Keywords

The Healthy Cities and Communities initiative is an exercise in what some call ‘futuring’. From the start, the concept of a healthy city brings with it a key question: what is a healthy city? Answering that is an exercise in futures thinking, and more explicitly in visioning, because there is no such thing as a fully healthy city—nor is there ever likely to be. It will always be a vision of what might and should be, an aspiration to which we strive rather than a ‘most likely’ extension of the present.

These few short sentences touch on many of the key aspects of futures thinking. This chapter will cover them in more detail, beginning with an overview of futures thinking and followed by a discussion of health futurism based on the work we have done together in this field over more than 30 years, before we move to focus more specifically on futures thinking in the context of Healthy Cities .

FormalPara How far away is the future?

The belief that the future will be shaped by human decisions and actions is a characteristic that most futurists share. They recognize that while the immediate future (the next 5 years) will be shaped largely by decisions previously taken (while recognizing that ‘discontinuities’ such as the 1973 oil shock or the 1989 fall of the Berlin Wall can dramatically alter the future very swiftly), the medium-term (5–20 years) and long-term (20–50 years) future will be substantially shaped by the decisions we make today.

Beyond 50 years, the future is so far removed as to make thinking about it extremely difficult. For example, how much of what we accept as commonplace today could have been anticipated in 1965? And how little of what was commonplace in 1965 would have been anticipated in 1915?—most of the mechanical and electrical equipment of the 20th century? This does not make thinking 50 years ahead irrelevant, but it frees us to make use of science fiction literature, which can be very helpful in thinking about dramatic changes which may surprise us in the coming decades.

Thinking About the Future

The comment that opens this chapter by James Robertson, a leading British expert on alternative futures, contains the essence of futurism. Good futures work is to some extent concerned with attempting to forecast the future, but more importantly it is concerned with thinking about the future and in helping people who are not futurists to think and act more wisely about our tomorrows. As Edward Cornish, founder of the World Future Society, puts it, ‘futurists take historical fact and scientific knowledge and add human values and imagination to create images of what may happen in the future’ (Cornish 1977).

James Robertson is also making another important point: thinking about the future is relevant to the decisions we make today. Futurists don’t actually study the future, since it does not yet exist. Rather, they study ideas about the future, most often in the belief that the future is ‘plastic’ and can be shaped. Futures thinking is a tool for wise action that stimulates the imagination, encourages creativity, identifies threats and opportunities, and allows us to relate possible future choices and consequences to our values. While some experts argue that futures research should simply be able to develop accurate predictions—a dubious proposition in the first place—and that it is not the role of futurists to be normative and to work in the area of vision, good futures work includes both futures research and vision. These in turn contribute to strategic management by aiding in anticipation, setting direction and securing commitment.

Four Sorts of Future

We tend to talk about ‘the future’ as if there was just one, yet we know that there are many possible futures facing us, and that to some extent we create them—which is not to say that a large asteroid or a massive volcanic eruption or a war might not change everything. One way of categorizing the futures that we face has been proposed by Henchey (1978), a Canadian futurist. He suggests that we think about the future in four ways, presented in Fig. 19.1:

Fig. 19.1
figure 1

The futures cone . Source: C. Bezold and T. Hancock, An Overview of the Health Futures Field for the WHO consultation, July 19–23, 1993

Full size image

  • Possible, i.e. what may happen.

  • Plausible, i.e. what could happen.

  • Probable, i.e. what will likely happen.

  • Preferable, i.e. what we want to have happen.

There are two ‘zones’ in this model: the outer zone of possibilities, which is very large, and the narrower zone of plausible futures. Within this narrower inner zone there can be a number of scenarios; the probable future is one of these, but others can be described. The preferable future is often different from the probable future and is usually—but not necessarily—within the plausible zone. The futures cone makes clear that all futures start from where we are today, then diverge. The closer they are to today, the harder it is to tell them apart, but over time it becomes more clear that choices made now can have dramatic effects later.

Possible futures are all the things we can possibly imagine, no matter how unlikely. They may include ‘science fiction’ futures that transgress presently accepted laws of science (for example, we may learn how spiritual healing works and will be able to treat people by using the energy aura of the healer). Also included here are ‘wildcard’ futures; these are typically low-probability but high-impact events. Having a sense of what type of wildcards might arise is useful, although most planning efforts are barely able to deal effectively with the zone defined by the more plausible futures. Yet the fall of the Berlin Wall and the transformation of the Soviet Union remind us that dramatic, seemingly implausible change can occur very swiftly, while awareness of the possibility of a large meteor strike or a massive global mega-volcano eruption may give us pause for thought—if only to recognize how small and frail we humans and our civilizations might be. We need to be flexible enough to deal with surprises when they occur.

Plausible futures represent a narrower scope because they are those futures that seem to make sense, given what we know today. Plausible futures can be discrete forecasts of individual trends or a set of scenarios which combine differing trends and together describe a range of alternative futures. For example, common plausible futures include high technological growth; a ‘green’ or sustainable society; environmental, economic and social decline; a more controlled society; and a ‘high spirit’ or transformational scenario. For each of these we can describe a quite detailed societal scenario, including a description of, for example, a city, or health status, or health care system consistent with it. (The health care system, for example, will reflect the society of which it is a part, not the other way around, which is why we need to begin with the societal scenario.)

The probable future is the future we think is most likely to happen, based on the examination of our present situation and the appraisal of likely trends and future developments; it is a subset of the plausible future and is sometimes referred to as ‘business as usual’. This consideration of likely or plausible futures is often called descriptive forecasting. Most people see the future as an extension of the present with little significant change; likewise much government and business planning assumes that the probable future will be a straightforward extrapolation of the present. Ironically, history has shown that ‘the most likely future’ turns out to be the most likely not to occur: as Jim Dator, one of the world’s leading futurists, likes to say, ‘the probable future is unlikely’. Descriptive forecasts which are based solely on recent trends can preclude futures that are different; they also often turn out to be the future we don’t want! As Dator has also remarked, ‘trends can take you with unerring accuracy to where you don’t want to be’.

The preferable future is the one future we would like to have happen, and is sometimes called prescriptive futurism , or normative forecasting; this is where vision becomes important because, ‘vision is values projected into the future’ (Bezold). Visions, or preferable futures, generally begin by identifying and trying to create a future that does not yet exist. Vision moves reality beyond the present toward the best that can be; it should include visionary scenarios that move well beyond present realities. Creating a shared vision of a preferred future health care system or of a healthy community can be a powerful technique for mobilizing an organization or community around a common purpose (for more on vision, see Hancock 1993; Bezold 2009).

In our work, we usually use a combination of alternative future scenarios and visioning (or other ways of defining a preferable future). We may ask people to rate the probability and desirability of various alternatives and, in the case of a preferred future, its feasibility.

The value of the alternative futures approach is that it enables us to compare a range of quite plausible options and to choose among them. In making our choice we also make explicit the values that we hold, individually and collectively. There are other benefits of alternative scenarios. They can make us examine futures we don’t want, which may lead us to seek ways to prevent them from happening, or at least to prepare for them. They can help us compare the future we think we will get with the future we would like to get, and if they are not the same, to think about how we can change our path to move closer to a desired future. And they can be a way of engaging people in a rich discussion about their future and what they intend to do about it.

The Future We Don’t Want

None of us like to contemplate an unpleasant future, but just because it is undesirable does not mean it is implausible. So one or more of the scenarios—which, we need to recall, are based on existing driving forces—should be a plausible alternative future that involves ecological, economic or social decline or collapse—or all three. These are not scenarios that we like to explore, any more than we like to explore what it would mean to have cancer; but, as with cancer, ignoring it does not make it go away.

Indeed, a failure to consider negative scenarios may actually make them more likely, because if we don’t take them seriously we will not plan to avoid them or figure out how to cope with them. As will be discussed later, there are some very plausible ‘bad news’ scenarios for some, perhaps many cities; we had better learn to think about these alternative futures and either figure out how to avoid them or plan how to manage them.

Probable vs. Preferable Futures

There is often a marked difference between the future we think is likely to happen and the one we would prefer to have happen. It is important to stress the value of examining both the probable and the preferable futures, a process which can be very liberating. Too often our image of the future is the image of what we think will most likely happen; if we don’t like the way we think things are going, this may bring with it an awful sense that the light at the end of the tunnel is a train coming toward us! The probable future is something that seems to happen to us, something over which we have little or no control, and sometimes—perhaps often—something we don’t like very much.

But the process of contemplating a future we find likely but undesirable, rather than a future we consider desirable but less likely, can be a great motivator for action; if we don’t want the future we seem headed for, what can we do (together) to change the path we are collectively on?

The Preferable: An Empowering Future

If futures thinking focuses too much upon the probable, which it has a tendency to do (after all, planners—be they politicians, civil servants or private sector—like to know what to plan for, as do ordinary people) then it runs the risk, perhaps inadvertently, of disempowering people and denying them choice. If we are told ‘this is the probable future’, then the only choices left for us to deal with are how to prepare for it and if need be, how to brace for it. Such a passive way of thinking about the future inevitably results in apathy, in a feeling of impotence and lack of control.

The preferable future, on the other hand, is a liberating and empowering future, especially when it touches our more creative capacities. It not only enables but encourages us to say ‘this is the future that we value and that we want to create’ (the emphasis being on we; this should be a collective process). The energy and creativity released in a ‘preferable futures’ process can be quite astonishing (see the case study of Woolwich Healthy Community in Chap. 10; and earlier cases in Alternatives for Washington (Stilger 1978)).

Creating the Future We Prefer… Together

Clearly, if futures work is to help in creating a future that we find desirable, it must make policymakers and individuals better able to create the future they want. This brings us to two important and related points about futures thinking that were identified by Roy Amara, founder of the Institute for the Future, in a series of articles in The Futurist in 1981. The first point is that the futures field is concerned with creating new images of what is possible; the second, that good futures work increases people’s participation in thinking about and creating their preferable future.

Futurists by and large take a proactive stance. If they are not actively involved in seeking to create change themselves, they are certainly aware that their presentations and ‘predictions’ will form the basis for others to seek to create change.

At its best, futurism is—to use a phrase coined by Alvin Toffler, author of Future Shock and The Third Wave—a form of ‘anticipatory democracy ’, helping people to decide what sort of future they want and how they might achieve it. It is the very essence of democracy. Futures techniques that involve the use of complex and sophisticated technical models, professional expertise and language, and that limit their process to a small inner circle are anti-democratic. We must have techniques of anticipatory democracy (the basis for the establishment of the Institute for Alternative Futures) and they must become the standard form of futures work. We need techniques that work at the community level and with ‘ordinary’ people. Vision workshops and other approaches can meet these needs, as well as goals programmes and other efforts, and these have been present in a variety of settings (see ‘Anticipatory Democracy Updated’ (Bezold 2006).

Futures Methodologies

Just as there is a range of alternative futures, there is a range of methodologies for exploring the future. Some are more suited for exploring one sort of alternative than another, although most can be adapted to explore different sorts of future. For example, although vision workshops are particularly well suited to exploring a preferable future, there is no reason why they cannot be used to explore a probable future; similarly, the Delphi method (an iterative polling technique, usually done with experts) can be used to explore a range of futures, given the right questions.

The point is that the range of futures methodologies each has strengths and weaknesses:

  • Forces and trends: By identifying the major forces in the social, political, economic, environmental, technological, ethical and other sectors that will likely affect our city, organization or group, and by ‘scanning’ the scientific and public media, we can often identify emerging trends of importance. John Naisbitt popularized this approach in his 1984 book Megatrends.

  • Models: Sophisticated computer models can be used to explore various options and to develop ‘what if’ scenarios. Most commonly used in the economics field, they are also used to predict the impact of global warming, as ‘global models’ to examine the combined effect of environmental, social and economic change, and in many other situations.

  • Delphi methods : Various versions of this technique (which consults a number of people without convening them, thus protecting against the influence of powerful personalities) can be used to assess the feasibility or probability of certain events. For example, a panel of scientific experts might be asked to assess the likelihood of a particular set of medical advances being in place by 2030.

  • Cross impact matrices and ‘futures wheels’: These and related methods are used to understand the interaction of key forces and trends, and to explore possible unanticipated and unintended consequences. For example, an unintended consequence of a society strongly focused on wellness might be to victimize and discriminate against the unwell. Sometimes sets of forces are mutually reinforcing, and at other times they may cancel each other out. Trying to understand this helps in the construction of scenarios and the anticipation of the impact of various forces.

  • Scenarios: These are coherent ‘stories’ incorporating a large number of trends and forces, or plausible events , in a way that shows their interaction and their implications IAF recommends that they consider expectable or most likely futures, a challenging scenario that explores ‘what could go wrong’, and visionary or surprisingly successful paths to the future (see Bezold 2009). Often presented as narratives, scenarios may take the form of a ‘report’ from the future and should include tables that compare forecasts for key elements in each of the scenarios.

  • Visioning: This process creates a preferred future by projecting values and aspirations into the future and then seeking to describe that future succinctly, in a powerful phrase or sentence, and sometimes as a scenario as well. One technique of visioning is guided imagery (inviting participants to imagine their preferred future), which can evoke powerful images of the future. Visions are inspiring: they are for the heart (scenarios are for the head) and help us to be the best we can be.

The method—or better, if time and resources permit, the combination of methods—that we choose depends on what we are trying to do. In the context of a city, especially a large city, much of the technical work of scanning forces and trends, and perhaps even producing models, may be somewhat routine. Such cities may have several universities they can look to for expertise and advice, but be less able to engage citizens at the neighbourhood level in participatory processes and visioning. Small communities may lack the technical expertise and resources to undertake the technically intense work that large cities can handle, but may be effective in bringing local people together on a volunteer basis for a scanning exercise, a futures wheel and a vision workshop; they may also find participatory processes easier to establish and maintain.

Thinking About the Future of Health

Before discussing futuring for healthy cities, we recall a distinction we have already touched on: futurist thinking about a healthy city is part of what we call ‘health futurism ’. It is important to make a distinction between health futurism as we mean it here and what is often called health futurism but is in reality ‘medical care futurism ’. We need to distinguish between health and medical care, because otherwise we run the risk of falling into the trap of believing that medical care equates with health. The importance of health futurism is that it requires us to look beyond our mistaken preoccupation with medical care and to examine the real determinants of future health status.

Health futurism is concerned with the future state of health of a population—either a local population or the global population—and all the environmental, social, economic, political, cultural, biological and technological factors that will affect its health now and in the future. Inherent in those social, economic, political, cultural and technological factors is the way any given society or community chooses to organize the provision of medical care; but medical care is only one determinant of health, and not necessarily a very important one. It has been estimated that medical care explains only 10–20 % of health over the life-course (McGovern et al. 2014), meaning that 80–90 % is determined by other factors. Health futurism asks questions such as: Will we be more or less healthy in the future? What will be the major influences upon health in the future? What values will we attach to health and what role will health play in our decision-making in the future? What will be the future relationship between health and medical care?

A great deal of health futurism is thus concerned with societal futures in general, and particularly those aspects that will affect health and well-being. This includes such issues as wealth and poverty, future living and working conditions, the sustainability of the environment, the future state of social networks and social support, the extent of participation and empowerment and other issues that affect personal and collective health and well-being. Health futurism also considers the subject of healthy public policy, in other words, what future policies might be developed if achieving health and well-being were a prime determinant of public policy.

The value of health futures in the futures field more generally is that it serves to focus our attention on human and ecological ends, rather than on the economic and technological means that dominate so much of the work of corporate and governmental futurists and that is reflected in the field of medical care futurism . Thinking about the future in this way should lead us to examine more closely what we do and how we live today, and to ask what it takes to create a healthier future for all.

Healthy Cities and Futures Thinking

For an application of these concepts to the Healthy Cities and Communities movement itself, see Bezold and Hancock 2014.

So what does all this have to do with Healthy Cities? As noted at the outset, Healthy Cities is inherently an exercise in health futures thinking at the local level. It tends to be an exercise in what one might call optimistic futuring or aspirational futures. It envisions a preferred future for the city and then figures out how to achieve it. But what sometimes gets overlooked or ignored, as noted earlier, is the dark side of the future. While we all want a healthier future, there are many societal forces, not to mention environmental changes, that might push us in the opposite direction, so it is important to spend time examining the driving forces and the less attractive alternative futures that might result, rather than being focused only on the future we prefer.

Unhealthy Cities in the Future and in the Past

There are reasons to believe that cities in the future—or at least, many cities in many places—may be very unhealthy. For example, there are high levels of social inequity in many parts of the world, and in many cases it is growing. It results in significant inequalities in health, as documented in the report of the WHO Commission on the Social Determinants of Health (2008) and the WHO/UN Habitat report Hidden Cities (WHO/UN Habitat 2010). In addition, the ecological changes resulting from human-induced climate change—which are accelerating—hold many threats. For cities on coasts, sea-level rise and more frequent storms will be a growing problem, while others, especially in tropical and equatorial areas, will face more prolonged and severe ‘urban heat events’. All cities are likely to face more severe weather events; many will face shortages of water and of food caused by changes in both agro-ecosystems and ocean systems, and some will face growing numbers of eco-refugees (Intergovernmental Panel on Climate Change 2014, Chap. 8).

These and other problems arising from ecosystem change will add to and compound social inequity. In general, the poor live downhill, downwind and downstream, in low-lying land, in the most polluted parts of a city with the fewest public services and amenities. They are far more vulnerable to the impacts of climate change, and will have access to far fewer resources to help them cope. As resources such as food and water become more scarce, they will be unable to afford them. This combination of environmental and social inequity, together with climate change (and more broadly, global ecological change), poses a significant threat to the health of cities and their citizens in the twenty-first century (Friel et al. 2011; Hancock et al. 2015).

All of this is not inevitable, but it is plausible, and may have quite a high probability of occurring, especially in the often more vulnerable cities of the Global South that may have fewer resources and less capacity to respond. While decline and collapse is certainly not a desired future, it is a future that cities need to consider, to plan to avoid if they can, and to manage if they happen. In fact, thinking about how to manage decline—what might be thought of as a long, slow disaster—is something that we need to do in a systematic way, not only in our cities but as a society (Hancock 2015).

One place we can turn to when faced with such daunting challenges is history. It is a truism that good futurists need to be good historians: as George Santayana remarked, ‘those who cannot remember the past are condemned to repeat it’. In thinking about the unhealthy future for cities described above, we can be helped by considering the state of cities in industrializing countries in the nineteenth century. To read descriptions of, say, Manchester in the 1850s (e.g. Girouard 1985, Chap. 12) is to realize that the situation cities faced then is very much like the situation that many cities in the Global South face today. They had appalling environmental conditions, with little or no sewage management, and less treatment; dirty and dangerous water supplies; atrocious housing and working conditions, dreadful air quality, and many other environmental and social ills. The average age at death among the labouring classes in some of the industrial cities in England in 1842 was as low as 15 (Liverpool), 16 (Bethnal Green in London) or 17 (Manchester), according to Chadwick, while for the ‘gentry’ in those communities it was 35, 45 and 35 years, respectively (Rule 1986, p. 89). Today, while far from perfect, these cities are vastly improved, and those improvements largely came in a period of 50–70 years—two generations or so. They happened for a variety of reasons: the threat of revolution, the pressure for democratic and social reform, the enlightened self-interest of the wealthy, the championing of good governance, charitable good works and other factors. While those may not be the same forces that operate today, and while the twenty-first century is not the nineteenth century, there are lessons to be learned and hope to be gained from knowing our history.

Towards a Healthier City

Beyond just dealing with crises, there is a need for cities and their citizens to dream about and plan for and work to create the healthier, more just, more sustainable future they desire. It is no coincidence that a key recommendation of the WHO Commission on the Social Determinants of Health (2008) was to ‘place health and health equity at the heart of urban governance and planning ’, noting that ‘within cities, new models of governance are required to plan cities that are designed in such a way that the physical, social, and natural environments prevent and ameliorate the new urban health risks, ensuring the equitable inclusion of all city dwellers in the processes by which urban policies are formed’ (p. 6).

The need for what has come to be called ‘healthy urban governance ’ is growing (Barten et al. 2011; Kickbusch and Gleicher 2012). The crucial point here is that this is—or needs to be—an exercise in anticipatory democracy . One of the key characteristics of a healthy city or community is that people are involved and engaged, that they participate. But what does this mean in the twenty-first century, with the widespread and swiftly growing use of social media and other forms of internet connectivity? What does a participatory and anticipatory democratic process mean, what does it look like and how can it work—and how does it work in very different settings, from megacities to small municipalities, from large cities in the Global North that are richly endowed with resources to small villages in the Global South?

Clearly, when faced with such diversity, there are no ‘one size fits all’ approaches that can work; but we hope we have shed some light on the potential use of a variety of futures methodologies to explore together the futures we might inhabit, to prepare us for and to help us avoid the ‘bad news’, and to have the conversations that will help us to find our way forward, together, to the healthier future for our cities and our citizens that we all desire.

The path from here to there is not clear, easy or straightforward. Futures thinking is not about predicting the future, mapping out that future and then developing and implementing a clear plan to get us there. Rather, on our journey we will make false starts, we will make mistakes, we will sometimes lose ground, we might even fail. We will battle opposition and be buffeted by the changing circumstances of our world, our society and our city. But that is the nature of change: it is like a sailing trip.

One lesson we have learned above all others from our work in the futures field over the past 30 or 40 years is that getting from here to there requires the engagement of as many as possible in the development of a clear understanding and expression of our shared values, the expression of those values in a shared vision and a detailed description of a preferred future scenario, and the engagement of people in the process of ‘muddling through’ or ‘sailing’ towards that preferred future. This is the challenge facing the world’s cities. How well we do that will determine the fate of our cities, our civilization and our citizens, as well as the fate of many other species with whom we share this planet.

Sailing to Success

Nautical Tips for Navigating the Seas and Shoals of the Healthy Community Process

Dr Trevor Hancock, © 2001

I am a great believer in the ‘vision-directed muddling through’ approach to planning and action. Whether we are trying to create change in a community, a work place or any other setting, we need to have a very clear—and shared—vision of where we want to be and what it would look like if we achieve what we hope to achieve. But the process of getting from here to there is never a simple one, never amenable to simplistic and fixed plans. It is a process of muddling through, taking advantage of every opportunity that gets us a step closer to our goal.

As a student of sailing, I have found it useful to think of this process as analogous to sailing against the wind and through the reefs from one harbour to the next. Unlike the captains of power boats, who can just open up the throttle and go in a straight line from one harbour to the next (and who can end up in deep trouble if there is a mechanical failure or if they run out of fuel), change agents, like sailors, have to take sensible precautions and follow simple rules. For those of a nautical bent, such as myself, the following hints may be helpful.

  • When sailing against the wind, it is necessary to tack back and forth: sometimes you can sail a long way and yet make little progress towards your goal.

  • Sailors must be alert to shifts in the (political) winds: if the wind shifts (an election), you may have to change your course completely.

  • Sometimes, the only way to get around a reef is to sail back the way you came—which is usually when they evaluate you!

  • The ‘crew’ are involved in deciding what the destination will be; be prepared for the destination to change halfway there.

  • If the wind gets too strong, you may have to run for a safe harbour and wait for the storm to die down.

  • If the wind drops and you are becalmed, you just have to sit there and wait for the wind to pick up again. Be prepared for the journey to take a lot longer than you thought it would!

  • If things get really nasty, the boat may start to sink. Make sure you have a life raft and some emergency rations!

  • You need an experienced captain and crew, a team that works well together even in the roughest of storms.

  • The skipper has to be respectful of the crew, or risk a mutiny.

Finally, but perhaps most importantly, navigation hinges on two things: knowing exactly where you are and knowing where you want to be. This is equally true of the community development process. We need to know exactly where we are in terms of our community’s environmental, social, political, economic, health and cultural conditions, and we need to know both the good news and the bad news. We also need at least a pretty good picture of where we want to be, even if we don’t have the precise coordinates and the destination may change. And remember, much of the point of sailing is to enjoy the trip, getting to your destination is an added bonus!

Good luck and happy sailing!

A video of TH telling this story is available at https://www.youtube.com/watch?v=GPfVygl8IN0