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Cities under Siege: Urban Planning and the Threat ofInfectious DiseaseRichard A. Matthew & Bryan McDonaldPublished online: 26 Nov 2007.

To cite this article: Richard A. Matthew & Bryan McDonald (2006) Cities under Siege: Urban Planning and the Threat ofInfectious Disease, Journal of the American Planning Association, 72:1, 109-117, DOI: 10.1080/01944360608976728

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Cities under Siege

Urban Planning and the Threat of Infectious Disease

Richard A. Matthew and Bryan McDonald

In the th century, improvements in water and sanitation systems, vaccina-tion programs, and antibiotics provided great hope that the dangers posedby infectious disease could be minimized, and perhaps even eradicated

(Armelagos, ). But despite great advances in public health, microbes haveproven resilient and persistent (Garrett, ; Price-Smith, ; World HealthOrganization, c). Diseases such as malaria continue to take a major tollacross the developing world. According to Enwereji (), “The main obstaclesto the effective control of disease [in the developing world] are migration, urban-ization, socioeconomic conditions, and a lack of adequate communication be-tween researchers, health workers and the population” (p. ). Emerging diseasessuch as HIV/AIDS and SARS demonstrate how quickly infectious diseases canspread, and how vulnerable every community is (Satcher, ).

Centralized food production and the dramatic growth in fast-food consump-tion have increased social vulnerability to food-borne disease, especially in West-ern countries (Centers for Disease Control and Prevention, a; Jekanowski,; National Intelligence Council, ). Hospitals have become reservoirs ofdangerous antibiotic-resistant diseases such as Staphylococcus aureus. Accordingto Smolinski, Hamburg, and Lederberg (), “The ability of infectious agentsto destabilize populations, economies, and governments is . . . a sad fact of life.The prevention and control of infectious diseases are fundamental to individual,national, and global health and security” (p. xi).

Beyond threats from naturally occurring diseases, concerns about bioterrorismhave increased in the past decade. Siegrist (), for example, states that there hasbeen “a shift in the goal of terrorists, from trying to make a political statementthrough violence to maximizing the number of casualties” (p. ). Stern () arguesthat in the world of contemporary terrorism, “religiously motivated groups are in-creasing” that “are unconstrained by fear of government or public backlash” and“could attempt to use biological weapons” (p. ). Similarly, Henderson () con-tends that attempts “to dismiss biological terrorism as nothing more than a theoreti-cal possibility” are “without validity” (p. ). Whether the result of careful planning byan Al Qaeda cell or the impulsive behavior of a disgruntled worker in a food pro-cessing facility, the threat of a serious intentional disease event cannot be ignored.

In this context, it is important to ask what cities should do to prepare for amajor disease event. Do urban health care systems have adequate surveillance and

Many analysts argue that the potential fora natural, accidental, or nefarious infec-tious disease event to have a dramaticimpact on urban areas in the UnitedStates and abroad is growing. After re-viewing the justification for this position,this article considers what cities shoulddo to prepare for a major disease event.Recognizing that prevention and prepa-ration receive insufficient attention, werecommend that planners seek out andwork with both public and private sectorgroups with roles in disaster planning;design land and transportation planninginformation systems to aid and supportdecision makers during crises; encouragegreater self-sufficiency in food productionand consumption; assist in the design ofhumane, realistic evacuation strategiesand routes; and consider the effects oftheir day-to-day recommendations ondisease risk and response.

Richard A. Matthew is an associateprofessor in the School of Social Ecologyand director of the Center for Unconven-tional Security Affairs at the Universityof California, Irvine. He is the securityfellow at the International Institute forSustainable Development, and worksclosely with the Departments of Defenseand State. His research focuses on inter-national relations in the developing world,especially South Asia, and he has pub-lished widely on human and nationalsecurity threats including environmentalchange, infectious disease, terrorism,and landmines. Bryan McDonald is theassistant director of the Center for Un-conventional Security Affairs and a Ph.Dcandidate in the School of Social Ecologyat the University of California, Irvine.His research examines the changing shapeof world politics since the end of theCold War, with a focus on human, en-vironmental, and international security.

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surge capacity? Have cities stockpiled appropriate medi-cations and worked out effective quarantine, evacuation,distribution, and risk communication strategies? Are re-gional cooperation protocols in place? Is decision-makingauthority clearly established at the most desirable level? Arelinkages between the private and public sectors, and acrossgovernment agencies secure and have they been tested? Andare lines of communication established to ensure access toinformation, including classified information, and otherforms of assistance that may be required?

While we believe that the probability of biologicalterrorism is small (although impossible to calculate), recentWorld Health Organization (WHO) and Centers for Dis-ease Control and Prevention (CDC) warnings about theHN variant of Asian bird flu make clear that the threat ofa serious disease event is significant, and perhaps greatertoday than at any time since (WHO, a). AlthoughAmerican cities are robust and agile, we argue that techno-logical innovations and globalization processes have intro-duced new forms of vulnerability to infectious disease intourban settings. We conclude with several suggestions forsteps that planners might take to reduce the threat infec-tious disease poses to urban environments. Our argumentis informed in large measure by years of close interactionwith first responders in Los Angeles and Orange Countyand with policy experts at the CDC, as well as experiencefrom two research projects on the security dimensions ofinfectious disease.

Assessing the Threat

Natural and Accidental InfectiousDisease Threats

Naturally occurring infectious diseases emerge andspread primarily through interactions among people, ani-mals, and their shared environments. Throughout history,such diseases have had a significant impact on human soci-eties. The Spanish influenza pandemic killed more than, people in the United States and another to million globally (Crosby, ). The outbreak of SevereAcute Respiratory Syndrome (SARS) provides a more recentexample of the speed with which diseases can emerge andspread (National Intelligence Council, ). According tothe CDC, “SARS was first reported in Asia in February

and over the next few months the illness spread to more thantwo dozen countries in North America, South America,Europe, and Asia before it was contained” (CDC, ).

In February , Dr. Julie L. Gerberding, head of theCDC, warned, “We are seeing a highly pathogenic strain

of influenza virus [HN] emerge across . . . western . . .Asia. . . . [We] may see the emergence of a new strain towhich the human population has no immunity” (Lempi-nen, ). By mid , human cases of HN hadbeen reported, resulting in deaths (WHO, b). TheCDC and WHO believe that these cases were caused byhuman handling of infected birds, which are the naturalreservoir for HN, although anecdotal evidence fromSoutheast Asia suggests that human-to-human transmissionmay have occurred in a small number of cases. The greatfear of public health officials is that HN will become eas-ily transmissible among humans, something that is typicalof influenza arising from avian reservoirs, and that couldhappen very quickly. Should this occur, the CDC (b)estimates that it would cause between , and ,

deaths, with an economic impact ranging from $. to$. billion. Table shows factors contributing to infec-tious diseases’ emergence, re-emergence, and persistence.

Naturally occurring infectious disease extracts a tollbeyond human lives. Direct economic costs include work-ers’ compensation, lost productivity, decreases in tourismand travel, and reduced markets for goods. A report by BioEconomic Research Associates found SARS to be “thecostliest in a series of infectious disease outbreaks in humanand animal populations . . . that have cost over $ bil-lion (not including HIV/AIDS) to economies around theworld over the past decade” (Newcomb, ).

Nefarious Infectious Disease ThreatsDuring the Cold War, many countries such as the

United States, Canada, France, Russia, and South Africa(Center for Nonproliferation Studies, ) investigatedpathogens as potential weapons that they might use or towhich they might need to respond (Russell, ). Whilebiological weapons were outlawed in by the Biologicaland Toxin Weapons Convention, significant clandestineresearch programs continued in South Africa and theSoviet Union after the treaty was signed (Alibek & Han-delman, ). Today the expertise and technologiesdeveloped during the Cold War are surfacing on the blackmarket around the world. The development and prolifera-tion of advanced biotechnologies in recent years may alsoaid efforts to develop biological weapons, and raises thepossibility of creating more virulent or previously unknowntypes of biological weapons (Central Intelligence Agency,; Gilsdorf & Zilinskas, ).

Tampering with the food supply is widely regarded asa plausible and potentially devastating scenario. A study byWein and Liu () suggested that the introduction of asmall amount of botulinum toxin into the milk supplycould result in illness and even death for , people in

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the United States. These researchers at Stanford Universitycontend that the same is true for “similar food products,such as fruit and vegetable juices, canned foods (e.g., proc-essed tomato products), and perhaps grain-based and otherfoods” (p. ). The vulnerability of the milk supply holdsa special significance, as there have been several cases of ac-cidental contamination of milk products that have affectedlarge numbers of people, including an outbreak of Salmo-nella typhimurium in linked to the post-pasteurizationcontamination of milk from a U.S. dairy that sickened, people (Ryan et al., ), and an ice cream pre-mixthat was contaminated with Salmonella enteritidis, causingillness in over , people in states in (Hen-nessy et al., ). The CDC estimates that approximatelyone out of every four Americans develops a food-borneillness each year, resulting in , hospitalizations and, deaths (Mead et al., ).

While there is disagreement about the difficulty in-volved in creating and successfully employing biologicalagents as weapons (Alibek & Handelman, ; Zilinskas,), the anthrax incidents of October were suffi-ciently alarming to raise concerns about hospital surgecapacity and triage strategies in times of crisis (CDC, c;Glaser et al., ; Schultz, Koenig, & Lewis, ; U. S.Department of Health and Human Services, ); theneed for better disease surveillance and reporting systems(CDC, ; Emanuel et al., ; Stoto, Schonlau, &Mariano, ); the security implications of an open andtransparent research community (Kahn, ; National Re-search Council, ); and the adequacy of vaccination andresponse plans (Alibek & Bailey, ; Taylor et al., ).

Many analysts believe that the conditions for a naturalepidemic, a successful act of biological terrorism, or a large-

scale biological accident are in place (Garrett, ; Tucker,; Stern, ). Since cities function as hubs in eco-nomic, transportation, information, and social networks,they are likely accident sites, logical points of concentrationfor naturally occurring diseases, and ideal targets for thenefarious use of biological agents. Indeed, urbanization am-plifies many infectious disease threats. Hence the capacityof cities to prevent and manage infectious disease deservescareful consideration. Our focus here is not on those infec-tious diseases that are well established in U.S. urban set-tings, and for which public health systems are adequatelyprepared. Rather our concern is with dangerous infectiousagents that might suddenly be introduced into a city,successfully bypassing national defenses.

National Security and UrbanVulnerability

A well funded cluster of government entities, includ-ing the Departments of Defense, Homeland Security, andState; various intelligence agencies; the National SecurityAgency; and the Centers for Disease Control, work togetherto provide national security from external threats. While thecapacity of the United States to deter a foreign army is ef-fective, other threats from outside our borders are far lessamenable to traditional security strategies. Many transna-tional threats can move into the U.S. virtually unimpededby integrating themselves, deliberately or unintentionally,into legitimate transboundary flows (Matthew & Sham-baugh, ). For example, drugs can be smuggled in ship-ments of coffee, money earned through criminal means(also called “dirty money”) can be laundered through

Matthew and McDonald: Cities under Siege

Table . Factors contributing to the threat of infectious disease, with research citations.

Factor Example Source

Environmental and climate change Malaria Armelagos (); National Research Council (); Smolinski,Hamburg, & Lederberg ()

Human migration and urbanization HIV-AIDS National Intelligence Council ()

Economic development and land use patterns Rift Valley fever National Intelligence Council ()

Misuse of antibiotics and microbial adaptation Nosocomial (hospital- National Intelligence Council ()acquired) diseases

Processes of globalization such as rapid travel SARS Brower & Chalk (); National Intelligence Council ()

Poor quality health care and the collapse of health Tuberculosis National Intelligence Council ()care systems

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complex and seemingly legitimate banking transactions,and an infectious disease may be carried onto an airplaneby an innocent and unsuspecting carrier, infecting peopleentering several other countries long before manifestingany symptoms. This last example is precisely how SARSemerged and spread during (CDC, ). An inno-cent carrier might even be intentionally infected with anagent such as smallpox.

Network theory helps us understand why such threatsare so hard to neutralize. Networks are composed of linkednodes (Barabasi, ). In scale-free networks, the mostcommon type in both nature and society, some nodes haveconsiderably more links than others. Barabasi () suggeststhat typically about % of a network is linked throughabout % of its nodes, called hubs. The only way to dis-able a scale-free network is to disable, or lock down, its hubs.The problem is that this will disrupt many other legitimateflows through the network, thus the cost of a lockdowncan be enormous. To try to address this issue, securityexperts focus on devising filters that can screen out threatswhile allowing hubs to function normally otherwise. Butfilters are less effective than lockdowns for isolating threats,whether the hub is an airport or an internet search engine.

As long as threats enter and traverse the U.S. on net-works that we rely on for information, transportation, food,and communication, comprehensive national strategiesaimed at prevention are likely to be of limited utility. Citiesnow connect to the world through multiple pathways, eachmade up of many links. City leaders and planners shouldnot assume that external threats are being deterred or man-aged effectively at the federal level, as they were during theCold War era. Instead, they should assess the vulnerabilitiesand resources of their particular communities, and plansecurity postures that complement or even act independ-ently of national security policy.

The United States Department of Homeland Security’sNational Response Plan (NRP) calls for developing a mul-tidisciplinary, all-hazards approach to addressing domesticincidents (U. S. Department of Homeland Security, ).The NRP recommends that prevention, preparedness, re-sponse to, and recovery from natural, accidental, and ne-farious hazards be broad and inclusive. It advises involvingall necessary stakeholders in developing robust responsesystems that are both mindful of local needs and condi-tions and integrated into state and federal response net-works. This ongoing process provides an opportunity forplanners to consider such threats and work to integratelocal and regional planning expertise into the preventionand preparedness steps of the response process.

Elements of a New Urban SecurityParadigm

In the past several years, governments carried outseveral exercises designed to assess urban preparedness formass casualty crises involving biological, chemical, ornuclear weapons. These exercises were local and regional(Orange County, California’s, Orange Shield exercise inSeptember ), national (TOPOFF in , DarkWinter in , and TOPOFF in ), and even inter-national (Atlantic Storm in ). While these exercisessimulated intentional attacks, reports analyzing themunderscore weaknesses in two areas that are generallyrelevant to the topic of urban preparedness for a majordisease event: command and decision making, and medicalcapacity and procedures.

According to these reports, responsibility for com-mand and decision making is poorly defined at all levels,and those likely to be in charge generally have given littlethought to how they would respond to a situation involv-ing a biological weapon. It is important to remember thatthose first on the scene will be in charge, at least initially.In the case of a biological threat, whether natural or nefari-ous, it is during this crucial initial phase of response, beforededicated resources and experts can be brought to the scene,that decisions will determine the scale of human and othercosts (Federal Emergency Management Agency, ).Even when the experts arrive, who is in charge will mattergreatly to local residents. If no one who is credible withlocal residents reassures them that the situation is undercontrol and provides clear answers to simple questionsabout medical assistance, water, and the need for evacua-tion or relocation, they may become antagonistic, exces-sively alarmed, or distrustful of official communications.

In addition to managing the public, on-the-spot deci-sions will be required concerning quarantines and evacua-tions. Throughout this initial response, the competing goalsof saving lives, preventing further injury, reassuring thepublic, limiting liability, and gathering evidence, usuallyinvested in different agencies, can lead to confrontation andfailure unless there is an effective decision-making center.In short, if cities have not thought about response andtrained the appropriate personnel, the consequences willinevitably be higher.

Through private discussions with the Federal Bureauof Investigation agent in charge of evidence collection atthe sites of the Oklahoma City bombing and the firstWorld Trade Center bombing, we learned that in bothcases each of the various agencies involved quickly set upits own command post. Interagency competition and lackof established protocols choked the flow of information,

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made it difficult to coordinate actions, and led ultimatelyto costly, suboptimal decisions.

Second, the various exercises strongly suggest thatprocedures to establish medical priorities and distributemedical supplies to affected populations remain problem-atic. Moreover, in the event of a major incident involvinglarge numbers of casualties, the medical and healthcaresystems of large urban areas would be overloaded in a mat-ter of hours. Few concrete steps have been taken to plan,prepare, and educate the population about what to do inthe event of a major crisis. Yet such actions could signifi-cantly reduce the hordes of “walking well” likely to demandmedical care although they do not display any symptomsof exposure. Simpson () expressed concern that al-though many people assume that medical interventionsafter the fact will be sufficient to address a significantbiological attack, accident, or major epidemic, such anapproach may prove ineffective, costly, and upsetting tothe general public. Simpson instead recommends devotingfar greater resources than in the past to preparedness,prevention, and detection.

Safer Cities: Big Picture, Small Steps

The findings from the exercise reports referencedabove, recent research on disaster management (Burby etal., ; CDC, ; Federal Emergency ManagementAgency, ; Gilfillan et al., ; King, ; Lasker,), and extensive interaction with first responders andpublic health experts helped us to identify six foundationalareas in which we recommend steps to reduce urban vul-nerability to infectious disease. As a general rule, plannersshould be integrated into existing disaster managementsystems so that they can bring their expertise to bear onimmediate challenges such as urban evacuation and foodsecurity, and so that they become sensitive to the ways inwhich planning decisions might affect the public’s vulner-ability to infectious disease threats.

Early Warning SystemsThe infectious disease threats discussed in this article

fall outside the routine experiences of urban public healthofficials and doctors. But as in many areas of national andhuman security, the speed and accuracy with which athreat is detected will greatly affect its overall cost to soci-ety. Early warning schemes such as syndromic surveillancesystems that track clusters of symptoms are often regardedas an additional burden hospitals prefer not to shoulder.Both the CDC and WHO track infectious disease globallyand issue advisories, but both depend on input from doc-

tors and hospitals. Thus it is important that urban andhealth planners work with first responders to assess theearly warning needs of urban areas and design appropriateinformation systems that can support local decision mak-ing and harmonize with state and federal systems.

Resource ManagementIronically, some of the resources a city needs in order to

survive and flourish, such as a steady supply of food, can alsofunction as effective disease vectors. While water systems arecarefully monitored and thus are somewhat more difficult tocompromise with a biological agent, the food supply is notnearly as secure. Food is now produced through vast globe-spanning networks that are vulnerable at many points, suchas during processing and packaging. One partial solution isto encourage higher levels of reliance on local agricultureand markets, including through land use regulation and in-frastructure planning. If planners encourage a greater degreeof self-sufficiency in food production and consumption,they also enhance security and public health.

LogisticsPreparing for a major disease event should include se-

curing, testing, and communicating to decision makers thelocation and adequacy of medical supply stockpiles, triagepractices, and surge capacity in hospitals and other facilities.This will greatly facilitate access to critical resources such asvaccines and medical care should such an event occur.

Adequate supplies of medication, water, and food areof little value if they cannot be distributed in a timelyfashion. Our discussions with first responders suggest thatthey are frustrated by the limited access to many strategi-cally important and densely populated urban areas. Forexample, the economic value of the Long Beach–LosAngeles Port system is enormous, and it has often beenidentified as a potential target of terrorist activity. A nefari-ous or accidental biological release in the port could alsopose a serious rescue challenge. How should the diseasebe contained? How should people be evacuated quickly?Transportation planners should work with public healthofficials and first responders to develop systems that willchannel information to decision makers during a crisis, andalso assist in the design of evacuation routes and lock-downprocedures. Transportation and infrastructure plannersshould also systematically consider how their day-to-dayrecommendations might affect the city’s ability to respondto an infectious disease incident in the future.

The efficient distribution of a vaccine or other medi-cation could also be a serious problem for many cities.Freking () reported that Health and Human ServicesSecretary Mike Leavitt told Associated Press reporters and

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editors that the current system of delivering medicines wasinadequate in case of a major emergency. Leavitt recom-mends using the U.S. postal service for its ability to rapidlymove large volumes of goods with a high level of reliability.Vaccines, however, pose a special problem in that they needto be administered by health professionals. The distribu-tion process could be accelerated dramatically if suppliescould be delivered directly to necessary locations and ifvolunteers were trained to do the paperwork during anemergency. In many areas, arenas, concert halls and sportsstadiums have been designated for use in emergency situ-ations. even though they may not be well suited to suchroles. City planners can help both in identifying the rightlocations for such surge deliveries, and in thinking abouthow to design and prepare such spaces for their roles intimes of crisis. Planners can also help identify those in thepublic, private, and nonprofit sectors who could be trainedto assist with logistical issues, such as handling confidentialpatient information in the case of a major disease event.

CooperationIt will also be key to ensure smooth coordination

between local private and public sector entities, acrossagencies, and between local and outside sources. Peoplewant to help during an emergency. Anyone who has di-rected a major event scene knows that a cascade of offersarrives in a very short time. Coordinating these offers is anenormous challenge. Following the bombings in New Yorkin and Oklahoma City in , considerable time wasrequired to work out a viable framework for coordination.This time would have been better spent assisting the public,assessing damage, and collecting evidence. Planning direc-tors might begin by securing invitations to make presenta-tions of their information resources and staff capabilities toprivate sector groups, such as the Homeland Security Advi-sory Council for Region I (Southern California), whichbrings business leaders together with the Los Angeles andOrange County Sheriff’s Departments.

CommandAs noted earlier, exercises found disaster command

and decision making to be poorly defined. It should beclear who will be in charge during a major disease event,what intelligence will be essential to support decisionmaking, what resources will be available to support deci-sions, how decisions will be communicated, and how theirimplementation will be monitored, with new informationcycling immediately back to the command center. As itstands, there appears to be widespread faith that things willwork out. Experience demonstrates that this is not the case.

In the case of a major disease event, someone mayhave to order an evacuation or a lockdown. While studiesdemonstrate that citizens respond well to sensible plansimplemented by confident authority figures, a lack ofconfidence can result in panic. First responders in South-ern California worry that if many people attempt to fleean incident by car, congestion could transform the areainto a giant parking lot. Land use and transportationplanners have the information to support humane, realisticstrategies that would effectively move or contain largenumbers of people.

CommunicationFinally, those in command must manage public reac-

tion to the crisis by communicating with the public andothers, including state and federal officials. While histori-cally radio and television have been the preferred ways ofreaching the public, the internet and cell phones are dis-placing these media. During the attacks on September ,, many individuals trapped inside the World TradeCenter used cell phones to communicate with the outsideworld and obtain guidance. Ironically, those who con-tacted friends and family members and learned what wasbeing said on television fared far better than those whocontacted and were told to wait until first respondersarrived. Self-organizing networks based on a mixture of cellphone, internet, television, and radio will surely be the adhoc communication systems of future disasters. Authoritiesshould develop strategies for working within these networksrather than independently of them as happened, at greathuman cost, in New York in . One goal of currentinformation technology research is to find ways to channelinformation from self-organizing networks to decisionmakers. Transportation, land, and infrastructure planninginformation systems, such as web sites or phone hotlinesthat provide information about current levels of trafficcongestion, may be useful to individuals as well as officialresponders in these situations. Planners should consider thiswhen designing such systems, and seek input from othersin the community with disaster planning responsibility.

Conclusions

Many analysts believe that today’s large urban areasare more vulnerable to a range of transnational infectiousdisease threats than has been the case for almost a century(Garrett, ; National Intelligence Council, ). It istherefore important to prepare for natural, accidental, andnefarious infectious disease events in urban areas. We have

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identified six components of emergency preparedness andresponse needed for a satisfactory urban defense. Amongfirst responders and public health professionals, we seeheightened concern that public officials are not actingquickly and decisively to take the commonsense steps thatcould prevent dangerous situations from spiraling into di-saster. Many of these steps relate to access and movement,areas in which planners have information, expertise, andpractical influence. Overall, we recommend that plannersseek out and work with both public and private sectorgroups with roles in disaster planning; design land andtransportation planning information systems to aid andsupport decision makers during crises; encourage greaterself-sufficiency in food production and consumption; assistin the design of humane, realistic evacuation strategies androutes; and consider the effects of their day-to-day recom-mendations on disease risk and response.

Notes. The Center for Unconventional Security Affairs at the University ofCalifornia, Irvine, participated in the “One World, One Health” projectled by the Wildlife Conservation Society, which explored the linksbetween conservation practices and the transfer of zoonotic disease tohuman populations, and a study led by Bio-Era, which modeled thebusiness and economic impacts of a bird flu pandemic. For details, seeour web site (www.cusa.uci.edu). See the following sources for more information: TOPOFF (Inglesby,Grossman, & O’Toole, ); Dark Winter (O’Toole, Mair, & Inglesby,); TOPOFF (U.S. Department of Homeland Security, );Orange Shield (McDonald, ); Atlantic Storm (Smith, ).. Historically, the question of who would be liable for accidental deathshas slowed developing and disseminating vaccines and other prophylacticmeasures to the public. The possibility that producers might be legallyliable for adverse reactions is also one explanation for declining numbersof companies making vaccines.. This information comes from private communications with RickHahn in and . Mr. Hahn is retired from the Federal Bureauof Investigation.

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