Urban Afflictions. Global Health Crises in Metropolitan Contexts. An interview with Hilary Sample

Ice cream and influenza. Mexico City

The global crisis unleashed by the 2003 SARS outbreaks seemed all but forgotten in most parts of the world, until the threat of a global pandemic resurfaced in the media (old and new) only a few days after the appearance of a mysterious, unknown and presumably deadly virus in Mexico City. In a crazy turn of events, the megacity was practically shut down and brought to a standstill for days, with consequences that we are only beginning to come to terms with.

What have we learned from these massive public heath crises that are a product of our interconnected, now predominantly urban world? How are governments, institutions and organizations (at the local, national and global scales) reacting to these crises in terms of urban policies and design? We’ve asked Hilary Sample, Assistant Professor at the Yale University School of Architecture and partner of mos, to comment on these issues, taking her upcoming book, Sick City, as a point of departure.

Where: First of all, can you give us some insight on the subject of your book, Sick City? What exactly would you say is a "sick city", or a "healthy city" for that matter?

Hilary Sample: Sick City is a book project that began during the SARS outbreaks in 2003. I became interested in the sudden, urban shifts that took place as a result of the outbreaks while I was living and teaching in Toronto, and examining the post-event effects. The book is not only about SARS, it starts with SARS as the first major global health crisis event in the 21st century, but also focuses on other urban crises; looking at the problems and solutions that result from contagious disease situations or threats, from hurricane Katrina to AIDS. Essentially, I was interested in the unpredictable events that were not malevolent causes, and the urban remedies.

The SARS outbreaks became true public crises in March 2003, within weeks, if not days, of the start of the Iraq War. The media focus in North America was practically concentrated on the war up until the SARS outbreaks, which became a focal point of news coverage in Canada, and it seemed to me that this divide between terror and disease was significant in its own right. Each would have (and has had) a great effect in terms of socioeconomics, health and urbanism. It was interesting to see the difference between the U.S.’s concern regarding terrorism and Canada’s concerns about the spread of SARS. There is no question that war is so devastating because of its physical consequences, I think, but in the moment, disease outbreaks are no less significant, though the aftermath is usually subtler and as a result seems less significant. Still, the consequences of a disease like SARS have had major urban effects, such as the development of the Biomed City (we get into this further on in the interview).

In the terms of the book, a sick city is one that has undergone an unexpected change as a result of disease; a city whose life-sustaining infrastructures have been affected beyond their intended performance. The book also looks at the governance of world health, the agencies and foundations doing this work and the development of the health headquarter building, a new typology that emerged in the twentieth century, which defines the way worldwide health is organized. (An early paradigm is Le Corbusier’s Ministry of Health and Education building, in Rio de Janeiro.) Sick City looks at building types associated with health and examines their performance. It’s a kind of loop, looking at the sick city, its sick buildings and the organizations that renew and restore the city, and then looking at buildings that are meant to facilitate urban health.

Reforma Avenue. One of the main (usually crowded) throughfares in Mexico City.

W: What is your reaction to the current 2009 A/H1N1 flu affair? Where do you see our cities standing compared to the first SARS outbreak in terms of being prepared (or not) for this kind of public health crises?

HS: Disease is unpredictable, but there are social and spatial patterns that emerged with SARS and are emerging again now: school closings, hospitals restricting access to only the sick or even designating parts or entire hospitals for the infected, scanning at the airport. The big question will be how these events are handled and what they look like.

With SARS, everything happened so fast that hospitals, for example, were closed or cordoned-off, wrapped in yellow tape, limiting entrances, looking more like a crime scene than a hospital. These instances caused more fear and panic than were probably necessary; keeping individuals from going out in public, from doing normal activities like eating out or taking public transportation. This fear and resistance to going out in public has significant economic impacts on a city. Compounded with a weak global economy, this will raise new challenges to the operation of public health facilities. In the U.S. and Canada, there has been a great push to build new research space in cities for the purpose of identifying contagious diseases to pollutants.

Super Hospital. Birmingham, U.K.

W: Can you give us some examples of how these global health crises are changing our cities in terms of urban design and infrastructures? I imagine that certain building types (hospitals, quite obviously) would be almost immediately affected.

HS: The hospital is our most contested urban building type today. Unlike any other building type within the last fifteen years, hospitals have been the site of significant urban trauma, form war or terrorist targeting, to takeovers and quarantines. At the time of the SARS epidemic, the hospital was the place where most of transmissions of the disease occurred, as the virus often spread to health care workers, other patients and visitors. In the aftermath of Katrina, in New Orleans or Galveston, many hospitals closed and remain closed.

At the same time, we see different types of hospitals on the horizon, a new breed of “super hospitals”.

We see this idea of the super hospital establishing itself in the U.K., and plans are under way for this type of development in Montreal. There is a project under construction in New York City, the East River Science Park (ERSP), which is really anything but a park. It is a research institution that is being built adjacent to one of New York City’s most celebrated hospitals, Bellevue Hospital. Unlike its counterpart in Toronto, the ERSP has little space dedicated to the public. Toronto’s MaRS project, an addition to the original 1913 Toronto General Hospital building, includes a public atrium which links into the rest of Toronto underground system, a public auditorium, and even a food court. The hospital became too costly to repair for use as a hospital, and now has been renovated and added to for office and lab space. It really acts as a place for meeting in the city.

Even though both projects are being built by the same developer (not coincidentally) they are fundamentally different: MaRS promotes an exchange between the public and the user, where ERSP has strict entry controls and checks. Here we see the difference in mindset between the US and Canada, one city affected by 9/11 and the other by SARS. One would expect the opposite kind of spatial response — a prophylactic situation emerging where germs had been spread — but in fact Toronto’s MaRs development has public spaces and links to both the Toronto General Hospital and the Toronto underground system and subway.

SARS: Yesterday's news?

W: At an even larger scale, another extremely interesting concept in Sick City is the idea of the “Biomed City” you mentioned earlier. What exactly is a BMC? Does it actually exist somewhere, or is it only hypothetical?

HS: In the book, we see the BMC as a 21st-century urban paradigm emerging from New York, to Toronto, to Singapore. The term has been adopted by various cities, where certain areas — and in some cases entire cities — are adopting this “brand”, placing an emphasis on health and its industries as the new economic driver of the city. One interesting thing to note is that in cities less prosperous, such as Buffalo, New York, the health-care industry is now the largest employer in the city.

In response to the SARS epidemic, Toronto reworked its most visible hospital and introduced the program of rentable office and laboratory spaces dedicated to health research in the downtown urban core. Typically, this kind of work space was only seen in suburban corporate parks. With BMC strategies, we see unlimited configurations of health and work spaces converging.

In Toronto, there has been an all-out effort to build civic buildings at that heart of the city and the U of T, both of which converge at one corner of the city, with new buildings largely built of glass, emphasizing a literal transparency, housing new spaces for health research. There were three reports written after SARS in Toronto, all of which cite a lack of transparency in the health system. Certainly building transparent buildings doesn’t indicate that a city will be better prepared, but it does demonstrate that research related to health is no longer being done in opaque and distant locations.

The sites of these outbreaks are typically the city centers: this is where the capacity for care, research and a quick response is needed. New York, Toronto, Rotterdam, Beijing and Boston, among others, have all built their own biosafety laboratories, which means they don’t need to rely on sending disease samples to national labs and wait for a response. These tests can be performed in the heart of the city. The development of these labs — some of which house lethal viruses — has been strongly contested, particularly in Boston.

W: It’s really interesting to see how all of these factors you mention have resurged in the Mexico City outbreak: problems with lack of transparency and coordination, as well as the issue of immediacy and speed (since Mexico did not have the capacity to identify the new strain, it had to send samples of the virus to Canada and the U.S. before it could be properly detected, delaying the response for days).

HS: This reflects the importance of establishing critical life-sustaining infrastructures (hospitals, research laboratories and mobile care) that should all be available in any urban environment. After the SARS outbreaks, the cities that thought they were the most “prepared” in almost every case found short comings. Many of these cities had major plans on the drawing board, but I have no doubt that in the aftermath of SARS gave them an even stronger and urgent reason to update the city. I don’t think this suggests that we should adopt an emergency urbanism attitude towards designing in the city, it would not be practical to design for full-blown pandemics, but as we’ve seen in the trend of medicine to look to prevention, design can facilitate new methods of spatial organization. I think this is particularly true at the site of the hospital, and the way the general hospital and specialized hospitals are organized in the city today.

Riding the subway in Mexico City

W: We’ll keep discussing these and other issues (including government involvement, networked responses, flexible infrastructures, and the gap between prepared and unprepared cities) in the second part of this interview. Stay tuned. In the meantime, you can download a PDF version of "The Biomed City" from the Actar blog.

(Photos from Flickr users amegally, pvcg, seth trotman, zverina.com and eneas. The original full-sized color version can be viewed by clicking the photo.)

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