Below is an excerpt from the introductory section of a white paper I am developing.
Human society in the 21st century will be impacted by global forces such as pandemics, climate change-driven weather events, and geopolitical conflict. As witnessed during the COVID-19 pandemic, governments could improve their “disaster preparedness” particularly by assessing and utilizing existing facilities better for the provision of emergency aid, instead of spending large sums of money on inefficient new facilities for the sake of expediency. This is a low-hanging fruit in the disaster space, and the design & construction industry has a key role to play. This paper outlines how a tool measuring preparedness may be developed and speculates upon further initiatives enabled by such a tool.
Overview & History
Infectious diseases and the organisms that carry them have existed on this planet longer than homo sapiens. In human beings, and our remarkable ability to congregate and cooperate in large numbers, viruses and bacteria find a medium particularly conducive to their own proliferation. Epidemics and pandemics are both made possible by and strong catalysts for the ongoing transformation of human society, from the Black Death helping to end European feudalism to tuberculosis’ effects on city planning in the 1800s to smallpox’s role in accelerating the colonization of the New World in the 16th century.
People across the globe underwent a further flourishing of interconnectedness and densification by the turn of the 3rd millennium with the advent of affordable air travel and the internet. By 2007 more than 50% of the world’s population lived in a city or urban area. Despite broad advances in medicine, however, the global community also witnessed a number of outbreaks in this time period, including SARS in 2002-2004, MERS in 2012, Ebola in 2014, Zika in 2015-2016, and COVID-19 in 2020. Concurrently, humankind is undergoing another phase of transformation. The “New Normal” coined during the COVID-19 era may not be referring to measures taken to combat SARS-CoV-2 specifically, but instead to the growing scientific consensus that disruptive outbreaks are expected to become commonplace in the globalized 21st century.
International organizations such as The World Health Organization (WHO) and The United Nations (UN) may have the resources to combat epidemics and pandemics but consensus protocols make them too slow to respond. Conversely, individuals and companies may have quicker response times but cannot cast a net wide enough to stop a virus from spreading around a continent. Governments, by contrast, wield the balance of size and spending power commensurate with the nature of viral outbreaks. One weapon in their arsenal is the development of plans of action against future outbreaks, such as the one developed by the Obama Administration titled “Playbook for Early Response to High-Consequence Emerging Infectious Disease Threats and Biological Incidents.” While providing clear step-by-step decision trees, legal & statutory bases for executive action, and key agencies involved, its scope is limited to management from within the executive branch of the United States government. Other publications such as “Toward Epidemic Prediction: Federal Efforts and Opportunities in Outbreak Modeling,” by the National Science and Technology Council (NSTC) are the result of active engagement with experts outside the Federal government, but are ultimately esoteric, leaving the knowledge isolated from the citizens they are meant to protect. More synergy is needed between governments and communities.
COVID-19 in the United States
As of this writing, the United States Centers for Disease Control and Prevention has recorded over 970,000 COVID-19-related deaths and 79,000,000 cases.
The first and easiest response available to government was to restrict movement to prevent the rapid spread of the virus (i.e., “flattening the curve”). States issued travel bans, stay-at-home orders, guidelines against gatherings, and the like. Though it remained unclear on such restrictions itself, the White House approved emergency spending packages on March 6th, March 13th, and March 18th. An immediate second phase, once federal dollars were unlocked, consisted of resource mobilization across state lines and the coordination of multiple agencies, such as FEMA, The National Guard, and USACE, in order to help localities treat the high volume of infected people. Everything was in short supply, including medical staff, equipment, and—critically—healthcare space and infrastructure. It was simply not enough for hospitals to cancel elective surgeries and adaptively turn operating rooms into ICUs. Additional facilities had to be built or retrofit, logistical arteries staked out across the landscape, and utilities expanded virtually overnight to treat or house the infected, quarantine travelers, distribute tests, store equipment, and process samples. The terms of art for these emergency facilities are Alternate Care Facilities (ACF) and Federal Medical Stations (FMS). In early 2020, USACE evaluated hundreds of potential sites across the country, and stewarded the construction of 38 ACFs and 41 FMSs. At this scale and speed, federal entities and the healthcare community needed assistance across the public and private sectors. To best funnel the available cash, USACE issued Requests for Proposals (RFPs) for the construction or adaptive reuse of existing facilities close to COVID hotspots. This is the point at which the Architecture, Engineering, and Construction (AEC) industry and the design community became involved.
Above: Map of USACE ACFs in the United States. Notice the clustering of sites around larger cities such as New York, Chicago, or Denver, by number of beds and number of patients treated once the ACF was brought into operation.
Above: Bar Chart of USACE ACFs in the United States, by number of beds, number of patients treated once the ACF was brought into operation, and construction cost per bed. Only one ACF, the Austin Convention Center, treated more patients than it had beds.
The Role of the Design Community
Without a doubt the US reaction to the first wave of COVID-19 was defined in part by the involvement of architects, engineers, builders, and their colleagues. Credit is due: their execution of the RFPs, in constant coordination with USACE and multiple Authorities Having Jurisdiction (AHJs), resulted in over 15,000 beds being brought to readiness nationwide, in just 2-3 months, during a time of desperate uncertainty. But could the response have been better? In New York State alone, the ratio of beds used to beds built was just above 0.25. As an example, the new facility at SUNY Old Westbury cost $116 million to build and yielded 1,024 beds, a cost of $113,281 per bed. 1,095 patients were treated in ACFs across the state, at a cost of $345.6 million in taxpayer money. Nationwide, only a fraction of the facilities built—according to my research, 9 of 45—ended up being used, although some did stay up long enough to become testing and vaccination sites, improving the return on investment. Critically, those facilities which involved substantial new construction rather than retrofitting, and were thereby the costliest, remained mostly in disuse. New infrastructure and decommissioning (taking apart a facility, taking stock of the parts that remain, reusing them and storing them when necessary) are the costliest components of these ACFs, according to a disaster specialist at AECOM, my firm of current employment. There is no visible correlation between dollars spent and healthcare provided. Ignoring even the number of patients treated, several facilities were able to construct over 100 beds for under $10 million (such as the Hagerstown Correctional Facility, St. Luke’s Medical Center in Phoenix, or the TCF Center in Detroit). The only noticeable pattern among those few ACFs which cost $30 million or more is that they are located in dense metropolitan centers (New York City, Washington D.C., Chicago).
Experts have been recommending areas of improvement to pandemic response since the first wave of COVID-19. See the Congressional testimonies of Caitlin Rivers, PhD, MPH, on May 6th, 2020, Peter Gaynor, FEMA Deputy Administrator, on July 24th, 2020, Mark Ghilarducci, Director of the California Governor’s Office of Emergency Services, on March 16th 2021. Across the board, however, there is little mention of improvement in the building of buildings.
While it is unfair to use cost and utilization as measures of judgment in retrospect, since in the early days little was known about the virus, the glaring numbers of one kind of facility in comparison to another nonetheless beg the question: could resources have been used better? Namely, could a better understanding of existing resources in COVID hotspots resulted in faster facility construction, smarter retrofits, cheaper price tags, and more secure operations? The rapid survey & evaluation by USACE of hundreds of sites across the country, for instance, could have involved architects, engineers, and planners to better understand which sites struck the best balance between feasibility, operability, durability, and cost. In Rhode Island, the state bore a greater cost-sharing burden for its response efforts, and so delivered better on dollars per bed (see chart above). Furthermore, the construction and operation of buildings accounts for 39% of global carbon dioxide emissions, according to the United Nations. Even pandemic-scale emergencies do not exonerate us from the need to build more sustainably. In the AEC industry, which commonly stewards the development of sizable tracts of land involving sizable investment, long-lasting resource use, cost-benefit analyses, and “highest and best use” goals are standard practice. Could the design community have contributed more using this mindset? What does that tranche of the private sector know about the best way to utilize space for large-scale operations that could help USACE and other government agencies deliver the money where it is needed most?
Lastly, COVID-19 will most certainly not be the last time the country has to deal urgently with a lack of capacity in the built environment. Other epidemics, war, and climate change-driven natural disasters will require a similar response. What lessons can we carry through in order to embed more redundancy into our buildings, and more resilience into our communities?
Design professionals like to opine, in moments of perceived paradigm shifts, about the future of things—even now, we speculate about “the future of the office” or “the future of transportation” or “the future of suburbs.” But it’s easy to forget how desperate the early months of 2020 were, how “rapidly evolving” the situation was (to use the parlance), and how unconcerned with the future we were. It is in those stages of crisis—not just of this pandemic but of all future crises—that the design community can take a more proactive role.
 World Health Organization, “How the 4 biggest outbreaks since the start of this century shattered some long-standing myths,” September 1st 2015, https://www.who.int/news/item/01-09-2015-how-the-4-biggest-outbreaks-since-the-start-of-this-century-shattered-some-long-standing-myths, retrieved March 25th 2022
 See ProPublica’s database for the value of contracts awarded by the US Government, https://projects.propublica.org/coronavirus-contracts/categories/, filtering the search for various categories, including “architecture and engineering construction of hospital buildings,” “construction of other hospital buildings,” and “repair or alteration of hospitals and infirmaries.” See also USASpending.gov, filtering the search for “alternate care facility.”
More to come…