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A radical transformation in building and designing for health is underway—but not everyone will benefit equally

Sunbathers at a

Children sunbathing circa 1928 at an open-air "preventorium," a school for "pre-tubucular" boys that opened in 1922 in California. From the book Sun Seekers: The Cure of California (2019, Atelier Éditions)

Hospitals have not always been sites for curing. In a 1974 lecture entitled “The Incorporation of the Hospital into Modern Technology,” Michel Foucault outlined to a Rio de Janeiro audience that, prior to the late 18th century, spiritual healing and salvation was the most the ill could reasonably hope for in these dark, depressive quarantine centers. The eventual creation of hospital medicine and practices as we know them today were not a foregone conclusion either, he argues, but the result of a fusion of medical advancements and “the introduction of discipline into the hospital space.”

Foucault defines discipline here as “above all, [an] analysis of space…individualization through space, the placing of bodies in an individualized space that permits classification and combinations.” Moreover, it is “a technique of power which contains a constant and perpetual surveillance of individuals,” which, for example, manifests in the well-defined separation of beds in hospital wards that mirrors the ordered placement of desks in schools as well as cells in prisons. That this spatial organization was seen as particularly applicable and valuable in a hospital setting was due to epidemiological advances in botany that led to understanding “illness [as] a natural phenomenon” connected to the environment around an organism. The human body could not be considered a closed system, therefore treatment would need to extend to an individual’s surroundings. “The cure,” Foucault explains, “is no longer directed toward the disease itself, as in the medicine of crises, but precisely to the intersection of the disease and the organism, as it is in the surrounding environment: air, water, temperature, the regimen, food, etc.”

Today's focus on invisible solutions with inherent surveillance qualities–smart design, digital-based health advancements, and urban analytics touted by governments, the mainstream media, and designers alike—may limit the healthier, more visible changes that should be made to improve the qualities of both our interior and exterior environments, particularly those occupied by the most marginalized and oppressed communities.

Whether the COVID-19 pandemic will instigate as radical a transformation in building and designing for health as Foucault identified in the evolution of the modern hospital is unknowable. But his analysis of the synthesis between power and holistic medical treatment is worth revisiting at this moment. Today’s focus on invisible solutions with inherent surveillance qualities—smart design, digital-based health advancements, and urban analytics touted by governments, the mainstream media, and designers alike—may limit the healthier, more visible changes that should be made to improve the qualities of both our interior and exterior environments, particularly those occupied by the most marginalized and oppressed communities.

Despite America’s current obsession with wellness, any honest acknowledgment of mortality in the United States has been excised from homes and workplaces and instead relegated out of sight to the edges of society, be it eldercare facilities or even hospitals themselves. Smart design installed into our offices and homes and aimed at disease prevention—and healthcare broadly—may seem the method of least resistance to maintain this status quo. Yet however useful in limited and targeted instances, these tools more firmly concretize the existing stratifications within society in which migrant and factory workers, indigenous communities, sex workers, and the incarcerated, among others, will remain neglected. That these innovations are also paraded as universal despite their neocolonial uses and abuses also risks neglecting the unique issues—topographical, religious, economic, cultural—that individual communities, let alone entire metropolitan areas, face.

The issues these supposed innovations raise reach the level of human-rights abuses, says lecturer Malkit Shoshan, area head of the Art, Design and the Public Domain program at the Harvard Graduate School of Design. Her main concern during the pandemic and after is retaining civic values and resisting processes that will increase inequalities. “We should have the capacity to turn [these technologies] on and off rather than being continually exposed to this type of surveillance,” she argues. “It’s not only surveillance of our selves but of our bodies in relation to our entire environment. In America, these algorithms might be used for targeted campaign ads, but in Pakistan or Yemen, the surveillance is used for targeted killings. This type of technology never remains in one spectrum.”

Moreover, discussion about buildings that monitor the temperatures of those within them or even an increased implementation of automatic doors is useless for those without access to basic resources. “COVID-19 makes the politics of space and the quality of the built environment incredibly visible,” Shoshan continues. “Building for health is not just about the healthcare system but the entire city and built environment, the access to resources, and the type of livelihood made possible based on [such] access.”

Shoshan points to the Arab localities in Israel and Palestine as emblematic of these concerns. “Their access to resources is very limited, which has to do with policies of segregation and of master planning,” she says. “You have households in unrecognized villages that live off the grid with no access to water, and yet the first tool we need to protect ourselves in this case is clean water for washing our hands. There’s no electricity. It’s difficult to get to hospitals or clinics. And the immune system responds to this quality of infrastructure.” Rather than introduce information technology or improve sanitation, the Israeli government instead locks down villages in which outbreaks are recorded.

Similar conditions, both in terms of infrastructure and police control, are found in India, notes Rahul Mehrotra, professor of urban design and planning and the GSD’s dean designate. These examples highlight what he identifies as a primary concern which the pandemic has made impossible to ignore: “the value of the private ownership of property.” “These are fundamental political-economic questions,” he elaborates. “All of us who have access to information technology, and if not a home then a room, are going to tide through this and perhaps turn it to our advantage. But in Dharavi, India, [a slum] that has the highest density in the world most often with eight people to a room without water, none of the WHO’s recommendations for social distancing and washing hands can be played out. It’s linked to the fact that people don’t have appropriate housing. The biggest challenge for design-school pedagogy will be to use the pandemic as a hammer hitting you on the head to tell you that we have to address these questions, to force us to think about how we live appropriately on this planet and how we organize ourselves in communities. It’s about how we can be more flexible and nimble in making our settlements so that we can better deal with pandemics like this.”

Smart design installed into our offices and homes and aimed at disease prevention may seem the method of least resistance to maintain the status quo. Yet however useful in limited and targeted instances, these tools more firmly concretize the existing stratifications within society in which migrant and factory workers, indigenous communities, sex workers, and the incarcerated, among others, will remain neglected. That these innovations are also paraded as universal despite their neocolonial uses and abuses also risks neglecting the unique issues–topographical, religious, economic, cultural—that individual communities, let alone entire metropolitan areas, face.

Housing typologies should already have been rethought, says assistant professor of urban design Stephen Gray. The pandemic has just made the conversation more urgent. “In Boston, the majority of very low-income households are single-female heads of households—a single mother with one or two children,” he describes. “The space and services needs for that household type are very different from the two-bedroom apartment that the market will build, which is more than they can afford and isn’t well connected to services they need, like childcare.” As a solution, he proposes micro-units that maintain a balance between private and public spaces, with communal living rooms and kitchens and lockable bedrooms and bathrooms. “You’d reduce the cost per square foot for developers but increase the number of households served,” he says. The market is not inclined to do this by itself though. “It probably needs to be forced.”

The pandemic has also accelerated the full collapse of the home/office separation for huge sectors of the economy. Mehrotra believes that this change among white-collar workers could also instigate a discussion regarding how we might look at housing typologies in a way that returns work-life to more communities. “If you can get information technology to even the poorest people, you might have an eight-person household in which four work from home,” he proposes.

As beneficial as these ideas are, they cannot be considered in isolation from the exterior environment, from weather and temperature conditions to proximity to safe public spaces. Gray notes, for instance, that tree-canopy cover is often deficient in low-income communities of color. “People die every summer from not having AC in their apartments and nowhere cool and safe to go outside,” he says.

More trees in our urban landscape—the largest public areas within cities—would help reduce heat-island effect, argues Martha Schwartz, professor in practice of landscape architecture, who advocates for what she considers the neglected practice of urban afforestation. “We can replant linear forests—proper forests, not street trees, with a healthy plantation of many types of trees—in those areas that are underutilized,” she says. “If we open up linear trenches where the roots could properly spread, they could be pretty narrow, about four or five feet.” The benefits, she believes, would be numerable. “It would help with storm-water runoff, pollution and greenhouse gases, shading for housing, and a city’s overall temperature, all of which concern public health.” Such a large-scale project, she adds, would depend on public-transportation system improvements and perhaps an advancement in automated vehicles, too, both of which would potentially give landscape architects access to up to a quarter or a third of our streets.

With fewer cars driving in urban areas at present, streets have already been rethought, if only temporarily. During the lockdown period, bike lanes have been added in many cities and entire streets have been pedestrianized, with Oakland converting nearly 10 percent of its streets for the latter. Michael Hooper, associate professor of urban planning, has noticed that children’s access to these spaces has led to a positive, and unexpected, point of discussion. “As soon as you are thinking about kids and streets rather than arguing that kids shouldn’t be on them, it means you’ve already entered an interesting space,” he says. He goes so far as to muse that an application of prospect theory, which claims we value the loss of something of equal value much more than the gain of it, suggests that retaining these new forms of public space may not be impossible. “Converting a lot of automotive infrastructure to pedestrian and cycling uses”—and/or, per Schwartz’s suggestion, to increase afforestation—“and then taking it away might activate powerful social reactions that otherwise may be hard to mobilize of their own accord.”

Streets redesigned in this way would begin to solve low-income communities’ lack of access to safe escapes from their interiors, stifling or not. Better yet, they could become pleasurable, community-health supporting passageways to the parks, parkways, and park systems that Chris Reed, professor in practice of landscape architecture, believes we must double down on now. “Landscape architecture in America, as a discipline, grew out of the social-reform efforts in the mid- to late-19th century, starting with clean water and growing into the idea of creating parks as a respite from the everyday life of the city, particularly for workers who didn’t have access to healthy air, the countryside, and nature,” he says. That remains the case throughout the world and particularly in Boston, where the mayor boasts that all residents live within a five to ten minute walk from public open space. But Stephen Gray says that the small size and poor quality of many of those spaces in majority non-white neighborhoods make the metric “useless.”

As a part of the solution, Reed advocates for an emphasis on large-scale projects. “As smaller-scale parks and playgrounds close due to fear of contagion, the prevalence of park systems or the linear park has grown in importance,” he observes. The behaviors now taking place in these sprawling spaces even suggest a return to former rhythms of urban life. “In the last 10 to 15 years, there has been an emphasis on landscapes and public spaces that could be heavily programmed with lots of events, but those activities are being shut down right now,” he says. “This brings us back to the fundamentals of what you do in a park: walking, running, riding, and experiencing nature. It’s refreshing for me to come back to the importance of the longue durée as a way to escape the stresses we’re dealing with day by day, hour by hour.”

This ethos, as well as an impulse in line with Gray’s clarion call to create better public spaces for all, drives a current project by Reed’s firm, Stoss: the redesign of Moakley Park, located 15 minutes from Boston’s poorest to wealthiest communities, that would potentially complete Frederick Law Olmsted’s Emerald Necklace. If the City of Boston facilitates a parkway link along Columbia Road from inland Franklin Park to Moakley Park at the edge of Boston Harbor, the resulting system would allow the poorest and most marginalized communities access to the entire harbor and a premiere existing park system. It would also encourage potential encounters between people across economic and social sectors.

However lacking in public funding Reed’s and Schwartz’s ideas may be, the notion that a proliferation of green spaces could serve a public good remains well accepted. Rahul Mehrotra believes that even more radical innovations should also be undertaken—projects that would extend a legacy of multifunctionalism historically at the core of landscape architecture—which could even be created in conjunction with parks both large and small.

He argues that just as afforestation turns the street into the source of temperature control and closing off car lanes for children’s access makes the same space a possible recreational zone, sanitation infrastructure should also be rethought as multifunctional. “In H2O and the Waters of Forgetfulness, [the philosopher] Ivan Illich wrote that water was always very sacred and societies even celebrated it in the way it was dealt with architecturally until engineers invented pipes in which it could be circulated invisibly and became H2O. You opened your taps and hoped for the best,” says Mehrotra. “How can you bring sanitation—places where water is being filtered or sewage is being treated—back to the lived experiences of people and not just something that is invisible and periodically engineers come and fix? How do you make it an aesthetic experience, a part of public space, something that is almost celebrated? When a piece of infrastructure becomes multifunctional like this, it will propel us to another imagination of cities and urban space.”

History has given us enough material to rethink the DNA of our settlements, he says, citing London’s cholera epidemic and the epidemiological maps it produced as well as the Great Plague in Mumbai when people moved into tents in parks as authorities disinfected neighborhoods. No major changes or evidence of the nimbleness of thought and design that Mehrotra advocates for our cities has occurred though. “We’ve injected them with infrastructure and invariably made what we depend on to live increasingly invisible,” he says.

Concealment does little to instill an increased awareness of our interconnectedness or of how our environments impact not just single individuals but entire publics. These understandings are foundational to the synthesis of public planning and public health, but they’re antithetical to the ideology underpinning smart design. “The Fitbit, for example, is very individualistic,” says Michael Hooper. “A lot of these private-planning enterprises—the data-oriented, urban analytic companies—are focused on an individual’s behavior and data. The shared civic infrastructure is always a struggle for them.”

“Infrastructure, in its most philosophical form, is that instrument by which we relate to each other as human beings,” Mehrotra says. “We relate to each other through the shared infrastructure of the cell-phone network or the water that’s piped. So when infrastructure goes wrong, our relationships begin to crack.”