One hundred and fifty years ago, using a map of London and data of the water supply system, physician John Snow identified the source of a cholera outbreak in London. His analysis proved that the neighborhoods supplied by a specific water pump were more affected by the disease than others. By closing the pump, they managed to control the epidemic.
This incident is more than a historical anecdote; it was an inflection point in urban design for two reasons. First, it showed the importance of a multidisciplinary approach to city planning—how citizens would benefit from the collaboration of different domains of expertise. Second, it proved the connection between design and health and the importance of incorporating health considerations in city planning and urban design.
Accordingly, in the decades that followed, public health experts joined urban planners and architects. Thanks to advances in science, new technologies, and flourishing economies, living conditions in cities improved, and standards and regulations to guarantee the health and safety of city inhabitants were defined and implemented. Success bred complacency, however, and the relationship between these disciplines frayed: urban design and public health parted ways again. This was the genesis of the challenging situation in which we found ourselves today—dealing with an as yet uncontrollable pandemic.
Let’s review how a viral epidemic works: in general, the onset of many epidemics like COVID-19 happens when an animal reservoir infects a human with an unknown virus. Depending on the capacity for this virus to spread, its severity, and the context, the infection can evolve from a few cases into an epidemic and then into a pandemic in a matter of weeks—before the health authorities even agree on the definition of the scenario. With COVID-19, we had a high-density populated area, easy and fast transportation links to the rest of the world, and a highly contagious virus. And since this virus doesn't kill its reservoir quickly—and it can be transmitted before any signs of infection are shown—it has time to spread to other people.
So what do designers have to do with the spread of an epidemic? The disconnection between public health and urban design happened during an unprecedented level of urban growth in the mid-20th century. Growth is not a problem per se unless countries are unprepared to handle it. In many regions of the world, the rural-city displacement outpaced the capacity for governments and planners to provide an adequate response to people's needs. This led to the proliferation of informal urban settlements. Today, more than one billion people live in unplanned and unregulated areas in cities, a staggering figure that is expected to double by 2030.
These settlements, usually found in low- and middle-income countries, share a common trait; they lack the minimum levels of infrastructure to provide a safe environment in which to live and thrive. They also lack the necessary sanitation, so water contaminated with fecal matter and dirt runs between poorly built houses. Their markets are, in many cases, sheltered under semi-temporary structures, without any sanitary regulation in place, and it is not rare to see wild animals, dead and alive, sharing space with food. These environments are the perfect breeding ground for new infections and epidemics to develop.
Over the last few decades, we've gone through numerous outbreaks of infectious diseases. And the more the world develops, the closer the outbreaks are to each other. Since the 1970s, there have been multiple lethal Ebola episodes in small villages in the middle of the African forest, where they wipe a percentage of the population and disappear. What has changed now? Our societies, hungry for land and resources, are getting too close to potential viral reservoirs by irrupting into wild animals’ habitats. And we do it without taking any precautions. On the contrary, we're cramming people into unhealthy environments while improved transportation means that viruses can spread easily. We have created the perfect epidemic storm.
There's a lot designers can do not only to mitigate the impact of an epidemic but also to prevent the spread of the next viral disease. Here are some of the areas where we should invest money and resources:
We must invest in developing healthy marketplaces. By controlling the environments in which wild animals are sold, we can stop the disease at the onset. This is exceptionally complex due to the importance that food markets have in different cultures. So we must develop interventions that, without being disruptive, limit potential animal-to-animal, and animal-to-human transmission.
The COVID-19 epidemic began in a modern city in China, but the next one could start in a slum in Bangladesh or in a megacity like Nairobi, with very limited resources to tackle the spread of the disease. In 10 years, an estimated 20 percent of the world's population will live in urban environments with a limited access to appropriate water, health, and sanitation infrastructures. Designers need to step up and find solutions to improve conditions in cities with low resources. It's easy to build a fancy new green space in a modern city. The real challenge is to reduce the infant mortality rate due to inadequate living conditions in a sub-Saharan African slum. That same slum could also be the epicenter of the next pandemic.
During the 2014 Ebola outbreak in West Africa, the Chinese government built health facilities at an incredibly fast pace (something repeated in Wuhan during the current epidemic). Doctors Without Borders can deploy an inflatable working hospital with ICU capacities in a matter of hours, as they did after Haiti's 2010 earthquake. In fact, humanitarian organizations have responded to epidemics for decades. However, these solutions are adapted for specific contexts, mainly low-income countries with limited resources after catastrophic circumstances. Since epidemics can happen anywhere now, the next big challenge is to provide an adequate healthcare infrastructure once the hospitals are overloaded in a city like New York. To do so, designers need to work with health practitioners and authorities to prepare contingency plans that are ready in advance for every major city in the world. During outbreaks, there's little time to think and no time to discuss. Instead, we need to act. Fast.
These are just a few practical examples of how critical the contribution of urban planners, architects, and designers can be when dealing with epidemics. Nothing here is groundbreaking, but for one reason or another, investing in epidemics or underserved communities hasn't been on the agendas of governments or urban developers. Unfortunately for all of us, epidemics are here to stay. In addition to viral epidemics, like the COVID-19, we must address the noncommunicable disease epidemics—such as cardiovascular disease, cancer or diabetes—that are responsible for more than 70 percent of deaths worldwide. Designers play an essential role in the prevention, control, and response of many of these diseases, so getting involved is not a matter of a choice anymore, but a duty.
Dr. Elvis Garcia is an expert in epidemics and a lecturer at the Harvard Graduate School of Design. His 2020 course Public Health in an Era of Epidemics: From the Camp to the Building draws on ten years of experience in the field with Doctors Without Borders responding to epidemics like Ebola in Liberia and cholera in Haiti.