Over the past few days, normal life at Harvard has been upended by government, university, community, and business responses to COVID-19. What role do planning and design have in this kind of pandemic?
Recent reports from London’s Imperial College and Harvard Global Health Institute (HGHI) lay out the broad problem. The influential Imperial College report explains that since COVID-19 is a new disease, the general population does not have immunity. Until there is a vaccine—which is expected to be 6 to 18 months away—or a large number of people have been infected and develop immunity, infection rates will be high. The threat, outlined clearly by the HGHI, and illustrated by the Washington Post, is that hospital and intensive care beds and staff will be overwhelmed. The Imperial College report estimates that with no action, given that COVID-19 is already in the population, over 2 million deaths will occur in the US.
That leaves non-pharmaceutical interventions; in the Imperial College report these are termed “mitigation” and “suppression.” Mitigation aims to slow the disease using measures such as isolating those who are sick, quarantining household members, and implementing social distancing for those over 70. This would spread out infections and has been used effectively in the past. However, using various assumptions, the report shows that even with a plausible mitigation approach, the US will still need eight times as many intensive care beds as it currently has, with the peak occurring in the summer of 2020.
For the past decades, those looking at the intersections of planning, design, and public health have focused less on infectious diseases and more on chronic disease, hazards and disasters, and the vulnerable. The current pandemic brings the question of designing for infectious diseases back to the forefront and raises important questions for future research and practice.
This leaves suppression—including closing schools and universities and social distancing of the entire population—as our new normal, for a period of months, not weeks. Of course, estimating the effects of various strategies involves many assumptions, but the situation is not a simple one. This is why universities, schools, governments, and businesses are changing how they operate; Harvard has gone to online instruction, for example. A key problem is that when suppression is used as an intervention, people do not build up immunity, so suppression needs to be in place until a vaccine is released, immunity built up, or until systems can be put in place to test, track, and trace at a massive scale. Countries such as Singapore and South Korea, that are now exemplars for managing the disease through testing and monitoring, experienced SARS or MERS in the past decades. They were prepared for COVID-19. In places without such preparation, suppression is buying time to make those preparations. A New York Times op ed by members of the University of Pennsylvania faculty explains the suppression strategy well.
Additionally, the economic fallout from suppression may endanger the health of the vulnerable: older adults, children, those with preexisting conditions, anyone with a low income, and those otherwise marginalized in society. People may lose their housing, find it harder to access routine health care and prescription medications, and eat less well. Stress is caused by economic hurt as well as uncertainly over the pandemic itself. These are not good times for human health.
What does this mean for urban places? There are very obvious disruptions at the global scale—with grounded flights, required isolation for travelers, and closed borders. More will need to be done internationally to try to stop diseases crossing from animals to humans—a task that is compounded by climate change altering habitats and people moving into previously unsettled areas. But here I want to examine three smaller scales and the built environment.
Cities and regions: In the context of COVID-19, some have questioned the future of urban life. This is a bit premature. Metropolitan areas are quite varied in density and character; they range from leafy suburbs to apartment buildings in the core city. It is also important to distinguish between high population densities (counted as people per acre, for example) and crowding (often operationalized as people per room). Singapore has so far avoided the worst of the crisis with widespread testing, isolation, and clear communication. Italy, where suppression is in full force, shows the social solidarity possible in higher density areas—like people singing from their balconies. COVID-19 is emptying out public transportation in many places, but transportation is already in a transition period due to automation. The key health crisis from COVID-19 is likely to appear in more crowed settlements without adequate water supplies and sanitation—in both urban and rural settings—but these have been a focus of public health concern for a long time. While cities will not be eliminated, a long period of suppression may well change patterns of urban life.
Neighborhoods: With more people working at home, and more deliveries, the neighborhood can provide support, challenge, and delight: support for healthy activities; challenges to stimulate oneself both physically and mentally; and delight in a time of stress. For all except the strictest suppression approaches, people can get out and about for exercise and errands, while still keeping social distance. With gyms closed, meetings going online, and grocery stores limiting numbers of visitors, the outdoors is all the more important. Of course, this assumes people retain their housing as economic conditions worsen—also a key planning and design concern.
Home: People will be home—a lot—with more family members in the same place at the same time. This is not the case for everyone—health professionals, delivery workers, people caring for physical infrastructure, those cleaning and maintaining essential facilities—may be out quite a bit. But for most people, homes also need to provide support, challenge, and delight to maintain physical and mental health. Not all homes are healthy. For example, poor indoor air quality caused by mold or poor ventilation is a substantial health hazard. Physical activity can be carried out indoors but may involve changing behavioral patterns. This is surely a design issue, and again one more critical for those with fewer resources. More than ever, access to the internet, as well as to physical public spaces, are key planning, design, and health concerns.
An infectious disease pandemic challenges recent research in the area of healthy places. In the 19th century, the emerging planning and design professions shared a core interest in infectious diseases. Building regulations and sanitation systems were common responses. Infectious diseases are certainly a top concern again today; they are also a continuing issue in places where low incomes lead to crowding, lack of sanitation, and the like.
For the past decades, however, those looking at the intersections of planning, design, and public health have focused less on infectious diseases and more on three other areas: chronic disease, hazards and disasters, and the vulnerable. For chronic diseases—those lasting a year or more—the environment can provide options for healthy behaviors such as physical activity or mental restoration. For hazards—such as climate change—planners and designers need to address flooding, droughts, and climate-led migration. And for the vulnerable, the environment needs to focus on those who are old, young, have preexisting conditions, or have low incomes. The current pandemic brings the question of designing for infectious diseases back to the forefront, however, and raises important questions for future research and practice.
Ann Forsyth is Ruth and Frank Stanton Professor of Urban Planning at the Harvard Graduate School of Design. She is co-Director of the Healthy Places Design Lab.