Design in the age of pandemics

Throughout history, how we design and inhabit physical space has been a primary defense against epidemics

By Diana Budds  Mar 17, 2020

The Lovell Health House, in Los Angeles, is one of those places that makes you green with envy. Perched on a hillside, the gleaming, all-white modernist house is bathed in sunlight and has floor-to-ceiling windows throughout. There’s a soaking pool, avocado trees in the yard, huge porches, and a roofdeck. It’s house porn with a higher purpose: Its architect—Richard Neutra, famous for his case study houses—designed it in the late 1920s for Philip Lovell, a nutritionist, naturopathic doctor, and Los Angeles Times columnist who believed in the virtues of a raw-food diet, ample sun, and fresh air. His home was tailored for a lifestyle of health and wellness—and it takes its cues from buildings designed to cure tuberculosis.

For thousands of years, humans have looked to physical space to treat and cure sickness, just asPhilip Lovell did. People have redesigned cities, infrastructure, architecture, and interiors all in the name of minimizing the risk of infectious disease. Meanwhile, enterprising businesspeople have capitalized on the fear of germs to sell products and services that supposedly stopped the rumored causes of illness (spoiler: they usually didn’t work). It’s only recently—with advancements in virology, bacteriology, epidemiology, and medicine mostly in the 19th and 20th centuries—that antibiotics and immunizations have been on the frontlines of infectious diseases. Now, with new diseases emerging, like COVID-19, and no vaccines or cures to fight them, one of the most effective solutions is to go back to the physical: social distancing, quarantine, isolation, and, perhaps, adaptations to our cities, neighborhoods, and homes.

“We have novel diseases that we don’t have a cure for and we have global travel so that means a pathogen can jump into a human being and that person can be in basically any global city within 24 hours and so the only thing we have left is quarantine,” says Geoff Manaugh, who, along with his wife Nicola Twilley, is writing a book about quarantine, due out in spring 2021 from MCD Books. “We have to return to this kind of medieval spatial response to disease control, which means that architecture and urban design suddenly become medical. There’s something totally fascinating about that—that we can use the built environment as a way to control epidemic spread.”

It’s an innate human instinct to distance yourself from danger, to put space between you and whatever it is. As early as 400 BC, Hippocrates theorized that poor physical environments, like bad air and water, caused illness and disease, and believed that going to areas with fresh air and water were essential to health. The word quarantine—which means restricting the movement of people of goods—is rooted in the latin word for “forty days,” a reference to preventative measures taken in Venice during the middle ages to stop the spread of the bubonic plague. Ships arriving from areas affected by the “Black Death” were required to anchor for 40 days before the crew could disembark. After the Apollo 11 astronauts returned from the moon in 1969, NASA quarantined them in an Airstream trailer for 21 days out of precaution for bacteria or organisms that they might have brought back with them from the mission.

“[Quarantine is] a spatial buffer, it’s a temporal buffer,” Manaugh says. “It’s almost like an algorithm of adding space and time and preventing something from encountering us immediately. That’s stayed the same over the centuries.”

Manaugh and Twilley’s book is based on years of interviews and travel, and grew from earlier curatorial research for exhibition they organized the Storefront for Art and Architecture in 2010 called “Landscapes of Quarantine.” The exhibition explored historic spaces of quarantine—like NASA’s Airstream; the Chernobyl Exclusion Zone; areas of Guantanamo Bay that the U.S. used to imprison HIV-positive Haitian refugees; and the islands around New York City, which were once used to hold immigrants before entering the country, for smallpox patients, and for people who had other infectious diseases, like Typhoid Mary.For the exhibition, Manaugh and Twilley invited designers to imagine the future of quarantine given the urgency of our era of antibiotic resistance, new diseases, pandemics, and bioterrorism. These speculations included a satirical public health campaign about making the most of your time in quarantine, and a look at how cities might accommodate more spaces for quarantine, which raised issues of ethics and discrimination.

Space, as it relates to infectious disease epidemics, isn’t just about quarantine; it’s also a design problem. If you look around most neighborhoods today—in cities and suburbs—you’ll see evidence of how humans have responded to infectious disease by redesigning our physical spaces. Sara Jensen Carr, an architecture professor at Northeastern University, is exploring the connection in her forthcoming book The Topography of Wellness: Health and the American Urban Landscape, due out from the University of Virginia Press in fall 2020.

Carr’s book focuses on design interventions from the industrial revolution until today and explores them through the lens of epidemics, including infectious diseases like cholera, typhoid, and tuberculosis; how the burgeoning field of urban planning used public health to advance its ideas in the 19th century; how 20th century modernist architects viewed their buildings as a type of medicine; how the language of epidemics was misused during the 1960s to advance discriminatory city planning; and today’s interest in using urban design to address obesity and mental health.

During the industrial era, modern sanitation and water systems were originally created to fight the pathogens that causecholera and typhoid. Before indoor plumbing and sewer systems were common, it was typical for raw sewage to flow out of buildings and directly onto city streets. It wasn’t until a severe cholera outbreak in London in the 1850s that a physician proved contaminated drinking water caused the deaths. Prior to that the prevailing theory was “miasma,” the medieval understanding that disease was spread through contact with “bad air,” like vapors emanating from rotting organic matter.

This eventually led to a sanitary reform movement, which created drinking water and sewage infrastructure. As Carr explains in her book, this worldwide movement led to straighter, smoother, and wider streets that were necessary to install underground pipe systems and that could be washed down.

Frederick Law Olmsted, who was a sanitary officer during the Civil War, used public health to convince New York City to build Central Park, arguing that its open spaces would become “the lungs of the city.” His belief in the medicinal qualities of green space also influenced his 1868 master plan for Riverside, Illinois, a “garden suburb” that was viewed as a healthier alternative to city life due to widespread access to recreational space.

The sanitary reform movement also became a domestic issue, as germ theory—or the scientifically proven theory that microorganisms cause disease—began to overtake the miasma theory as the accepted reason why people became sick. As Nancy Tomes explains in her book The Gospel of Germs: Men Women and the Microbe in American Life, large-scale public health campaigns between the 1880s and 1920s began educating people that microorganisms caused illness and an obsession with cleanliness took root, particularly in affluent homes.

Certain furnishings were perceived to collect germs so it became popular to get rid of them. An 1887 manual urged women to break with the Victorian style of home furnishings and opt for items that wouldn’t collect dust, which was believed to carry disease-causing microorganisms: “To propitiate the goddess of health, we can well afford to sacrifice on her altar the superfluous draperies, carpets, and ornaments of our living and sleeping rooms,” it said.

Before the 1880s, bathrooms were decorated similarly to other rooms in affluent homes, complete with carpet, drapes, and wooden cabinetry. Removing those items became popular in the late 1800s and early 1900s. At the dawn of the 20th century, companies selling flooring and wallcoverings capitalized on the assumption that smooth, impervious surfaces were healthier than carpet and textiles. Materials like porcelain, tile, and linoleum became coveted for the spaces that were most closely associated with germs, like kitchens, bathrooms, and laundry rooms.

Modernist architects believed that clean, sanitary spaces were essential for treating illness and Sara Carr explores this phenomenon in her book. Sanatoriums, for example, treated tuberculosis by isolating people with the illness and giving them access to sunlight and fresh, dry air. Hallmarks of modernist sanatorium design—which experienced a surge in the 1920s and 1930s—included large windows, balconies, flat surfaces that wouldn’t collect dust, and white paint, which offered the appearance of cleanliness and made residues and smudges visible.

Those traits crossed over from health care architecture into residential, like Neutra’s design for the Lovell Health House. Le Corbusier, arguably the most famous modernist architect, was notorious for his obsession with cleanliness in his designs. The Villa Savoye, an influential modernist house he created, features a handwashing sink right near its entrance.

“Le Corbusier viewed light and air as being medicinal,” Carr says. “He talks about the exact cubic feet of air and square footage of windows [in his architecture]. It would be the perfect amount for optimum health. He’s thinking about doses and germ theory.”

Infectious disease was also one of the drivers of housing reform and the urban renewal era between the 1930s and 1970s. In New York City, overcrowded living conditions in tenements were perceived to be “fever nests” and “lung blocks” for the high rates of residents with tuberculosis infections.

Public health was used to rationalize slum clearance programs, which disproportionately targeted African American and Latino neighborhoods, which were perceived to be diseased, to make way for “healthier” public housing towers. 1930s Works Project Administration propaganda posters proclaimed that “Planned Housing Fights Disease.”

“By comparing urban blight to cancer and infectious diseases in terminology and by mapping blight door to door like cholera, [policy makers] were able to convince people it was ‘contagious,’ like it could spread to the suburbs, so that the only possible solution was eradication,” Carr explains. “Slums and urban blight were not actually disease in of themselves, rather the result of policies, disinvestment and racism, so really the only effect was the displacement of the people that lived in these neighborhoods, which in turn left them vulnerable to social conditions that continue to plague their health today.”

As immunizations, antibiotics, and antiviral drugs became more advanced, using the built environment to treat infectious disease epidemics waned. Building in new ways to fight disease was effective in mitigating the spread of disease, as was the case with sewer and water infrastructure and reducing overcrowded housing (which helped reduce transmission of some diseases, like tuberculosis), but it was a blunt tool in comparison to medicine.

“There was a real decoupling of environment and health interest when germ theory came to the forefront,” Carr says. “When we had diseases that were more effectively tackled by vaccines, like polio and Tuberculosis, there wasn’t that coordinated government action [on urban landscapes]. Vaccines and medicines became the best way to treat [these epidemics].”

Meanwhile, there was a split between medicine and public health during the 20th century. As medicine was used to treat disease, public health became more about behavior and societal systems. But now, with no medicine available to treat emerging infectious diseases, like the COVID-19 pandemic, using space as a way to address epidemics has renewed interest.

In a recent article for The Conversation, three professors specializing in environmental health, urban geography, and global suburbanization, argued that deeper understanding of how we build our cities is urgently needed.

“We need to understand the landscapes of emerging extended urbanization better if we want to predict, avoid and react to emerging disease outbreaks more efficiently,” they wrote. “Rapid urbanization enables the spread of infectious disease, with peripheral sites being particularly susceptible to disease vectors like mosquitoes or ticks and diseases that jump the animal-to-human species boundary.”

In a recent Citylab story, Michele Acuto, professor of global urban politics in the School of Design at the University of Melbourne, speculated that building out our digital infrastructure—from a need to stay connected while being socially distant—could be the equivalent to the 19th century’s use of civil engineering and urban planning to address cholera and typhoid.

Carr hopes that there might be a revival of the sanitation movement that brought us infrastructure like safe drinking water and sewage systems. Consider the lack of safe, clean, accessible public bathrooms in all across America. The CDC recommends washing hands after sneezing, coughing, blowing your nose, or using a public space to reduce the risk of COVID-19 infection. How are we supposed to do that if public bathrooms aren’t readily available?

“Kigali had mobile temporary hand-washing stations. Will we see a version of that in the U.S.?” Carr says. “The problem is, we’re terrible at maintaining infrastructure…The United States has abandoned its public realm. Maybe we should think about the value of the public realm and public space in combating this thing.”

Manaugh could see a use for technology in addressing the need for quarantine and isolation to slow the spread of epidemics: “In terms of keeping people isolated, maybe [a smart home] can read your temperature and it knows you can’t go out into the shared parts of an apartment building,” Manaugh says.

While some version of Alexa confining you to your home sounds pretty dystopian, Manaugh also imagines more pragmatic approaches. “What I think would be interesting to see is, fast forward five years or even 10 years, if the average American home has surreptitiously and kind of quietly absorbed design cues from the health care industry in order to make the domestic interior safer for germ transmission,” he says. “That might mean new materials, it might mean totally different kinds of design.”

The future remains uncertain, and as the COVID-19 pandemic continues to spread, more questions will undoubtedly arise. Seemingly overnight, our way of life has changed as hospitals overflow, as cities go on lockdown, as schools close, and as working from home becomes more prevalent. Larger societal implications and how they’ll manifest through design is something Carr is actively thinking about.

“One thing we’ve gotten away from looking at—and this is in early writing from Hippocrates and [the ecologist] Aldo Leopold—is thinking about how our bodies reflect disruptions in the ecosystem,” she says. “What’s good for the body is good for the ecosystem. My body of work is looking at how climate change impacts our health: What does [climate change] mean for air pollution? For vulnerable populations? I always wonder: What do these pandemics have to do with a warming world? What will we learn in the long term?”