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Ten Ways Cities Fought Pandemics Before COVID-19

1850 can teach us a lot about coronavirus, and about life. As the US took its first steps toward the Civil War and the formation of its industrial economy, 95 percent of the world lived in poverty. Only a fraction of the US worked for “wage labor”, as opposed to working on the farm. Mothers bore children from childhood until their death, with the average household size well over five and age of last conception around 40, even as average life expectancy stood a dismal 38.

Not only was life hard and short, but it was subject to the risk of an unpredictable end at any time. Infant mortality was high – hence the need for large families – and variability in lifespan was longer then than it would ever be afterward. The relatively gluttonous causes of death that predominate today – heart disease, cancer, and stroke – were not among the tip ten leading causes. In those days, rather, infectious disease was the great equalizer: tuberculosis, dysentery, cholera, malaria, typhoid, pneumonia, diphtheria, scarlet fever, meningitis, and whooping cough together killed the overwhelming majority of people around the world.

Predictably, the risk of being killed by anything you might catch badly influenced the psyche of Americans. Despite the massively lower wages in those days and the lack of opportunity beyond popping out babies and breaking one’s back on the farm, depression was barely considered a medical issue, treated only at 1/50th its current rate. Instead, “fear” – predominately fear of death and fear of symptoms – predominated over 90 percent of the terminology in mental health literature. Anxiety, despite our modern obsessions, was over twice as prevalent. The looming threat of infection dominated life, and everyone lived in perpetual fear.

Today we live over twice as long. We languish in depression and dysphoria about our physiques in the statistics like never before, but we are generally killed by comparatively luxurious causes. While genetic diseases continue to affect many of the countries of the world in large numbers, only influenza continues to exist among the top ten causes of death in the world of all the infectious diseases. And, at least until a couple months ago, we no longer have had to live in daily fear that medicine cannot cure us from ordinary illness.

For all of its press coverage, COVID-19 is statistically far from the worst pandemic we have faced. It has killed less than 1/200th as many people globally as the Spanish Flu, for instance, and to most of us will not threaten our ability to survive it. What is has done, however, is jostle our psyches. What the numbers from 1850 to today suggest, more than anything, is that two things – poverty and infection – have been radically eradicated. A visitor from that era, in no two other ways, would not begin to recognize the contemporary world, at least statistically. And yet COVID-19 has given us cause to renew the fears about infectious disease that for 150 years we had made such progress in eradicating. New risks of infection are not something we are used to. It signals a move backward, rather than a move forward, and is the equivalent to what we might experience should we be subject to a massive global reversal in GDP projections over the long haul or a massive dip in technological capabilities. We have come to take so for granted that infections are becoming a thing of the past that the threat of even a relatively minor new one has changed life as we know it.

Urban Planning: Legacy Tool for Fighting Pandemics

The steady march toward progress for a century and a half – and the reason we are so jarred by this need to re-confront the afore-assumed disappearing issue of infection – is thanks in no small part to the innovations of the modern city. Even as the world has urbanized and densified dramatically over the last two centuries, transmissible disease has become less of a threat, not more of one. Even amid the industrial revolution, which for a time created a life more polluted, dangerous, and dismal than the agricultural life that preceded it, new innovations in city planning have cleared the way for a world free from the mortal threats once wrought by infectious disease.

In the 1800s people moved to cities for economic opportunity knowing it was a risk to their health. Stephen Johnson’s “ghost map” of London traces the origins of a cholera epidemic in London. As Alex Krieger quotes him: “A sort of existential doubt lingered over the city, a suspicion not that London was flawed, but that the very idea of building cities on the scale of London was a mistake”. There, tuberculosis and typhoid fever were the results of badly crowded and unsanitary conditions, and there was for a long time a sense of global doom that industrialization could not come without the risk of infection.

The storylines of how urban planning changed this narrative are overwhelming.

#1: Paris

When Baron Haussmann introduced the grand boulevards to Paris, he did so with good reason. The city had been rocked by the cholera epidemic there in 1832 and working-class neighborhoods were notorious hotbeds of infectious disease. The early city had been a place of narrow streets with many areas of ground that never saw sunlight. Standing pockets of water and dampness never dried due to lack of airflow and malaria festered. The rats and mosquitos loved it, but to humans it was a death pit. The boulevards changed that.

#2: Chicago

When Jane Addams opened her Hull House as the precursor to the modern apartment building, it was in response to the conditions of the day: routine blocks of thousands of residents without a single bath or shower, inadequate airshafts, no ventilation, no central hallways, and again, festering disease. Her vision for the modern apartment that reflected the same human dignities for workers that also drove the union movement changed that.

#3: Philadelphia

When Philadelphia created its transformational water purification plant in 1911 – the first to do so – it was in response to a massive cholera epidemic and also the woeful sewerage conditions of the day. While Philadelphia was badly hit by the Spanish Flu as the result of poor social planning, it at least did not have to fear the risk of accompanying epidemics of cholera, dysentery, or other water-borne illnesses.

#4: Chicago

When Daniel Burnham helped Chicago deliver its 1909 plan for the modern city following the principles of the City Beautiful, it was in direct response to the three principled aspirations of convenience, health, and beauty. The solution relied heavily on parks, and it changed the health outcomes for a dingy city.

#5: Suburbia

Parks had been the prescriptions of Frederick Law Olmsted for eradicating the risk of infections, who writes extensively about the health benefits of “fresh air”, which accompanied simultaneous movements in healthy eating and “athletics” to accompany them. To Olmsted, part of a city was the breathable “restorative” nature of open spaces.

Even the birth of actual suburbia – often maligned in contemporary literature – had a public health origin, from Howard to Olmsted. Said Olmsted amid his plan for Riverside: “Let the citizen build up his stores and his warehouses as high and as close together as he pleases, but he doesn’t want to live among them and there is no longer any need of doing so. He can live in much better style and cheaper in a part of the city entirely given up to dwellings”.

#6: Washington, DC

Even the final commitment in 1902 to infilling and developing the old planned National Mall in Washington, following this same rationale, was in response to rampant malaria in the city’s swampy core. Forever it changed Washington.

#7: Estates

Louis Sullivan, Frank Lloyd Wright, and others blasted the inherent nature of cities as hostile to health, and especially hostile to children’s health, because of their inherent proclivity to spreading infectious disease. Wright was an idealist whose animosity toward infectious disease imbued every facet of his plans for Fallingwater and Taliesin, just as it was for other American icons from the Biltmore to the Hearst Castle. The escapism of the American mansion was its own brand of the European country castle, and for many of the country’s early elite it was these escapes that spared their families from countless epidemics.

#8: The Broadacre City

Wright went further than any of the others in blasting the old with his famous Broadacre City – the most notable of the master architects’ visions for a utopian future. In it, all of Frank Lloyd Wright’s repudiations of the city as a mousetrap of misery and disease came together: much more far-reaching than Howard’s garden city, Wright insisted the complete destruction of the city as we knew it was the only pathway toward sustainable human health. His was a vision for one family an acre dressed in vineyards, baths, stables, worship, and an arboretum, all the elements to facilitate the eradication of infection and the cultivation of mental balance. His vision was the ultimate in social distancing – the physical quarantining of families and the general elimination of public open spaces on behalf of private.

Wright was particularly suspicious of density and his one family an acre philosophy underscored it. Wright, like many others of his day, recognized the speeds of the automobile as a critical tool to achieving the kinds of lower densities that a healthful city would require. Coincidentally, that density and that automobile orientation is the density that comprises most of American suburbia as we know it today.

#9: New York

Even Moses, too, misguided as he may have been, had infectious disease in mind as he sought to remake his metropolis as a breathing organism with large outdoor spaces, the elimination of tenements, and easy movements of people from the working areas to the residential ones.

#10: Cape Town

Despite these successful examples, other cities have, unfortunately, installed less positive policies upon being spooked by major infectious disease outbreaks. Cape Town, for instance, used it as a driving motivator to install segregation of neighborhoods. While reprehensible, it was not the only story of using pandemics to foster bad policy - and should be a warning that using crises to reinforce existing biases for destructive ideas is as infectious a temptation for policymakers today as it was then. We must be wary. Other cities,too, at times, have used it to promote separation policies, rather than positive ones.

With the exception of #10, these other innovations – the boulevard, the settlement house, the sewer and water filtration system, the parks network, the highway, the contemporary suburb, and the low-density automobile-oriented city – were all at least partly, and in many cases directly, responsive to America’s 19th century preoccupation with eradicating the life-consuming threats of transmissible, infectious diseases. They are the hallmarks and the legacies of a century and a half of public health masterplanning to make the city livable, breathable, and critical in the cultivation of longer lifespans alongside better physical and mental health. And with overwhelming statistical success they worked.

COVID-19 is a Repudiation of 50 Years of Urban Planning Orthodoxy

These innovations, however, are also things that in many respects have been dismissively shunned over the last 50 years by planners as the world has moved on to addressing newer and more trendy challenges in our cities. Not without good reason, planners generally today shun suburbia, and behind their logic they have cited its proclivity to increase rates of asthma by way of automobile pollution as well as a reduction in physical activity lost by the preference for driving over walking. Planners often retroactively malign the actions of Haussmann and Moses, who gave literal and transportation breathability to their respective megacities through the opening up of highways and boulevards, but who did so by eradicating traditional apartment blocks by fiat. Density is back in vogue, cited far more aggressively than it should be as a cause for better social outcomes across a wide host of areas. With it is a professional sentiment prioritizing public spaces over private. Backyards, in particular, are discouraged. The separation of land uses is viewed as something no longer necessary, with integrated, mixed use – and the general mixing of everything – a widely advocated recipe for vibrancy. And, in general, the need to privilege the collective outcomes of the planet in the designs for our cities is cited far more often than the ongoing need for our cities to help us combat infectious diseases. Generally, there is a viewpoint that principles that guided us in the past are either wrong or no longer necessary.

Moving forward, many of the most visionary ideas for the future city are those that further pick apart past principles and which further privilege the planet over people. To the extent planning prioritizes health mental health is a more-often cited topic than physical. And where planning is innovating to achieve better physical health outcomes it is doing so to fight new diseases, such as Mohamed bin Salman’s efforts to build a new kind of city at NEOM that can eradicate inherited, as opposed to infectious, diseases. His is a truly Einsteinian level of aspiration, but it is in one facet of health only and it is not in infectious disease.

In short, with respect to infectious diseases, an argument exists that we’ve taken our eye off the ball. While city planning today is perhaps better than it has ever been in many respects, the principles that underlie it may have become lazy. We may have forgotten just how perilous it is for human beings to live at the kinds of densities that comprise our modern metropolises. A 2016 piece in the Washington Post highlighted research suggesting that humans are genetically evolved to live only at densities of around 23 persons per square mile. While the research called out the well-documented negative mental health impacts of us living at densities for which we are genetically not suited – and I have previously posted about such perils myself in the piece “The Paleo Cities of Tomorrow” – the physical health perils of cramming us together must be acknowledged as well. Just because we’ve removed the mortality risks from most infectious diseases and created healthy cities overall doesn’t mean the risk factors can be ignored moving forward. COVID-19 is a reminder of that.

The novel coronavirus did not become a pandemic because of failures of city planning or because cities are too dense, and the benefits that come with aggregations of concentrated labor and the exchange qualities of cities may well exceed those costs even if it had. This must not be forgotten – cities are the most important tool we have to achieving successful economic outcomes for all. But the qualities of the cities that most rapidly spread the disease did not help: density was a culprit for sure, and in New York City public transit was one of the most dangerous tools that helped rapidly spread a disease that without it would not have spread so quickly.

Unfortunately, these elements have become the fixations of planners over the last 50 years, and our advocacy for them as social and economic drivers may have caused us to get in front of ourselves on health. Planners have moralized relentlessly about the benefits of density and of transit, and also, for that matter of open office spaces and of the virtues of random chance encounters with strangers – the idea that one out of a thousand people you bump sweaty shoulders with on a train might become a good friend or professional collaborator. We now see there may have been wishful thinking in those sentiments that ignored crucial risk factors.

The COVID-19 era has taught us a lot about our ability to carry on society in many ways without the kinds of dangerous interactions that can spread infectious diseases. The notion of ZOOM as part of the toolkit of forging the modern city that could grant the world the benefits of shared knowledge without the perils of shoulder-to-shoulder interaction would have been a godsend to the visionaries like Haussmann, Wright, Addams, and Burnham. We now have more tools to fight the battles they fought against infectious diseases than we have ever had, and yet we are scarcely fighting them outside of what we consider to be a temporary condition. We should be.

What future vision for the city will emerge from COVID-19? To read the early articles from the urban planning community, most of their early responses have been defensive about the things they have been advocating for the last 50 years. But perhaps they need to think over a longer period of history about the principles have truly imbued planning its innovations on society over the better part of the last two centuries. Planning shouldn’t play defense against things it’s done inadvertently recently for other reasons that might have helped to spread a deadly pandemic. Rather, we must draw inspiration from the things we did intentionally throughout our past that have helped to slow and eradicate pandemics more generally. And from them we can find ways for the future city to reduce our risk.

With COVID-19 a reminder, perhaps it is a good time for planners to re-imagine with fresh eyes the many principles that helped it get 99% of the way there in eradicating infectious diseases over a full century. We’ve now been reminded that those City Beautiful principles of convenience, health, and beauty are as important as ever today.

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