and face-to-face information provision, and
the creation of intrinsic and extrinsic incentives from ICT devices to spur behavioral change.
These approaches represent a wide range of urban stakeholder configurations and differing
degrees of technological and data dependency. Key outcomes of these initiatives include
enhanced community building from joint learning, and resident participation around shared
values of preventative health. Digital tools are also providing novel opportunities for
municipal actors and health professionals to communicate more effectively with residents
around health issues. The experiences in Kashiwanoha also highlight potential obstacles to
a smart health agenda that revolve around data privacy issues, commercialization
opportunities, and engaging with a large sector of the population. While Kashiwanoha’s
smart health strategies have produced mixed levels of success, they provide novel insights
into how smart city agendas can be stretched to encompass attempts to improve the social
and wellbeing dimensions of urban life. Moreover, they demonstrate how technological
innovation can be framed not as an end in itself but as a means to address localized social
problems and enhance the lives of urban residents.
2.1 Expectations, tensions and shortfalls of the smart city agenda
The majority of smart-sustainable projects focus on entrepreneurial forms of urban
development that utilize cutting-edge technologies to simultaneously boost the economy
while reducing environmental impacts (Viitanen and Kingston 2014, Glasmeier and
Christopherson 2015, Hollands 2015, Glasmeier and Nebiolo 2016). This is the classic
formula of green growth that has dominated sustainable urban development discourse for
the last three decades (Schuurman et al. 2012, Tranos and Gertner 2012, Lee et al. 2014). As
Haarstad (2016:7) notes, “sustainability is largely an assumed result of more efficient, cost-
effective urban systems and greater availability of data.” Meanwhile, social considerations
are limited to supporting job creation and encouraging citizen participation through open
data platforms (Bakıcı, Almirall and Wareham 2013, Arrizabalaga, Seravalli and Zubizarreta
2016, Lee et al. 2014, Hielkema and Hongisto 2013). Glasmeier and Nebiolo (2016:2)
contend that “smart” labels that we attach to everything from wireless sensors to
automated vehicles are frequently unconnected to social objectives, arguing “the
unintended consequence of smart city “making” is to privilege technologies without
equivalency tests that make clear what the public values are and what the basic needs are
that these values seek to promote.” This suggests that the starting point for smart cities
should be social issues rather than the narrower goal of technology diffusion (Hollands
2015). In other words, technology-centered agendas should be demand-driven and focus
on residents’ needs rather than being supply-side driven and principally concerned with
growth and economic objectives (Söderström 2016). Thus, there is a need for smart cities
to be more relevant to a broader array of societal issues (Glasmeier and Nebiolo 2016).
The objective of enhancing public health has the potential to address the social
shortcomings of smart cities. Enhanced human health is increasingly seen as a co-benefit of
urban planning, particularly in the field of public health (Giles-Corti et al. 2016). This is
however principally from an urban engineering perspective where compact cities are
designed to provide sustainable public transport, opportunities for walking, cycling,
exercise, reduced crime, safe and nutritious food, vegetation in public spaces and clean air
(Ramaswami et al. 2016, Sallis et al. 2016). Greater wellbeing and health for residents is
produced by a cleaner and more livable urban environment. Whilst these physical
environment planning approaches hold much promise to promote healthy lifestyles and
positively impact the lives of urban residents as a whole, there is a flipside. Scholars like
Caprotti, Springer and Harmer (2015) underscore that that the privilege of residing in
corporation-driven new smart cities can constitute a luxury out of reach from poorer
populations due to high property premiums.
Developments in data management and health care suggest that digital technologies have
significant promise to advance human health and wellbeing in urban settings. In
conventional smart cities, the Internet of Things (IoT) and ICT sensors link appliances,
building components, transport systems and residents to increase efficiency of energy
usage and allocation of resources. Similarly, emerging research and experiments in
medicine and public health demonstrate that digital technologies can also link residents
and technological artefacts with data and information networks to optimize healthcare
efficiency and effectiveness (Andreassen et al. 2015). For example, wireless sensors can
measure physical activity and provide data-based diet and lifestyle guidance (Koch 2010),
electronic communication networks can link health care professionals, patients and family
caregivers to enhance health literacy and preventative care (Haluza and Jungwirth 2015),
“telemedicine” can enable homecare of the elderly and relieve doctor shortages (Obi et al.
2013) while social media applications and digital devices can promote the social inclusion of
care recipients (Hasan and Linger 2016). Moreover, Thomas and colleagues (2014) argue
that dominant conceptions of urban health need to be expanded beyond illness and disease
to encompass mental and social wellbeing. This points to an important challenge for smart
cities—that of using technologies to promote not only physical health but also mental and
Recently, interest is mounting around the potential to harness such ICT innovations to
public health in smart city developments. As part of the U.K. Smart Cities Forum, the City of
Leeds and the University of Leeds advocated a vision and set of national government
recommendations for a “smart city for health and wellbeing”. The authors propose that
such a city “…takes an integrated approach to the use of digital technologies to increase
the connectedness of people to the information and city functions that improve health and
wellbeing, reduce inequalities and support a higher quality of life for all its citizens” (Leeds
City Council and Leeds 2015:13). This vision calls for a balanced focus on wellbeing, illness
prevention and treatment. Digital technologies are framed as tools to empower residents
to transgress the role of a passive patient and become “active participants” in a shared and
digitalized health care system.
2.2 Smart cities and health in Japan
Japan is a world leader in smart city developments with an estimated 160 projects funded
by the national government up to 2014 (Mah et al. 2013, Nyberg and Yarime 2017). The
realization of smart cities is a strategic priority of the national government and supported
through the significant expenditure of public funds. DeWit (2013) notes that prior to the
Fukushima disaster, trials of smart city technologies by Japanese corporations and officials
were limited to a few pilot cities with the aim of developing an export market to position
Japan as a global leader in the field. These projects were predicated on the continued
dominance of nuclear power and centralized energy provision. However, the Fukushima
nuclear disaster of 2011 and consequential closure of Japan’s entire nuclear fleet shattered
these assumptions. The national government rapidly refocused the smart city agenda on
the domestic market and prioritized energy conservation and disaster resilience through
the development of local renewable energy and smart grid projects (Nyberg and Yarime
2017, Yarime and Karlsson in press).
A few Japanese smart city initiatives focus on retrofitting existing cities while most involve
the construction of entirely new districts or towns. In addition to a focus on boosting the
disaster resilience of energy supplies through diverse and distributed renewable sources
(Kono et al. 2016), the national smart city discourse explicitly states that ICT will improve
the quality of life for urban residents by tackling social problems such as disaster resilience,
population aging, and stagnant economic conditions (Kijou and Rure 2014). Japanese smart
city projects are frequently underwritten with generous government funding while their
implementation is spearheaded by a handful of large corporations (Mah et al. 2013, Yarime
and Karlsson in press) in partnership with municipalities who willingly open up public
resources for private sector exploitation. In the majority of cases, citizen involvement is
largely absent (DeWit 2013, Kijou and Rure 2014) or limited to “a very specific and limited
set of expression and actions” (Granier and Kudo 2016:72). This situation echoes
observations from scholars regarding global trends where the dominating corporate smart
city model fails to translate technological innovation into the creation of novel participatory
roles for citizens in urban governance (Hollands 2015).
However, the national issue of an ageing population in Japan has the potential to open up
the smart city agenda to democratic engagement with urban residents. The country
continues to struggle with the emerging economic consequences of the most rapidly
greying population in the world due to a chronically declining birth rate and increased life
expectancy (Muramatsu and Akiyama 2011, Shirahase 2015). Both governments and
corporations are increasingly looking to ICT and smart innovation to reduce healthcare
costs and mitigate a looming viscous cycle whereby, on one hand, health expenditures rise
in accord with population greying trends whilst, on the other hand, a shrinkage of the
young working population leads to a decrease in taxes for public services (Obi, Ishma tova
and Iwasaki 2013). Accordingly, a growing number of municipalities have started
experimenting with ICT to promote public health. Since health ultimately concerns
lifestyles and requires the buy-in and engagement of residents, this emerging development
signals an interesting development in smart cities for strengthening their social agenda and
participatory function. In other words, it is through health and wellbeing that the social
dimensions of smart urban development have the potential to flourish in Japan.
The Japanese smart city of Kashiwanoha provides a real-world case study of how the health
and wellbeing agenda is being addressed through smart urbanization. Health and longevity
has formed a central and explicit focus of the Kashiwanoha Smart City since its
establishment in 2008. This long tenure of a smart health agenda thus provides an
important opportunity to reflect on achievements to date. That said, the Kashiwanoha
example is not intended as a model of best practice. Instead, it illustrates how smart urban
development strategies and digital tools can be stretched or reinvented to potentially
address localized social issues (in this case an aging society) alongside environmental and
The empirical findings are derived from qualitative data collected from primary and
secondary sources. Primary data was collected between 2014 and 2017 through four site
visits and semi-structured interviews with eight actors including the private developer,
public health professionals from the municipality, university researchers, non-profit sector
planners and volunteer health workers. Interviewees were selected to provide a range of
perspectives and experiences on the smart health initiatives in Kashiwanoha. All interviews
were conducted in Japanese by the first author in person (except one conducted via Skype).
Interviews were recorded, transcribed and coded manually to identify major themes.
Secondary data was derived from a desk-based study of newspaper and magazine articles,
smart city promotional and explanatory materials, internal project documents and
4.1 Background on Kashiwanoha Smart City
Located in Kashiwa City, the Kashiwanoha Smart City was initiated with the opening of a
new train line connecting Tokyo with the northern city of Tsukuba in 2005. The developer,
Mitsuifodusan, owned abundant undeveloped land in the station vicinity and this created
an opportunity to develop an entirely new city from scratch. At present, Kashiwanoha is
comprised of mixed-use developments on a 273-hectare plot that includes retail and dining
facilities, a satellite campus for the University of Tokyo, a hotel, a hospital, commercial and
venture incubator spaces and several high-rise residential buildings. Over the last decade,
the smart city’s population grew from zero to about 6,0000 residents. By 2030, it is
expected to reach around 30,000 residents. Property prices are relatively higher than
nearby areas and thus, most residents are retired couples or wealthy middle-class and
young families who commute to Tokyo for work. The promise of healthier living thus
addresses itself principally to a wealthier segment of Japanese society although, as we
outlined later, many health orientated initiatives offer access and benefits to a wider
population in the surrounding area.
Although driven by private investment from the developer, Kashiwanoha Smart City has
unfolded through intimate industry-university-government collaboration. The non-profit
planning headquarters Urban Design Centre Kashiwa was established in 2006 to facilitate
collaborative planning of the city and promote citizen participation (UDCK 2017). Spurred
by this broader governance framework for cross-organizational collaboration and
innovation, a culture of experimentation with technical and social approaches to societal
problems has burgeoned in the new city (Trencher et al. 2015). In 2008, the developer
teamed with the prefectural government, two local universities (the University of Tokyo
and Chiba University) in a collaborative visioning process that lead to the proposal of an
“International Campus Town”. A 13 km2 area (encompassing Kashiwanoha station, two
universities and government research institutes) was designated as a “campus” or urban
laboratory for research and implementation of academic knowledge. Three areas were
designated as development priorities: environmental sustainability, high-tech business
creation, and health and wellbeing (Kurata et al. 2013).
Effectively serving as the common binding thread for pursuing these three objectives,
smartness is interpreted principally from two dimensions. Firstly, by applying cutting-edge
knowledge and innovation produced through university-government-industry
collaboration to development of the city (Kurata et al. 2013), and secondly, by integrating
ICT and digital technologies to various energy and lifestyle domains. In addition, the city
has fixed a long-term goal of reducing CO2 emissions in 2030 by 60% (compared to a
Business as Usual scenario) by rolling out a smart grid, renewable energy generation and
storage, energy efficiency, and residential energy consumption visualization. Kashiwanoha
is aggressively marketed as a ‘smart city’ and touted as a new Japanese model of urban
development that is the fruit of cutting-edge innovation attained through industry-
university-government collaboration (Mitsui Fudosan 2017).
4.2 The vision of a smart, healthy city
Beyond CO2 emissions and energy efficiency, a core objective in Kashiwanoha is to enhance
resident health and wellbeing. This goal attaches high expectations to the potential of ICT
and mirrors the focus on smart technology and real-time visual feedback of building energy
consumption to advance energy sustainability in the city. In addition, there is a distinct
focus on preventative health; i.e. preventing illness by encouraging healthy lifestyle habits
for diet, sleep and exercise etc. The city’s health and wellbeing narrative encourages
residents to adopt a daily maintenance mind-set and assume greater responsibility for their
personal health. It touches on an array of lifestyles issues ranging from diet and sleep to
walking and socializing activities. By doing so, the preventative agenda explicitly
communicates an objective of reducing health related expenditures for the local
municipality by fostering healthy lifestyles that would eventually lead to lower reliance on
post-illness consumption of medication and professional medical services. Although the
aim is to address residents of all ages, Kashiwanoha’s fixes an explicit goal of advancing
longevity. It thus affords special consideration to promoting elderly health, neatly aligning
with the national government’s funding expectations that future-orientated urban
development in Japan address the growing needs of a greying society. Addressing health
and longevity today is therefore seen as an investment in social capital for tomorrow, when
aging trends and associated burdens on public welfare will be further pronounced.
Beyond preventative health, there is a strong emphasis on fostering social cohesion. This is
driven by growing realizations in the Japanese medical community that elderly citizens
residents leading socially active lifestyles are more likely to avoid early deterioration of
physical and mental capacities. In connection to this, one interviewed smart city planner
emphasized how the pursuit of health and longevity is intended to encompass mental
wellbeing, and secondly, to be “fun” and thereby transcending a narrow focus on physical
health. From another perspective, core to the vision of Kashiwanoha’s smart, healthy city is
the developer’s rhetoric that “…residents can become healthy just by living here”, so
explained other interviewees. This mirrors nicely the alluring effortlessness promoted by
Kashiwanoha’s marketing efforts, which similarly, promise that residents can lead an
environmentally friendly lifestyle by simply residing in the city.
Several distinct motivations for the focus on health and longevity in Kashiwanoha emerged
from interviews. The developer emphasized how the health identity serves to distinguish
Kashiwanoha from other smart cities, potentially creating greater demand for real estate
assets in a competitive marketplace and aging society. For the municipality, motivations
are also financial since health expenses are rising annually due to an increasing number of
elderly residents requiring medical care. Health promotion initiatives therefore represent
an opportunity to mitigate this growing financial burden on the municipality and the
shrinking workforce that contributes to the local tax-base. For university researchers,
Kashiwanoha smart city and surrounding Kashiwa City offer a myriad of opportunities to
use the urban environment as a laboratory for emerging research and trialing solutions to
societal challenges in conjunction with willing residents and private and public actors.
4.3 Approaches to smart health and wellbeing
Empirical findings reveal three principal approaches to pursuing smart health and wellbeing
in Kashiwanoha: experiments in monitoring and visualization, education through
information provision, and enticement for behavioral change. Table 1 summarizes the
defining attributes of each approach as described in the following sections. Each is
described individually but it is important to note that there is significant overlap and
synergies. Since 2012, this portfolio of approaches forms an interconnected and iterative
strategy for fostering smart health, continuing to evolve.
Table 1: Smart health approaches in Kashiwanoha
Tar ge t p op ul at io n
• Use visual feedback of health data to
promote active lifestyles and health
• Create new business opportunities for
• Motivated, active
• Private industry
Transition to digital child health diary for:
• Storing health data and enabling mutual
learning across couples
• Diffusing tailored health information from
municipality and increasing accessibility
• Young parents
to entire City of
• Private industry
• Establish walk-in preventative health care
center (Ashita) to educate public and
• Older residents
• Open to all,
• Private industry
Incentivize daily walking by rewarding with
purchase redeemable points (extrinsic
incentive) in Sukoyaka Links initiative
• Motivated, active
• All residents and
• Private industry
Raise exercise motivation/intensity through
intrinsic incentives by:
• Aggregating and disclosing data collected
from individual activity recorders
• Fostering a group mentality and sense of
competition by ranking individual
performance against cohort average and
• Motivated, active
• Private industry
4.3.1 Experiments in monitoring and visualization
Several large-scale experiments were conducted in Kashiwanoha with wearable ICT
devices. These generated and stored health and lifestyle data on a cloud server and then
delivered this to participants as real-time, visual feedback through an Internet portal. These
ICT experiments aimed to support preventative health by generating continuous data
streams from an array of daily activities (sleeping, walking, running, working, stepping on
weighing scales etc.) and delivering results to participants as easy-to-understand graphs
and metrics. One notable example of such experimentation was conducted over five weeks
in 2013. In partnership with three medical-tech firms and the municipality, the developer
recruited 150 residents to trial the following four types of technologies in differing
combinations and then provide feedback to the developers:
1. Wearable ICT activity monitors to capture continuous lifestyle data (see Figure 1);
2. Digital pedometer to record steps walked/ran;
3. Digital scales to record weight, Body Mass Index (BMI) and body fat percentage (see
Figure 1), and;
4. A cloud server and Internet portal to store and display real-time data, and additionally,
a forum to receive feedback and advice from municipality health professionals like
nurses and dieticians.
Key visualizations derived from health data included graphs depicting shifts over the two-
month period for steps walked/ran, exercise intensity (shown as Metabolic Equivalent), BMI
and weight. As an attractive feature, participants in the groups wearing the wristband
activity recorder could access a colored, tapestry-like graph showing a 24-hour ‘lifestyle
scene’ over the experiment duration (Taniguchi et al. 2014). This enabled participants to
identify at a glance any inconsistencies in their lifestyle habits such as working or sleeping
hours. Organizers report that this experiment generated positive outcomes on health. In
the group trialing both the life recorder and ICT scales, time spent exercising increased 34%
whilst participants reported that sleep quality and daily vitality increased markedly. In
addition, across all groups the majority of participants reported high satisfaction with the
technologies and reported an increase in motivation to exercise.
The developer explained that this health data visualization strategy was similar to the
activities to monitor home energy consumption data. In both cases, ICT is used to influence
user behavior by providing visual “cues”:
“The same goes for health. To assist people in leading a healthier lifestyle it is
necessary to first of all quantify and then provide back visually that person’s health
condition. Therefore, the wearable life recorder for example aims to render visible
that user’s lifestyle pattern and then, by showing the duration or infrequency of sleep
patterns, provide cues to improve this.”
Participants could check the status of their health condition in real-time and however often
they desired. This set of technologies therefore permitted vastly more frequent interaction
with vital health indicators than an occasional hop on the scales or doctor’s visit. This
experiment was therefore underpinned by grander ambitions of boosting the effectiveness
of healthcare. The developer explained that the experiment organizers anticipated this
data visualization approach could be eventually commercialized to provide objective
feedback data on lifestyle patterns to medical professionals, who traditionally, rely on
anecdotal evidence from patients when assessing health conditions and or illnesses origins.
Although today’s marketplace abounds with similar technologies like the Nike+ ‘Fuelband’,
the developer emphasized the cutting-edge and “epoch-making” nature of the prototype
ICT devices since they were trialed a few years before similar technologies entered the
4.3.2 Education through information provision
Driven by assumptions that a more informed public would produce healthier choices and
lifestyles, Kashiwanoha also fosters smart, healthy residents through various educational
initiatives. In late 2014, the University of Tokyo enrolled the developer and ten private
corporations in the establishment of a physical headquarters for the smart city’s focus on
preventative health and longevity. This free-of charge, walk-in educational facility called
Ashita (see Figure 1) aims to increase citizen awareness and knowledge about preventative
health and longevity strategies. Smartness in this approach thereby involves education and
the provision of information to inform resident lifestyles. Although the facility targets all
ages, around two-thirds of the roughly 2,000 residents enrolled are over 60. Interestingly,
Ashita’s open-door policy allows free use by residents outside of the city, with some users
traveling from neighboring towns.
Education efforts are concentrated in three areas: walking, eating and socialization. The
name ‘Ashita’ reflects this triple focus by combining sounds from the Japanese words for
‘walk’, ‘eat’ and ‘talk’. As shown by the focus on ‘talking’, another defining feature of
Ashita’s distinctly human-centered approach concerns the resolve to advance preventative
health and longevity by increasing socialization opportunities. As noted above, researchers
from the University of Tokyo established that elderly residents who have frequently social
interactions and outings are less likely to develop dementia and walking disabilities. The
socialization strategy was also informed by feedback from various visualization
experiments where participants voiced the need for personal interaction to complement
individual ICT devices and Internet-based communication with public health professionals.
There are various education activities at Ashita with different objectives. The facility
provides visitors with demonstrations of exercise/strengthening techniques and
explanations of products. Equipment manufacturers are allowed to freely display their
devices to increase brand recognition and to spur sales. A second strategy includes
frequent events hosting where invited health specialists deliver lectures on specific topics
(e.g. alleviating joint pain, Nordic walking classes etc.) and more informal coffee hours and
musical performances that provide opportunities for socialization. A third approach relies
on data collection and assessment. Ashita boasts an array of sophisticated digital
equipment supplied free-of-charge by medical equipment firms. The equipment allows
visitors to monitor their physical condition through quantitative data on key vital indicators
such as weight, BMI, basic metabolism, muscle weight and distribution, visceral fat, bone
weight and artery health. The data is stored on membership cards to allow visitors to
review their individual results over time. Anonymized data are also provided to equipment
suppliers for commercial purposes. An interviewee admitted that while there were initial
ambitions to create ‘big data’ with commercial value, this is yet to be realized since only
around a third or so of the 2,000 enrolled members visit periodically). The center staff are
thus employing various marketing strategies to increase enrolment numbers, visitations
and community awareness of the facility.
Far from a top-down approach, Ashita is run by a team of some 30 volunteers (all are local
or nearby residents) and a few paid staff. Interestingly, none of the volunteers are health
professionals. Instead, the center provides them with basic training and empowers them to
educate other residents to adopt pro-active and health-enhancing lifestyles. In connection
to this collaborative learning focus, a volunteer staff member half-jokingly expressed hopes
that visitors and volunteers would become “health evangelists” and spread healthy living
habits throughout the community.
Beyond the health center, the municipality has also seized the experimentation
opportunities offered in the smart city to develop and test a transition to digital health
records and an app-based health information and public education strategy. In late 2014
they partnered with the developer and several private IT firms to recruit 70 young mothers
for a 30-day trial to assess the suitability of a cloud-based maternal and child health diary
platform. This was intended to supplement traditional paper-based diaries to record basic
health data such as height, weight and vaccination history. Paper-based child health diaries
containing this information are a legal requirement for doctor visits in Japan. The smart
diary fulfilled this basic function but also introduced dynamic temporal visualizations of the
child’s height and weight alongside healthy averages. The initial experiment harbored
ambitions of seamlessly linking this function with health databases in the municipality that
store medical information from child doctor visits. In addition, the was integrated with a
vaccination appointment scheduling tool to minimize doctor visits and reduce time burdens
on working parents.
More important, however, the smart diary was designed as an educational package to spur
mutual learning around child health in couples and families. Accessible from smart phones
or computers from either parent, it features for instance municipality produced video clips
on correct bathing, holding and feeding techniques, and additionally, numerous text
articles on various child health topics. Content of the digitally delivered health guidance is
tailored to the age of the child. Interviewed health professionals from the municipality
emphasized the importance of this tailored education in a society increasingly comprised of
isolated nuclear families where young parents have few opportunities to learn from other
child raising families. They also underscored that the transition to a smart diary addresses
the growing societal need for digital and targeted health information that is easily
accessible to career juggling couples.
The smart diary was received positively by users. This justified the launch of a full city-scale
experiment in 2015 and the public launch of a formal municipal program in 2016 (the first in
Japan). While the pilot version was originally limited to privileged Kashiwanoha residents, it
now serves the residents of the surrounding City of Kashiwa. However, the automatic data
uploading platform used in the pilot study was not scaled up due to server maintenance
costs and privacy concerns. Instead, health data must be manually uploaded by parents,
significantly reducing the convenience that a ‘smart’ diary promises. Reflecting on key
outcomes, a municipality nurse emphasized how the transition from paper to smart diaries
and digital education has facilitated enhanced communication around child health between
residents and the municipality. A larger audience is now reachable than possible via
traditional communication strategies such as pamphlets, posters, and parenting classes.
Reflecting this, interviewees shared feedback from the diary users that the relationship
between young parents and the municipality now “felt intimate”. Moreover, they also
remarked that the digital educational materials produced by the municipality enjoy a
particular level of trust due to their objective and tailored nature in a world abound with
information on child health of varying reliability.
Figure 1 Key ICT technologies and Ashita education center
Top left: Wearable ICT activity recorder (image by permission from A&D Medical Co. Ltd. ©
Bottom left: ICT scales (image by permission from A&D Medical Co. Ltd. © 2017)
Top right: Sukokaya Links program pedometer and points card (image by author)
Bottom right: Ashita walk-in health prevention educational center (image by author)
4.3.3 Enticement for behavioral change
Beyond information provision and technical experimentation, smart health initiatives in
Kashiwanoha also involve efforts to entice behavioral change in residents via both intrinsic
and extrinsic incentives. On the former, in several monitoring experiments, participants
wearing individual ICT activity monitors or pedometers were linked into a digital
community. A game-like, competitive ambience was fostered across the participant cohort
by aggregating individual-level data for key indicators such as calories burned and steps
walked or ran and then disclosing this via real-time graph visualizations on a cloud portal
accessible from the Internet. For each indicator, participants could assess their personal
performance against the cohort average. A rank was also generated for cumulative calories
burned to show an individual’s position relative to other “competitors”. This approach was
intended to spur ambitions of high achievement and create an intrinsic incentive whereby
participants were rewarded with the personal satisfaction of exceeding the cohort average.
By rendering visible the existence and efforts of other health crusaders through cohort-
level health indicators, these experiments also fostered a sense of community and shared
purpose to the traditionally individual affair of health and lifestyle management.
Smart technologies are also exploited to create extrinsic incentives. Smart city partners
reasoned that “health data visualization alone is not sufficient for engaging the population
segment that lacks interest in health. Some form of incentive is required”. They developed
a program to provide performance-based financial rewards to residents in accord with
steps walked or ran each month (as tracked by ICT pedometers). Rewards are collected via
points that are redeemable for purchases in the developer’s stores. Although they burden
the cost of the program, as they explained, “It is only by visiting our facilities that the user is
able to redeem their points…and that’s potentially good for our business”. Thus, there is an
explicit connection between public health and economic development. This approach was
trialed extensively across various ICT experiments between 2012 and 2014. It now forms
the basis of a Sukoyaka Links (meaning ‘healthy links’) initiative, launched in late 2015 by
the developer and a private medical technology firm. This Sukoyaka Links initiative
involves the trial of three technological artefacts (see Figure 1):
1. An ICT pedometer for recording distance walked each day (1,000 were distributed to
residents and workers in Kashiwanoha free of charge by the developer);
2. An ICT card for receiving digital points based on distance walked (limited to a monthly
maximum of 600 or the equivalent of JPY 600 or about US $5.50); and
3. A pedometer and point card scanning machine installed in the shopping center for
registering cumulative steps and calories burnt, generating visualizations of progress
over time, and redeem points.
The developer explained that learning accumulated from experiences in past experiments
had significantly shaped the Sukoyaka Links initiative. First, by distributing free-of-charge
pedometers to adult residents and workers in the smart city, the program is a first attempt
to engage the entire adult population of Kashiwanoha through ICT devices. This includes
laggards not inclined to exercise and contrasts to earlier experiments, which mainly
targeted smaller groups of motivated frontrunners. Second, relative to earlier experiments
with ICT devices, a notable shift towards a streamlined and simplified thematic focus on
walking occurred. User feedback collected by the organizers from earlier ICT experiments
suggested that too many technological artefacts and types of information (i.e. different
health indicators from ICT devices in conjunction with information from email exchanges
with health professionals) risked overwhelming the user. Sukoyaka Links organizers thus
reasoned that a simpler communication strategy would be more effective at fostering long-
term engagement of the population around exercise.
“In the early years, our experimentation with technology demonstrated that technically a
lot was possible….But these experiments only focused on a small population segment
with high interest in health. We have since realized that to attain a healthy city we must
engage the “base of the pyramid” that is not usually interested in health. For that we
require a population approach. We thus decided to narrow our thematic focus on simply
“walking”, which is easier to understand.”
The third shift occurring concerns a scaling-down of technological sophistication and
dependency, which in essence, removes the need for a cloud server to store information.
This eliminated the need for heavy investments in commercially vulnerable and immature
technologies, since pedometers are readily available at low-cost on the market. However,
despite much potential and careful design of the initiative, only 10% of the 1,000 users
receiving free pedometers regularly access the card scanning machine to redeem points.
This suggests that the potential of intrinsic/extrinsic incentives created from technological
devices to entice exercise only attracts a limited share of the population. This highlights the
need for other population-wide approaches to target what the developer terms “the base
of the pyramid”.
4.4 Challenges in commercialization, privacy and engaging residents
Private-sector led experimentation with ICT and data visualization technology was
underpinned with lofty expectations that new and lucrative business development
opportunities would emerge after the limited trials with residents. While experiments
revealed a wide array of possibilities—both in regards to commercial applications and
health enhancing effects on users —no experiment has reached full-scale development.
The notable exception is the digital diary project, where investment and ownership was
largely assumed by the municipality. Harsh business realities have betrayed the promise of
profit for the private sector from smart health initiatives. Private-sector led focus groups
with residents trialing wearable ICT devices revealed a hesitancy to actually pay for such
data services despite the fact that product satisfaction was high. Organizers noted that
although the experiments succeeded in gaining the enthusiastic participation of residents
by supplying technologies free of charge over brief intervals, a long-term commercial
arrangement involving subscription fees would substantially dampen interest. As a
compounding factor, an influx of competing technologies such as Nike Fuel bands and
health apps on smart phones have overshadowed the novelty of the health devices trialed
in Kashiwanoha. The developer also emphasized the unanticipated high costs of
maintaining data servers and noted that their shared ambition to link real-time health data
visualizations on an Internet portal alongside home energy visualizations was abandoned.
Regarding financial burdens, the developer argued that public health should primarily be
the responsibility of the municipality since their primary line of work concerned real estate
“On the issue of whose job it is to take care of health and welfare, it’s the municipality
that first comes to mind. But the municipality does not have the funds to invest heavily in
ICT experiments and so on… As for us, we are not trying to profit from the health agenda
so we too cannot afford to invest heavily.”
They underscored a split-incentive issue where the private sector invested in the smart
health strategy while the financial benefits such as reduced health care expenditures were
reaped by the municipality. This undermines the incentive for the private sector to invest in
smart health initiatives and raises interesting questions about who benefits from healthy
residents and who should invest and take ownership of a smart health agenda.
In addition, the continuing inability for private firms to freely access individual citizen
health data stored by the municipality (as part of the regular public health system) has
significantly hampered the commercial development of the smart health agenda. Municipal
datasets include individual-level health insurance expenditures, subsidized medicine intake,
frequency of health visits, and key health indicators obtained from health check-ups.
Private-sector led experiments and business plans over the years assumed that this data
would be freely provided for commercial—albeit public health advancing—purposes.
Instead, Kashiwanoha has become a graveyard for short-term experiments failing to
overcome privacy concerns of residents, and also, reluctance of the municipality and
associated medical advising groups to hand over datasets to private firms. This has
hampered the creation of new ICT health services in the smart city since their raw fuel and
commercial success depends on access to data—both that housed by the municipality and
that collected from ICT devices. Data acquisition roadblocks have also severely undermined
the ability of smart city actors to monitor and demonstrate the effect of health advancing
interventions on the population. The Ashita walk-in educational facility is one such
example. Since smart city partners have been unable to verify the impact of this initiative
on users through analysis of municipality health records, its effect on the health of users is
uncertain, and its scientific legitimacy is undermined. There are signs, however, that this
situation is slowly changing. Municipality datasets has been recently provided to one of the
local universities, opening the door for potential future analysis of the health status of
Finally, the smart health initiatives in Kashiwanoha reveal the inevitable difficulties of
engaging a significant number of residents in the city. The point-based incentives program
was conceived as a means of engaging, on the one hand, the laggard population segment
not inclined to exercise, and on the other hand, motivated frontrunners who might increase
efforts in response to certain benefits. This frames residents as lazy homo economicus
where interest in exercise can be unleashed via extrinsic and financial incentives. Interviews
suggested that the developer’s confidence that point-based incentives will continue to play
a key role in engaging the “base of the pyramid” is unwavering. Such expectations mirror
an increasing number of municipal initiatives in Japan that freely distribute pedometers to
residents with linked point-based reward schemes. However, a university researcher
suggested that this might raise social equity concerns since a point-based system rewards
healthy individuals able to participate in the program while neglecting those who are
unwilling or unable to participate. In this situation, “the healthy who can walk get healthier”
while those who cannot “lose out”, they argued. They pointed out that while current
financial incentives in the Sukoyaka Links initiative are funded by the developer, any future
attempt to leverage municipal taxes (like other nationwide initiatives) would be
problematic from an equity perspective, especially considering scientific uncertainty
around the health effects of such schemes. These concerns point to a need for alternative
approaches to engage the wider population in the pursuit of health.
As a step in this direction, the developer and private and academic partners have begun to
embrace the emerging urban planning paradigm of an “active city”, and in particular, a set
of guidelines designed for New York City (City of New York 2010, City of New York 2013).
To increase walkability, notable approaches advocated in the active city paradigm include
mix-used development in close proximity to residences, street greenery and beatification
to boost pleasure derived from walking, traffic calming features, and interconnected
footpaths with points of interest (street furniture, commercial/cultural facilities etc.). A
planning committee comprising the developer, university, municipality, non-profit and
industry actors is currently developing a Kashiwanoha vison for walkability and an
associated set of guidelines. These will steer the remaining street planning in the smart city
until completion in 2030. The emerging challenge for smart city planners concerns the
question of how to link the historically established urban engineering approach that
influences population lifestyles through built environment design with exercise incentives
and behavior signals created from ICT devices.
Kashiwanoha’s experiences suggest that smart strategies have the potential to transform
health and wellbeing from an individual pursuit to a collective and social endeavor. Early
experiments demonstrated that wearable ICT devices can collect individual-level data and
then contribute to community building by allowing participants to compare individual
performance with others. This allows for scrutiny of individual efforts (steps walked,
calories burned etc.) from a community perspective, connecting the individual to a wider
network of fellow residents sharing a common goal of improving health and wellbeing.
Similarly, the digital maternal and child health diary project explicitly seeks to promote
joint learning across couples and families by allowing multiple users to access common
educational materials. It also goes a step further by connecting residents and municipality
health advisors through an app-based email function. User feedback suggests that this
lowers communication barriers between the municipality and residents, promoting a sense
of comfort for young parents in knowing that a nurse is never more than a button click
Complementing the virtual community, the walk-in Ashita centre is an interesting beacon
of community building around shared values of preventative health. It emphasizes health
maintenance in seniors through socializing and offers numerous social gatherings and
group lessons. As explained earlier, the center is run by resident volunteers, creating an
arena of collaborative learning and education among non-experts. The initiative suggests
the possibility of a bottom approach to smart city governance that is driven by citizen
empowerment (Capdevila and Zarlenga 2015, Vanolo 2016, March and Ribera-Fumaz
2016). Equally, by enhancing citizen knowledge around preventative health via informal
education, the Ashita centre has the potential to reorient smartness towards people and “a
knowledge-intensive rather than a technology-intensive vision of cities and their
development” (Söderström 2016: 65). Citizen learning and capacity building in the Ashita
facility contrasts to the passive role of residents in ICT visualization experiments, which was
largely restricted to providing feedback to industry. This strategy of fostering smart and
empowered residents appears particularly novel considering that researchers frequently
criticize the smart city agenda—both inside and outside Japan—for not delivering on
promises to facilitate more participatory governance (Gabrys 2014, Glasmeier and
Christopherson 2015, Hollands 2015, Granier and Kudo 2016).
The contrasting strategies exploited to pursue a smart health agenda merit reflection.
Guided by iterative learning and accumulated experiences, the developer facilitated this
process by archiving experiences and playing a long-term and central role in all projects.
One strategy to realize a smart, healthy city relies on sophisticated technology, intensive
data collection and visual feedback. This involves a commercially risky technology push-
approach from private actors, a focus on smart devices, and an initial targeting of
motivated frontrunners. The approach represents a novel but direct application of the data
visualization and feedback paradigm used to influence demand side energy consumption in
residential buildings ( Gölz and Hahnel 2016, Timm and Deal 2016). This suggests that
resident lifestyles in a smart city can be mined to produce more than conventional
sustainability indicators such as building-level energy consumption. Visualization
experiments also demonstrated the power of this data, with positive health impacts
resulting from participant interactions with devices and feedback technologies. Ambitions
to couple data collected from individual-level ICT devices with municipality housed health
and expenditure records also promises a novel way to monitor resident wellbeing and verify
the impacts of public health interventions.
However, data acquisition challenges provide a sobering reminder to other aspiring smart
cities that data-driven approaches to health management risk bumping against social
norms. These principally concern the individual information that citizens and municipalities
are prepared to share with market actors due to privacy and security concerns. Also,
prompted by harsh business realities in ambitions to commercialize several technologies,
Kashiwanoha actors were prompted to pursue alternative avenues for smart health. These
consist of more people-centered and less data dependent approaches including education,
incentive building for behavioral change, and a strong focus on creating socialization
opportunities. These softer, low-tech approaches offer a notable shift from data-driven,
high-tech narratives about smart cities (Townsend 2014, March and Ribera-Fumaz 2016,
March in press).
Lastly, we highlight findings that several experiments and initiatives in Kashiwanoha were
opened to residents and commuting workers from outside the smart city. For example, the
walk-in center Ashita allows free-of-charge access to preventative health check-ups,
education and socializing events to all citizens—regardless of area of residence. Similarly,
although first trialed exclusively in the smart city, the electronic child health diary initiative
has now been up-scaled to provide free-of-charge access to all interested parents in the
surrounding and larger City of Kashiwa. Additionally, several experiments including the
Sukoyaka Links initiative targeted both local residents and commuting workers. By
addressing a population beyond the exclusive and economically fortunate residents of
Kashiwanoha, these open-door policies provide a direct way to address equity concerns.
Many smart cities risk exasperating social polarization by concentrating benefits (e.g.
healthier cleaner environments, advanced infrastructure and services, economic vitality
etc.) in specific areas while excluding less privileged populations from participation
(Caprotti et al. 2015, Hollands 2015). This points to the argument that even with the
seemingly widespread issue of public health, there is a need to consider who benefits and
who does not benefit from these activities.
This article set out to understand how smart city agendas are being stretched from narrow
aims of environmental protection and economic development to encompass social issues
through the pursuit of greater health and wellbeing. The findings contribute to an
emerging discourse on the possibilities for smart cities to utilize digital technologies and
smart planning strategies to improve the human dimensions of urban life. Active pursuit of
improved public health in Kashiwanoha has become a key part of the city’s identity. It
positions itself as a “campus” for the local universities and boasts its international and
health enhancing profile that is informed by academic knowledge. Our examination of a
combination of data visualization experiments, public education, and differing incentives
for behavioral change illustrate multiple ways that a potentially generic agenda of smart
health was tailored to specific needs and a diversity of residents. These strategies respond
to the urgent need to address the mounting challenge of an ageing population in Japan and
its increasing burdens on public healthcare. This specific and endogenous social problem
heavily defined Kashiwanoha’s smart city agenda focus on preventative health and
longevity, then prompting a search for specific ICT solutions. The case study suggests a
novel approach to smart urban development. Digital technologies are framed not as an end
in themselves, but rather, as tools to tackle social issues and improve citizen livelihoods.
Additionally, by tackling the issue of health and longevity, smart city partners in
Kashiwanoha have developed various strategies to intervene on the lifestyles of residents.
This offers a novel illustration of how the smart city agenda can potentially generate
important opportunities to apply smart technologies to the goal of enhancing the lives and
wellbeing of residents.
The stretched smart city agenda in Kashiwanoha holds significant implications on the roles
and motivations of the various urban stakeholders involved in pursuing greater public
health and wellbeing. The developer’s leadership in the smart health agenda cannot be
explained by altruism or corporate social responsibility. Instead, they recognized that the
smart health objective would create brand differentiation in a competitive real estate
market, and increase the commercial attractiveness of their assets. The municipality too
played a leading role in experimenting with digital technologies and developing new
services for residents. They hold a clear interest in reducing public health care expenditures.
This motivation prompted a shift beyond traditional roles of simply providing basic
infrastructure and services in return for taxes to an active digital educator role to assist
residents in making informed choices about health and wellbeing. Smart health thereby
offers an opportunity for local authorities to reimagine public service delivery while relying
on technical expertise from the private sector. This has the potential to reinforce the local
government’s role and increase their relevance and legitimacy as providers of collective
urban services. This has the potential to mitigate concerns about the neoliberal tenor of
smart urban development and the privatization of collective services (Glasmeier and
Christopherson 2015, March in press). Findings also showed how residents were actively
involved in bottom-up and joint learning initiatives such as the walk-in preventative health
center Ashita and intrinsic/extrinsic rewards programs. The experiences in Kashiwanoha
suggest a more fluid understanding of local governance as an endeavor shared by multiple
stakeholders with contrasting yet compatible motives.
As we have shown, the smart health agenda in Kashiwanoha complements and extends
existing aims to advance environmental protection and business development. It
demonstrates how smartness can serve as a thread binding the three sides of the
sustainability triangle (i.e. environment, economy and society). It also provides convincing
evidence that the notion of a smart city harbors potential to be stretched to encompass
wider social considerations such as “the intangible entity of a citizen’s wellbeing”
(Glasmeier and Nebiolo 2016:9). Moreover, findings hint at the wider opportunity for the
smart urban development agenda to address an even wider diversity of social issues such as
crime, poverty, education, and social cohesion(Glasmeier and Christopherson 2015,
Goodspeed 2015, Bibri and Krogstie 2017). Finally, although the empirical evidence from
this case study is far from definitive, it also points to the importance of customizing
universal smart city principles, technologies and development strategies to address specific
local circumstances and needs.
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