Urban Responses that Makes Future Cities Resilient to Pandemic Shocks - A review of relevant pre-existing UN Guidance

Author:

This document was developed by Xuanyi (Maxwell) Nie[1], intern with UN-Habitat and doctoral candidate at the Harvard Graduate School of Design (USA), with contribution by the UN-Habitat colleagues from the Future Cities Global Programme team, as well as Pamela Carbajal, from the UN-Habitat Planning and Urban Health Programme.

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Introduction

Human health has been a strong motivation for interventions in urban planning since the existence of cities. Critical attention to urban public health came in during the industrial revolution. The British social reformer Edwin Chadwick’s influential sanitary report in 1842 raised wide discussions on whether the government should intervene in a laissez-faire system. This intellectual stream was paralleled by Fredrich Engels’s critique on the cramped, grossly inadequate housing quarters manifested in the 1842 “The Condition of the Working Class in England”. This was furthered by John Robertson’s “Housing and the Public Health” in 1919 that systematically advocated for healthy environment as a mandatory public service associated with dwelling.

Figure 1 – Cover of ‘The Condition of the Working Class in England’

Although the fields of urban planning and public health share a common origin in the efforts to tame the ravages of early industrialization in the 19th century, the two disciplines somehow parted away in the early 20th century since the division of labor moved planners to increasingly focus on the built environment, while public health professionals narrowed in on biomedical causes of disease and disability.  Now health has returned to the forefront of urban planning, and this COVID-19 global threat can be viewed as an opportunity for significant urban planning reforms, and the propinquity of urban planning to preparing for epidemic shocks in the cities is rendered more urgent than ever. While many ongoing studies overly focus on developed countries, it is indubitable that this global challenge ought to be faced together by the entire population, and the insufficient health services and health infrastructures in developing countries brings non-pharmaceutical interventions such as urban planning under the spotlight of researchers and practitioners’ attentions.

This article, “Urban Responses that Makes Future Cities Resilient to Pandemic Shocks”, aims at suggesting essential urban elements that can help future cities resist pandemic shocks, and tries to  summarize key learnings that UN-Habitat’s Urban Lab team has gathered from the responses to the current pandemic, with special attention given to developing countries and especially the work across the 19 cities of the Global Future Cities Program funded by the UK Foreign and Commonwealth Office (UKFCO).

 

What Key Urban Elements for the Future Cities to Resist Future Pandemics?

In response to the Sustainable Development Goals and the New Urban Agenda, and the ongoing work of Global Future Cities Program at the UN Habitat, this article underscores a list of urban elements effective in resisting epidemic shocks and contributive to future resilient cities particularly in the developing countries: 1) Walkable and Cyclable Environment; 2) Mixed Land-Use; 3) Epidemic Prevention Areas; 4) Building Primary Care Network; 5) Inclusive Planning; and 6) Digital Governance. It also serves as a nexus that links with the best practices, ongoing projects, and relevant publications at the UN.

 

1. Walkable and Cyclable Environment:

For most emerging infectious diseases, prevention that mitigates disease risk is economically better than cure of adaptation to an outbreak. Urban population’s everyday life is heavily affected by our built environment especially in the megacities with fast-pace urbanization, and one particular concern is the relationship between the built environment and NCD (non-communicable disease). NCDs includes diabetes, cardiovascular conditions and raspatory conditions which may be risk factor for epidemics including COVID-19 (Gupta, Ghosh, & Singh, 2020; Zheng, Ma, Zhang, & Xie, 2020). It is widely believed that designing pedestrian-friendly and cycling-friendly cities will help to produce healthier living environments (Giles-Corti, et al., 2016). Evidence suggests that diabetes, cardiovascular disease and raspatory conditions could be reduced by better transport and green space planning that promotes physical activity (Nieuwenhuijsen, 2018),  and cleaner air quality which can mitigate the spread of COVID-19 (Zhu, Xie, Huang, & Cao, 2020).

Although this concern is mostly prevalent in developed countries such as the U.S where car-dependent urban forms have led to the creation of obesogenic (‘obesity inducing’) environments, the dominance of motor cycles are equally apparent in megacities of the developing world such as Bandung in Indonesia shown in Figure 2. The GFCP has launched several transportation-related projects in these developing countries, and details can be seen on the GFCP Knowledge Platform. The predominant causes include untailored urban sprawl and lack of public transport infrastructure that lead to over-reliance on private motorcycles, weak municipal capacity in the provision of public goods including good-quality public spaces, streets and sidewalks, and rambunctious private sector development that maximizes land use and density, leading to gated complexes and little public benefits. Ensuring city resilience through planning that enhances urban population health is a long-term yet essential task for building global future cities. Key areas of focus for an effective urban response for COVID-19 can be found in recent UN-Habitat publications on key messages for Public Space and Urban Transportation.

_{Figure 2 – Traffic congestion Jl Asia Afrika Bandung, and the GFCP launched the ‘Development of an Integrated Public Transport System’ addressing the transportation issue}

 

2. Mixed Land-Use:

Closely pertinent to walkability is compacted land-use that encourages a walking-friendly environment. While public health originally advocates to reduce densities, the latest research now favors more compact cities where active transport (usually include walking, cycling, and public transport use) can be improved (Newman & Matan, 2012). This is because distance is significantly correlated with the use of active transport, and shorter distances represent increased convenience and reduced cost for individuals. As a result, healthy transportation choices are improved through increase density, mix of land uses, accessibility to transit and public and green spaces, and appropriate active transport infrastructure. Higher density leads to shorter distances between origins and destinations. Mixed land uses, such as breaking up the uniformity of residential development with commercial uses, can result in shorter distances between origins and destinations.

UN Habitat has been advocating for mixed land-use, which is listed among the five principles for A New Strategy of Sustainable Neighborhood Planning. The adoption of single-use zoning strategies has resulted in serious problems for cities including urban sprawl, declination of the quality and vitality of many urban centers, and car dependence and traffic congestion. The purpose of mixed land-use is to create local jobs, promote the local economy, reduce car dependency, encourage pedestrian and cyclist traffic, reduce landscape fragmentation, provide closer public services and support mixed communities. But the implementation of mixed land-use faces pressing challenges in the developing countries. UN Habitat claimed in the Land Challenge that “90 per cent of landholdings in developing countries are not documented, administered or protected, while urbanization is increasing pressure on land, with people living in cities expected to grow by 175 per cent by 2030.” The joint force of lack of formalized ownership and need for more land together stimulates urban expansion to happen faster than proper planning, resulting in unplanned development that buries the opportunity for mixed land-use. This challenges was iterated by the Habitat III Issue Paper 9, calling for more attention to realize mixed land-use through multi-agency efforts that comprehensively address the land issues.

 

3. Epidemic Prevention Area (EPA):

Directly related to quarantine policy response is the “epidemic prevention area" (EPA). Sudden and diffuse human migration can amplify local outbreaks into widespread epidemics through movement of people to and from their workplaces, local traffic between cities, or sudden population outflows which happened in Wuhan (Jia, et al., 2020). Travel restriction is the forefront policy to contain the spread. Interventions such as immediate and intensive contact tracing followed by quarantine and isolation can effectively reduce the control reproduction number and transmission risk (Lai, et al., 2020; Tang, et al., 2020). But travel restriction will disrupt a variety of urban activities ranging from daily work commute to business and trade. Therefore, a fundamental question is whether strategic partial restriction that deals with the most severe areas, such as highly connected hub airports as means to save economy, is viable. A research by UNESCO and Southeast University in China proposes for “epidemic prevention area" (EPA) that certain districts can be quarantined while others are still running, avoiding devastation to the economy of the entire city.

_{Figure 3 – Dimensions of Regional Urban Form, from “Spatial Structure and Productivity in US Metropolitan Areas” (Meijers & Burger, 2010).}

The implementation of EPA would need to be reached by a rather polycentric urban form compared to the traditional mono-centric urban form, which decentralizes urban functions from the city center, allowing relatively independent urban function clusters to be quarantined without hampering the overall functionality and economy of the city. As illustrated in the ‘centralized-polycentric’ model in Figure 3, the metropolitan territory of a city is strategically divided into districts, each having their own essential urban function clusters to support the population needs, making it less difficult to control population movements, cut off the virus transmission route. Empirical research using data in the US also suggests that living in a relatively polycentric region is significantly associated with a lower obesity probability. Individuals living in relatively polycentric regions tend to spend less time on sedentary activities and more time on moderate-to-vigorous physical activities (Yang & Zhou, 2019). For existing monocentric cities, strategies such as urban regeneration in areas surrounding the city center can help decentralize the otherwise concentrated urban functions in the mono-center, thus diversify urban livelihood in each district.

Beyond polycentric urban form is the legibility of virus transmission routes, which can include regional linkage such as food supply and international trade. Accompanying the decentralized urban functions with EPA across cities is the strengthening of regional linkages, or a “complex web of connections between rural and urban dimensions” defined as the ‘Urban-Rural Linkages’ by UN-Habitat in “Implementing the New Urban Agenda by Strengthening Urban-Rural Linkages”. The regional linkage acknowledges the interdependence of rural and urban regions and the need to achieve a balance between both regions in regard to promoting equitable, managed and mutually reinforced development to achieve a ‘Metropolitan Development’. This web of interconnection further helps the decentralization of urban functions from the city center by interconnecting the sub-centers so that the mono-center no longer monopolizes the transmission routes, easing partial lockdown in the cities without damaging the entire connection network.

Furthermore, there are other benefits brought in by polycentric urban form and its resulting polycentric, multilevel territorial governance. For example, the combination of spatial–territorial polycentricism and multilevel polycentric governance in EU was carried to address the challenges of managing external shocks, providing an adaptive and robust framework for the long-term sustainability of urban systems (Finka & Kluvánková, 2015). This also aligns with the city-region multilevel governance advocated by UN-Habitat in “International Guidelines on Urban and Territorial Planning”. The decentralized governance helps the integrative and participatory decision-making process that addresses competing interests, promoting “local democracy, participation and inclusion, transparency and accountability, with a view to ensuring sustainable urbanization and spatial quality.”

 

4. Building Primary Care Network:

One big challenge in public health of developing countries is the accessibility to healthcare infrastructure, particularly for disadvantage groups. The debate between equity and efficiency in health has never ceased. As a type of welfare, it ought to be distributed with equal access for urban communities; as a type of commodity, it needs also to rely on market and private sector financing to ensure efficiency. WHO has made much efforts in promoting “Human Rights and Health” that “health services, goods and facilities must be provided to all without any discrimination”, and “a country’s difficult financial situation does NOT absolve it from having to take action to realize the right to health” (The Right to Health Fact Sheet No. 31). But the hard reality is, in many cities of the developing world, the disadvantaged groups may find it difficult to access proper healthcare, due to the cost of service, segregation from facility locations, and urban sprawl.

Research found that although accessibility to primary health care (PHC) in urban settings is crucial, there are nevertheless under-served urban areas because of segregation (Shah, Bell, & Wilson, 2016). Large urban hospitals are usually located in the city centers, and the lack of universal healthcare coverage (UHC) in most developing countries, together with the their heavy dependence on commercial insurance schemes in financing healthcare services, may exclude disadvantaged groups who are more vulnerable to costs including travelling cost and medical service expenditure. These exclude the disadvantaged groups from preventative measures such as physical examination and vaccination, and pharmaceutical cures including medication and hospitalization.

With the intention to maximize welfare, urban planning should address equity of health, but the understanding of such issue should be accompanied by a deeper understanding of political and economic decisions. The geographical preference of large urban hospitals to be located close to the city centers, where population and research and educational talents are, cannot be simply altered by the advocates for equity of health. One solution is to strengthen a ‘primary care network’ that spread-out in the cities and provide relatively equal access to disadvantaged and poor communities. While urban hospitals are responsible for inpatient services, hospitalization, and academic research, the primary care network can take actions in providing for quicker and cheaper basic care services. This concept should be differentiated from the conventional primary care clinics – these providers in a primary care network can be government-subsidized agencies or NGOs who are affiliated with hospitals so patients can be transferred should more services needed, while providing for cheaper services compared to the clinics. Furthermore, this decentralized distribution of health resources across urban regions align with the aforementioned principles of EPA that shorter travel distance is needed for the patients to access care, compared to accessing urban hospitals concentrated in the mono-center of the city.

_{Figure 4 – Hospital Referral System, from “Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development” (Meara, et al., 2015).}

Hospital beds, intensive care units (ICUs), and ventilators are vital for the treatment of patients with severe symptomatic COVID-19 infection, and during an epidemic shock, it is common that hospitals can run out of inpatient capacity  (Moghadas, et al., 2020). This is the moment when the primary care network can step in to diffuse the patient burden. This deficiency of medical facilities can be offset by community-level medical institution to postpone the spread. An interesting model is the village doctor in China, also known as the ‘barefoot doctors.’ Their mobility and short-term but essential training (reduced cost for service) increased access to health care in China’s rural communities. But these interventions require a collaborative effort from both the government to take the political and fiscal initiative, and the planning agencies and professionals to ensure the implementation through master plans and planning policies. Both national and local governments should prepare for a ‘health crisis fund’ similar to a ‘rainy fund’ for municipal finance when dealing with epidemic shocks.

 

5. Inclusive Planning:

_{Figure 5 – Informal Settlement in Northern Jakarta next to a Reservoir, Photo Taken by the Author}

Paralleling the discourse of ‘the rights to health’ is inclusive urban planning that does not exclude disadvantaged groups from services in the cities. The basis of large population groups in a restricted area can provide the perfect conditions for different epidemics, particularly for overcrowded slums with low-income households who lack access to safe drinking water or proper sanitation can be more susceptible to infections. Disadvantaged groups, particularly those from minority status groups or informal settlements for instance, are disproportionately exposed to harmful effects of the built environment as they are segregated from advantaged groups. As a result, they experience a corresponding increase in related disease morbidity and mortality.

Moreover, population demographics matter too. Wu (2020) conducted a study on using data in China and found that compared to those aged 30–59 years, those aged below 30 and above 59 years were 0.6 and 5.1 times more likely to die after developing symptoms, and the risk of infection increased with age at about 4% per year among adults aged 30–60 years. Extra care and attention should be given to disadvantaged groups such as the elderlies, minorities and poor because they are more vulnerable to epidemics. Promoting equal access to urban health amenities for all can also be ensured through inclusive planning to include low-income households in well-located areas. Key tools for planners include inclusionary urban designs and plans i.e. ensuring areas have mixed use of functions and a social mix, which provide incentives or rules for including low-income households in new housing and commercial developments. Habitat III Issue Paper 8 accentuates inclusivity in planning, recognizing that “every person has the right to benefit from urban development. In terms of outcome, it promotes everyone’s access to services, jobs and opportunities and to city civic and political life.”

 

6. Digital Governance by national governments and cities:

If collecting global data on existing Covid-19, an intriguing phenomenon is that the reported cases are positively associated with the income levels by countries, shown in Figure 6 below. But this does not mean that population in the developed world is less resilient to the virus, nor does it imply that the developing countries are responding better to this pandemic than the developed countries. This may actually be caused by the lack of data on cases and lack of access to tests for population in the developing countries. Informality consists of a large proportion of the population in the developing countries. These populations not only lack access to care providers to take tests, but also lack information on knowledge, latest information, and even mechanisms for self-reporting to the government. This is caused by the lack of digital governance which monitors new cases and population mobility for better responsive policies. Furthermore, while the increasingly interconnected global network makes a total shutdown of these routes impossible, the movement of goods, services, and population and be made visible with digital governance for more expedient preventative measures.

_{Figure 6 – Relationship between GDP per Capita and Total Cases per Million Population by Countries, Population Density as Plot Size, Drawn by the Author, Data Source: https://ourworldindata.org/covid-cases}

Digitization of data related with health, mobility, requires developing cross-sectoral strategies that capitalize on the data and involving experts from various disciplines collaboratively. This should be combined with the development of public awareness of the epidemic using digital technologies. When the epidemic breaks out, without proper guidance by the public sector and the media, the public's tolerance for the crisis will become very low. The lack of understanding will seriously affect the normal urban functioning which has led to the loss of precious early response opportunities for cities (such as sudden and drastic population outflow due to panics). As a result, the government departments, the media, and professional organizations should provide accurate information in a timely manner. One good example is the COVID-19 Readiness and Response Platform offered by UN Habitat. If people could get the right information in time, then cities can effectively avoid unnecessary social panics and even riots, and make limited public resources play their due role.

 

Envisioning a Resilient Urban Future:

Our cities have become increasingly entangled with the global financial networks manifested through consumerism and celebration of financial and technological triumphs. Paralleled by the stylistic neo-liberal governance and globalized political economies, decision makers can easily believe that the evolutionary institution and resilient market can precisely accommodate for the civic demands and therefore constantly reshaping the datum of urban norms. However, the unique nature of health being both public good and commodity underscores the immediacy of creating a new fashion of urban planning practice and governance measures that critically reflects upon the existing paradigms. For example, state intervention could be reconsidered to balance the prevalence of place-based development in the redistribution of healthcare resources across all areas, to ensure equitable access to care for all.

The ‘COVID-19 and Urban Planning Position Paper’ by UN Habitat also highlighted key principles in regional development such as ‘network of cities’ to advocate for decentralization of services from megacities to medium sized cities, and from urban to rural: “This decentralization of services will also help relieve megacities from meeting the housing and employment needs of millions and will also provide a certain degree of self-sufficiency and autonomy to regions.”

Although starting as an epidemic crisis, the COVID-19 outbreak and the following quarantine policies have ascended to become the ignitor of socioeconomic crisis including public panic, overload of health sector, dying small and medium businesses, and the resulting unemployment surge. However, the COVID-19 outbreak can also be interpreted as an opportunity to retrospectively review the processes of urbanization globally, and the new norms of urban virtue require profound transformation of multiple aspects in the existing paradigms.  Understanding that the pandemic will change urban life forever. UN Habitat asked 11 leading global experts in urban policy, planning, history, and health for their predictions in “How Life in Our Cities Will Look After the Coronavirus Pandemic”. During a time when nothing can be certain, listening to different voices and engage in finding pathways to solutions can interweave our knowledge into new findings to keep us aware of our progresses as well as to remind us of the challenges ahead.

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