Should cities be built with pandemics in mind?

If COVID-19 is here to stay, one of the first things policymakers should look to improve is how cities can be designed to limit the spread of the virus, Paul Barnes writes.

To many the name Jon Snow might be instantly recognisable as the ‘King of the North’ in the much lauded Games of Thrones series, but to environmental and public health specialists, Dr John Snow, a physician of London in the 1850s, is better known as one the forerunners of modern-day epidemiology.

In 1854, London was beset by an outbreak of cholera. Using the location of households with the disease, Dr Snow established that a common factor was access to water from a communal pump.

Then, he convinced town officials to remove the handle of the communal water pump on the street, making it impossible to draw water from that location. This led to the incidence of cholera trickling to a stop and the return of residents who had left their homes and businesses in the area out of fear of the illness.

At the time, this discovery was a significant step in the evolution of environmental and public health. It was reported, however that, officials at that time expressed a degree of reluctance to agree to Snow’s recommendation: a dynamic currently playing out in pandemic responses in some parts of the world.

Importantly, the growth of cities has arguably been paralleled by the growth of public health as a professional speciality, and now, just as it was in 19th century London, a key factor for the spread of disease is humans living in close proximity.

Physical distancing, staying at home, good hand hygiene, and mask policies are all aimed at breaking the chain of direct or indirect viral transmission between people, and are analogous to removing the handle of the COVID-19 pump.

As this example reveals, population density and communal spaces are a key challenge when it comes to safeguarding populations against disease. Effectiveness in working toward this goal is then much harder in urban spaces is than it is in more dispersed areas, and this has been demonstrated both nationally and globally from early in 2020 with the COVID-19 pandemic.

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History is of course replete with pandemics, many of which have impacted the course of geopolitics and human endeavour, and restricting movement across borders or throughout regions as a means to limit the spread of disease is not a new practice.

Similarly, limiting the movement of people within cities impacted by contagious disease is well documented.

Health authorities in seventeenth-century Florence, for example, were aided in their response to the plague epidemic by forming police-like groups tasked with limiting public contact and movement into and within the city.

Generally, the likelihood and criticality of disease in human populations is impacted by a convergence of several factors. First, genetic and biological factors, second, physical environmental factors influenced by climate variables, third, ecological factors, and finally, social, political, technical and economic factors.

In cities and urban settings, these factors are all important, but most dominant are issues of overcrowding and very high frequencies of human interaction.

On top of this, the effects of climate change are also likely to profoundly affect the causality of infectious disease and are especially prevalent in many of the world’s cities.

Given these challenges, innovation in city living and planning will be needed, especially given that Britain’s Chief Scientific Adviser has warned that COVID-19 is likely to become endemic – like influenza – even with availability of vaccines in the near-future.

Speaking to a House of Commons National Security Strategy Committee in London, Chief Scientific Adviser to the United Kingdom Sir Patrick Vallance said the rollout of successfully trialled vaccines would occur hopefully after the start of the northern hemisphere spring but cautioned that these vaccines were unlikely to totally eradicate the virus across populations. This cautious view is shared by other experts too.

If COVID-19 becomes endemic, environmental and public health practices will remain critical for years to come, and adequate healthcare system capacity will need to be maintained at local, regional, and particularly city levels in the long-term.

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Thankfully, important steps to guide thinking in this direction have been taken. Of particular note is UN-Habitat, which is actively bringing together the efforts of urban leaders and both health and planning professionals. These efforts have become even more important given the emergence of COVID-19 pandemic.

The disruptive effect of COVID-19 in cities is obvious to city officials worldwide, who have been rethinking strategies to sustain liveability and restart their economies, but what kind of specific steps can be taken at the city level?

Well, architectural design for physical security and safety is well established in modern built environments, and merging the aesthetic with the practical will become a critical way cities deal with future health risks.

As might be imagined, city-focused efforts among health and design professionals have been promoted considerably over the past year, both internationally and in Australia.

On a positive note, while cities have been impacted by significant financial shortfalls, intense pressure on health services, and forecasts of people leaving them in increasing large numbers, they remain ‘engines of creativity and resourcefulness’, and have many strengths that they can draw on.

While noting recent efforts from the United Nations and other institutional networks to enhance the resilience of cities – including improving the ability of local authorities to build and manage resilient infrastructure – policymakers need to remember that such endeavours are not entirely new and build on the achievements of the past.

The 1987 Report of the World Commission on Environment and Development: Our Common Future along with the detail laid out in the Ottawa Charter for health promotion, advocated boosting a range of social determinants that underpin health.

A major intent of this work was enhancing equitable access to health services and promoting collaborative outcomes fitting the needs of all segments of society. This work collectively provided the mandate for the widely implemented Healthy Cities Program, a framework city planners could still find useful in tackling the challenges to come.

A key difference between those halcyon days is 33 years of high-density urban growth, an increasing globalised and just in time ‘linked’ economy, net increases in warming, climate and weather effects and, of course, a global pandemic.

What may be under emphasised though, is synergy between resilient design, environmental health intervention, and public health activities. Given the combined effects of a warming climate driving regional and national fluctuation in weather patterns, existing seasonal disease prevalence, and the potential for COVID-19 becoming endemic, planners need to enhance innovation by bringing urban design professionals together with practitioners of environmental and public health.

Ultimately, the only way to keep cities healthy into the future is to invest in thought, innovation, and collaboration, and to do it now. Strike while the iron is hot!