Resilience Roundtable: A Medical Anthropologist Says Planners Are Vital to COVID-19 Recovery

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[00:00:12.270] Jim Schwab, FAICP: Welcome to the American Planning Association podcast. This episode continues our series that looks at how different communities prepared for and responded to natural hazards, such as floods, wildfires, hurricanes, and more. How have planners in these communities promoted resilience in their hazard mitigation and disaster recovery planning? We'll find out on this episode of Resilience Roundtable, brought to you in conjunction with the American Planning Association's Hazard Mitigation and Disaster Recovery Planning Division. I'm your host, Jim Schwab, FAICP. I'm chair of APA's Hazard Mitigation and Disaster Recovery Planning Division. Our guest today is Dr. Monica Schoch-Spana, a medical anthropologist and a senior scholar with The Johns Hopkins Center for Health Security. Dr. Schoch-Spana is also a senior scientist in the Department of Environmental Health and Engineering at The Johns Hopkins University Bloomberg School of Public Health. Her areas of expertise include community resilience to disaster, public engagement in policymaking, crisis and risk communication, and public health emergency preparedness. Welcome, Dr. Schoch-Spana.

[00:01:26.870] Dr. Monica Schoch-Spana: Thank you so much, Jim. Pleasure to be here.

[00:01:29.560] JS: Monica, I suspect most planners may not be familiar with the type of training you have and the type of work your position entails. Can you give us a briefing on the nature of your field and how, in your view, it may relate to urban planning?

[00:01:45.380] MS: Sure. I'm trained as a cultural anthropologist, so I'm interested in how people relate to one another, organize their communities, how they feel about one another, how they organize their institutions, how they tell stories to one another and share knowledge. So I'm focused on people. And I got into the field of public health emergency management more than 20 years ago. And so I brought, I believe, an important perspective to the problem of epidemics, disasters, and other extreme events that would have negative health consequences. And my colleagues in medicine and public health focused a lot on technical and managerial issues, such as will our hospitals be able to handle large numbers of casualties? Will our public health departments be able to interrupt transmission of disease? Will we have medical countermeasures like antibiotics, antivirals, and vaccines that could both prevent and treat infection? And I thought, you know, those are great challenges, but there are sociocultural components that we need to pay attention to. So I've focused mostly, Jim, on the role of the larger community in managing extreme events.

[00:03:12.740] JS: Great. Well, what, in your opinion, is the most logical long-term area of potential collaboration between community planners and the medical profession, especially public health? Are there specific issues related to pandemics or epidemics, for instance, where planners can make a meaningful contribution to maintaining public health?

[00:03:32.180] MS: When I've interacted with planners, I've been struck by three capabilities in, in that workforce. And the first is having the big picture in mind and seeing the interconnections among all parts of society. I've also been struck by the long-term planning horizon. Most of us actually are, you know, stuck in the immediate, the now, the urgent, and we don't give much thought to longer-term impacts and thinking ahead. So that's a second piece. And the other is the involvement of a larger public in the decision-making process about how they want their communities organized. And those three skills or capabilities or perspectives I think are a profound gift to public health, which also as a community of practice is interested in the well-being of people. But what we're seeing in the pandemic is, with the active presence of COVID-19 disease, is of course the urgency of responding to that emergency. So the surveillance and monitoring of the disease, communicating to the public about protective actions. And so there's an urgency to public health's role in containing the spread of disease and making sure that people who are sick get the appropriate care that they need. So I don't want to take away from the immediacy of pandemics, but I think what planners can offer is that person-focused long-term perspective and big picture. And for those planners who have worked in disaster-affected communities, they know that strong desire to get back to business as usual. And we see this with the pandemic. I mean, people are stuck in a protracted, confining, chafing public health response to COVID-19. And we all want to get back to the way it was. And planners, I think, have proven so beneficial in offering that perspective of, wait, hit the pause button for a minute. Do we really want to go back to the way it was before? Or why don't we seize this moment as an opportunity for transformation? And I think that perspective on longer-term processes of improvement can really complement public health right now, which is so caught up — and rightly so — in trying to interrupt transmission of disease. And these processes of response and recovery should be happening at the same time, and planners can really bring an important set of skills to these conversations.

[00:06:34.830] JS: Yeah, you've captured something very important just now with that whole dynamic tension between the urgency of the moment with the disaster and the long-term perspective of what happens over the next several years as communities recover. We're going to get back to that in a moment. But before we do, I want to continue with this dialogue on public health. There's been some discussion of how planners can better work with public health officials on issues like the current pandemic. But it also seems that city and county public health agencies are very busy in that urgent situation, as you described, and overloaded with the work that's in front of them. Is now even a good time for planners to develop such relationships? And if not, when and how should planners and public health agencies establish effective working relationships?

[00:07:32.550] MS: Yeah, I think you've put your finger on a very important point, which is our public health infrastructure is very much engaged and stretched thin. And certainly one doesn't want to add on to those burdens. At the same time, public health is in a position where it needs both collaborators and cheerleaders. I think it's important people — for people to understand that public health is confronting COVID-19 — you know, active disease in the community. But if you look at the U.S. response right now, you have the added stresses of a highly politicized environment where there's a great deal of social fragmentation. And rapid-response social science has shown that people's responses to the pandemic often fall along political lines or along a political spectrum. So there is a lot — there's the, the issue of the disease for public health folks to manage, but there's also potential social and political pitfalls. So they're — they are a workforce who's under a lot of stress. A number of them, sadly, have actually left their positions due to the stress of managing the response, feeling fettered by political leaders who are trying to balance economic and public health aims, and some publics who are chafing at the confining nature of public health interventions, and that's, that's a major stress. So to go back to your question, you know, is now a good time for planners to strengthen their relationship with public health? Absolutely. Again, planners bring a set of skills and can have the backs of public health [officials] — you know, a workforce that is so focused on the response, and planners can take up the mantle of intermediate- and long-term recovery. There is in public health no workforce per se that is tasked with postepidemic recovery. And so planners can actually execute a very important role. And they need to cultivate their relationships or strengthen the ones they already have with their public health colleagues.

[00:10:10.160] JS: Thank you for that. You know, you've written about what recovery means in the aftermath of a pandemic, comparing a natural disaster to a biological disaster. There are obvious differences, such as the presence of physical damage to a community from a storm or an earthquake, for example, versus the public health consequences of a pandemic or epidemic. For instance, the latter involves much more personal and institutional recovery in the sense of long-lasting health impacts. Can you elaborate on that?

[00:10:42.850] MS: Sure. Well, we can touch on both the institutional and the individual levels. Right now, and we're seeing this with the pandemic response, health care facilities, often in the context of post epidemic recovery, have to — are struggling to regain full functionality because they've had workforce depletion, revenue losses, perhaps their facilities and their staff have been stigmatized. And there could be, depending on the pathogen — not so much with a COVID-19 context, but say with with the Ebola context — a concern over contamination. So we can remember the response to the 2003 SARS [severe acute respiratory syndrome] outbreaks in China, in Toronto. And I'll pick Toronto for an example. There, the health f— health facilities were facing a workforce that had been through a particularly traumatic experience, either being sick themselves or seeing close colleagues become sick and even, in some cases, perish. So you had a workforce struggling with the emotional trauma associated with the response. And also you had income-generating elective procedures put on hold. So revenues into the health systems were diminished. So you had a workforce that was burdened, and you had limits to the economic strength of individual facilities and in health systems. And so that's some of the institutional challenges that are posed by epidemics. And we're seeing things with COVID-19, also, where the health care workforce, which includes essential workers of many kinds, are facing some pretty traumatic situations, particularly in the context of scarce personal protective equipment. At the individual level, with a biological incident, you have not just the problem of infection and illness. You could have a protracted convalescence, and by — this is actually also happening for some people [with] COVID-19 — that then impacts one's ability to make a living, support one's household. A long convalescence can also exact an emotional toll. People who have recovered from COVID-19 in some cases are socially shunned because they're seen as potentially contaminated or associated with, with contagion, and people are a little leery of folks who have been sick with COVID-19 and also with other types of of illnesses. And some diseases actually have long-term, chronic sequela that can affect people both physically and socially. So in the case of Zika, you'll recall that we had children who are now living with developmental disorders that call for greater social-service support both for the children, but also for the parents. And that's an additional demand that's placed as a result of, of the actual illness.

[00:14:22.690] JS: One interesting point you just raised has to do with some of the personal impacts of COVID-19, because we — in the statistics that are always on the news, we tend to focus on number of new cases or total cases and deaths. But in between there are a lot of people whose impacts are forgotten, which is people who had COVID-19 and recovered but will have lasting personal-health impacts as a result of that experience that are probably going to affect them for most of the rest of their lives, if not the entire rest of their lives. And that is also a piece of the recovery that probably planners and public health officials need to think about. Do you have any special thoughts on that aspect of?

[00:15:18.110] MS: Yes. We, of course, are still learning about the disease and, at least in the U.S. context, we're about six months into it. So we are seeing, not among everybody, but there are individuals who are having a rough time of recovery. And if you look at other infectious diseases — even in the case of Zika, for instance, you could have a case of Guillain-Barré syndrome that lasts and could affect someone's ability to work and their productivity and their income-earning capacity. So, you know, most definitely, we could possibly see that here. In the case of Ebola, also there were long-term health effects for some individuals that take away their ability to earn an income, whether it is affecting their sight or their mobility or neurological robustness. So absolutely. And so we need to think in terms of systems of recovery that include our mental health infrastructure, because again, there, there are the physical health impacts. But the pandemic has created some pretty profound psychological impacts that are going to place demands on what is a pretty under-resourced infrastructure in terms of our mental health infrastructure in the United States and of course the social-service infrastructure. So I think we — while we are focused on the pathogen, of course, and issues of transmission and infection, if you think about people in a state of recovery as whole individuals, you have to have in mind issues of workforce development, mental health, access to social services. It isn't just about, you know, getting to the clinic to see a doctor. It's about you — we have to think of, of people who have fought off an infection with COVID-19 as whole, individuals that may require a variety of supports.

[00:17:32.630] JS: Thank you. You know, as some people have said, this pandemic kind of lays bare a lot of vulnerabilities and inequities in our society that we tend not to pay attention to, but we may be forced to pay more attention to them in the recovery. So with that thought in mind, let me ask, what do you see as the common lessons for both types of recovery, the personal and the institutional? And how can they be instructive for planners in thinking about the future of the communities that they serve? You know, what can they be doing differently, particularly with regards to issues of racial and social equity in health outcomes?

[00:18:12.910] MS: Yes, and this sort of circles back to that issue of seizing the pandemic as a moment for transformative recovery and not just a return to business as usual, because business as usual is resulting in disproportionate impacts, particularly for communities of color. And so we're seeing higher rates of infection, hospitalizations, and deaths among African Americans and also among Hispanics and Latinos and also Native Americans. And so we have to take a look at the way in which our societies are organized that would contribute to the uneven impacts. And so where planners, I think, can be particularly helpful is in helping break down or shed light on the structures that create these disproportionate impacts. So you can have people — working people, which includes large number of people of color — who are, for instance, living in tight living arrangements, high-density arrangements, which then creates a higher risk of exposure if, if someone in that living situation is actively infected with the novel coronavirus. We have folks who could also be exposed because they have to travel by public transportation with large numbers of people. They could be working in a, in a job which requires a large amount of interface with the public. And so all of these things accumulate into — all these what are called social determinants of health — accumulate in higher — a higher risk of exposure. And then on top of that, you have individuals who may not have insurance, who would postpone going to the doctor because they can't take time off from work or they don't have enough income to cover the clinic cost and may develop a more extreme set of complications because they haven't sought out care sooner rather than later. So where planners, planners can help sort of piece together these structural components and think about what type of, of, of planning do we need to do in order to revitalize our community postpandemic and in particular revitalize the, the settings in which working people and communities of color find themselves in, in, in riskier situations. I mean, how can we remedy that? So housing, for instance, right? Wouldn't it be, you know, as far as sort of preventing this, this risky situation, things such as having — living near one's place of work so you don't have to rely extensively on public transportation for long stretches of geography. Living in low-density housing arrangements so that people aren't on top of one another, making sure that there's large stocks of affordable housing. Making sure that parks are places where people can spread out and enjoy, you know, enjoy the sunshine, despite there being pandemic situations; making sure that we have enough park space and parks are kept up and are a priority for the community. So all of those things are actually important when it comes to preventing and containing outbreaks of infectious disease.

[00:22:24.910] JS: OK, you mentioned that we should, and I put this in quotes, "anticipate messiness" in recovery as, let's say, we stumble our way past this pandemic into some process of restoring normal activity. What do you mean by that, by anticipating messiness?

[00:22:46.260] MS: Well, messiness, I usually associate that with, with the human condition. And when it comes to recovery, I think in the pandemic context, is that it's not a linear, even process that kind — that unfolds in stages. There can be two steps forward, one step back, which is what we're seeing with regard to spikes in, in cases as a result of reopening of businesses and people gathering in groups again. So it isn't as if we got, we got through phase one and we're on to phase two. We've actually had two steps forward, one step back. So there's that type of temporal messiness. There's another kind of messiness, which is — it's the unevenness that can happen. Others have remarked on the fact that we're not having a pandemic, we're having multiple pandemics. Different communities are experiencing a hyper-localized version, their own hyper-localized version of the pandemic. And so what's happening in Austin, Texas, can be different from what's happening in Detroit, depending on what the local conditions are, as far as the presence of disease and what the health, public health policies are, what — the timing of that, when they were introduced. And there's a lot of uncertainty with regard to pandemics and outbreaks more, more generally. In the pandemic context, it'll make a difference if, if we indeed get a safe and effective vaccine to start rolling out at the beginning of the year, or if that doesn't happen and it happens two years from now. So there are those uncertainties about whether you have a medical countermeasure that's going to relieve some of the disease burden. So, again, there's a lot of uncertainty. And so it's, it's very place based in terms of an experience. It depends on what medical countermeasures you do or do not have. And that's, that's what I mean by messiness. It's not simple. It's not linear. It's not a progressive march forward to a better-off state. We can actually slide back.

[00:25:20.050] JS: That leads very easily into the next question, which is that, you know, a lot of concern and anxiety have been focused on the economic consequences of public health measures employed in the COVID[-19] pandemic, including closed businesses, lost jobs, disrupted travel. And so without trying to be an economist here, instead of a medical anthropologist, which you are, what financial implications do you foresee in this pandemic and how can we alleviate that stress without unduly compromising public health?

[00:25:57.070] MS: No, it's, it's a very important question. And I think we can all empathize with the undue economic burdens that the disease and responses to the disease have placed on our communities and in particularly marginalized and underserved populations. That said, and that is a reality, I think we can step back for a moment is if, if, if we broaden our perspectives to compare how different countries have approached the pandemic, we can see that there is not such an inherent conflict between public health objectives and economic objectives. So I don't want people to walk away thinking that there is an inherent conflict between public health and economic activity. Because what — these well-beings, these different states of well-being, actually complement and support one another, even though it can be counterintuitive to think that. And it's only by looking at what has happened across different nations that you can pull this lesson out. So for those countries that acted very quickly in monitoring the disease, instituting contact tracing and testing and self-quarantine and really great crisis and risk communication, you have a quicker, quicker containment of the disease and a speedier — but still with precautions — a speedier return to normal routines, or at least to routines. So there is that. So the U.S. response has been very uneven for a number of reasons. So we need to, again, broaden our perspectives about that, while at the same time certainly not undermining or not validating the reality of the economic costs that have taken place and been experienced in the United States. I think in terms of an economic future, I think what the pandemic in the United States case has shown is the strength of our public health infrastructure is going to help us in terms of, of keeping our economy going and from being interrupted. I know planners who serve coastal communities know that with the changing climate, we're having more severe and more frequent meteorological events. Well, there's something comparable going on in the infectious diseases space too. Over the last few decades, we're starting — the World Health Organization has told us, based on their monitoring, that we are seeing more outbreaks that are harder to manage occurring more frequently. So this is to say that a good way to protect our economy in the United States in the context of a ecosystem in which we're going to be facing more outbreaks of infectious diseases that are harder to manage, our economy will benefit from a stronger public health infrastructure that can intervene quickly and more effectively.

[00:29:44.120] JS: One issue that features prominently in discussions of this spread of COVID-19 is urban density. What may first have taken hold in New York and Chicago is now pretty widespread in states like Alabama and Arkansas and Mississippi, which suggests that density may not be the factor that some assumed it was. And I live in Chicago, where strict social distancing and other measures have apparently reversed much of that upward curve — for now, at least. I'm a little worried about what's going on broadly. But I have to wonder if the issue is not so much density then as it is proximity, meaning allowing activity that brings too many people too closely together, and if that is not the mistake that has produced the most recent upticks in other parts of the United States. And I might note in asking you this question that is going to occur just as easily in a funeral or a church service or a meat-packing plant in a small town as it can anywhere else. And they've, I think, seen this in places like Iowa and Nebraska. What is your take on this urban density question?

[00:31:02.900] MS: Well, your analysis is spot on, and that is, in an outbreak of infectious disease, human behavior matters. It isn't just about the characteristics of the pathogen. It's also how people comport themselves in terms of behavior within their social and built environment. So it's a very fluid and organic process. Outbreaks of infectious diseases are very organic processes. So while at the outset of the pandemic in the United States, you, you did see major impacts in urban settings, that's also a function of flows of people into metropolitan centers. But I think you're right to spotlight the fact that how we interact with one another in terms of the physical distancing and all — and then also, too, we have seen very uneven responses to the pandemic in terms of the frequency with which people are wearing masks and physically distancing themselves and avoiding large gatherings of, of people. And so you have — and that's in the context of, of, of, of many, many things, including uneven, uneven approaches to crisis and risk communication that have contributed to very differing perceptions about what the actual risk is. So I think in these smaller towns, initially to see the disease as affecting cities as opposed to rural communities might have created a sense of — that they weren't going to be affected, when the — in a pandemic, we're all at risk of this type of pathogen. And how we behave around the pathogen is going to affect the presence of disease, the extent of disease in our communities.

[00:33:15.800] JS: How would you sum up whatever you see as the most important long-term lessons for urban planning from the COVID-19 pandemic? What is the most useful thing for planners to know that health experts can share with them?

[00:33:32.630] MS: Well, I think it's important for planners to know that epidemics are not just about — well, in this case COVID-19 — the pandemic is not just about virology and epidemiology. That there are a vast number of disciplines, including planning, that need to be part of the development of solutions with regard to outbreaks of infectious disease. Epidemics — and, and also we're seeing this with the pandemic — are totalizing events, right? They affect all sectors of society. They interrupt our social relationships. They interrupt our economic activities. And so planners who work, who think in terms of systems, who think over the long-term, really can offer something. So they shouldn't feel as if they don't have the right credentials to weigh in on what it means to recover from something like a pandemic or an epidemic of infectious diseases. And at the same time, I think planners do have to, to recognize that biological hazards are different from meteorological hazards or from the earthquake hazards. So there are certain challenges, such as the extra burdens that the health sector faces in this type of extreme event, that planners need to be attentive to. Where public health and communities can benefit from planners, just to circle back to an earlier point is, planners are, in my experience, very much focused on and committed to involving the public and a variety of stakeholders in planning a recovery from an extreme event. And we really do need what planners bring to the table in terms of vision and process and accountability to the larger community.

[00:35:45.260] JS: OK, well, let's close by letting you tell us how listeners can find you online. And also, are there particular resources that they should know about that you want to tell them about and how they can find them?

[00:35:59.570] MS: I'd welcome everyone who's listening to come to the website of the Johns Hopkins Center for Health Security, and its center for health security dot org [centerforhealthsecurity.org]. And there you can sign up for free alerts and newsletters, including a situation report on COVID-19. It'll keep you up-to-date on developments both in terms of the disease and responses to the disease. We also have a newsletter called Health Security Headlines that will keep you abreast of all developments in the larger field of health security, including COVID-19. And then Johns Hopkins University has a coronavirus resource center, which has wonderful maps and graphic representations of trends related to the disease — not just cases and deaths, but also those cases in the context of social interventions to try and contain the disease. And you can see — you can track the disease process in connection with the social process, which I think is important from, from a planning perspective. And also just to highlight a report that's just coming out: It's called The Public's Role in COVID-19 Vaccination. It takes a user-centered perspective on what it will take to roll out vaccines against COVID-19 and the importance of all sectors of the community being invested in that initiative. And I think, your, your listeners would be interested in that, and they'll find that also at the Center for Health Security dot org website.

[00:37:54.680] JS: Thank you very much. You've introduced us to a number of perspectives, a number of ideas that I know don't know that most planners had thought about very deeply before this pandemic struck but things that we've had to learn very quickly over the last few months. And this really, I think, will help enlighten a lot of us going forward, so we really appreciate having you here today.

[00:38:20.870] MS: My pleasure, and public health welcomes planners. We all need to be invested in finding solutions to this public problem.

[00:38:32.150] JS: Thanks for tuning in to another episode of the American Planning Association podcast. For resources on hazard mitigation and disaster recovery, visit planning dot org slash resilience [planning.org/resilience]. To hear past episodes of the APA podcast, visit planning dot org slash podcast [planning.org/podcast]. You can also subscribe to the podcast on iTunes and Stitcher. Have an idea for a podcast? Send it to podcast at planning dot org [podcast@planning.org].

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