Coffee with Roger Keil and Jodie McVernon

A caffeinated conversation around cities and disease and the role of urban environments on global pandemics.

Recorded on the ominous Friday 13 December 2019, the discussion would prove to be prophetic as unbeknownst to our speakers COVID-19 had already begun to spread.

Our guests are Roger Keil, Jodie McVernon, and Michele Acuto.

  • S1E1 Transcript

    Kate Murray:

    On Friday, 13th of December, 2019, three academics met up in a cafe on the university of Melbourne Campus. Jodie McVernon, Professor and Director of Epidemiology at the Peter Doherty Institute for Infection and Immunity ordered a skinny latte. Michele Acuto, Director of Connected Cities Lab and Professor of Global Urban Politics at the University of Melbourne ordered a regular cafe latte. Professor Roger Keil Chair in Global Sub/Urban studies at York University in Toronto ordered a flat white. You might also know Roger from his book, Networked Disease: Emerging Infections in the Global Cities.

    Over coffee, a conversation took place about cities and disease, about the role of our urban environments in the spread of and the fight against disease. How viruses, not just people, travel across increasingly porous borders, and what outbreaks and contagions can teach us about sustainable urban development and living in a time of global interconnectedness and urban inequalities.

    The conversation would prove to be prophetic, because what our academics didn't know as they talked, was that across the world in China, COVID-19 had already started to spread.

    Hi, I'm Kate Murray. You're listening to Connected Cities where we have unashamedly academic chats about global city governance and urban research.

    It's funny, the conversation you're about to hear happened only a few months ago, and yet life has changed so much in that short span of time. Because of this, we've added brief updates from Roger and Jodie at the end of the podcast, addressing this topic in the current context of COVID-19. These updates are recorded in a time of quarantine. An experience shared by Roger in Toronto, Jodie and Michele in Melbourne, and probably by you, dear listener, wherever in the world you may be. Here it is, a coffee with Roger Keil and Jodie McVernon. Take it away, Michele.

    Michele Acuto:

    The World Economic Forum rates infectious disease as the second most pressing threat globally for destabilizing the world economy, and how we live in a predominantly urban world. The WHO and World Bank global preparedness monitoring board issued really strong cause for the fact that we need to be prepared for the worst, and we're not prepared for the worst. I guess that's something I'll poke a bit on as to whether we should really be prepared for the worst, and what does the worst look like.

    At the same time, WHO estimates that in the last seven to eight years, there's been at least 1,428 cases of epidemics across 172 countries and regions. So we're really talking about an ever present challenge and concern.

    Now, the question that I wanted to open this conversation on is very much what does the story of cities and disease look like in a predominantly urban world? Does that look as threatening and concerning as these type of conversations and debates and reports put it, and what does it look like from different perspectives, fundamentally from the medical sciences, from the expertise of modeling and analysis, and from urban studies, and sort of the global point of view on urban issues? Roger, why don't you get us started on that?

    Roger Keil:

    Thanks Michele, and thanks for putting this on while I'm here visiting Australia, which I enjoy a lot, and thanks Jodie for making the time. I am, I must say, a political scientist. So when I speak about disease, don't expect me to heal anybody or say anything knowledgeable about the disease as a disease.

    I'm looking at the intersection as we sort of heard of urbanization and disease. Let me just quickly say that today is a very important day for me because it's the end of a 10-year project on global sub-urbanization which I directed at York University. We handed in the final report yesterday, and so it's done. Looking back at what we have done over those 10 years with 50 researchers around the world confirms what Michele alluded to, which is that we now have to look at infectious disease in an urban age. Often, the 21st century is now called an urban century.

    What we have been on about over that decade of research globally is to say that the majority of that urbanization that we now face in the world is in fact sub-urbanization in one form or another. When we say sub-urbanization, don't think of sort of single family homes behind white picket fences, or any other sort of stereotype of the suburb in Anglo America and Australia. We are looking at the periphery of cities more generally, and that can involve the extension of informal settlements, and also can involve massive housing projects like in China or in Turkey.

    If you take that broader idea, we can still hold that the majority of what we now call urbanization in the 21st century will involve peripheral settlement, and that poses new kinds of questions. It's a quantitative issue because we do now believe that we will go up to about 10 billion people in the world out of 7.something now. By the middle of the century, perhaps we're going to be about 10 billion people.

    The majority of those, three billion people added to the world's population will never be rural. They will immediately be urban people. As I argued, they will be sub-urban people to some degree. So it's a quantitative thing that the majority of us will live in one form or another of that peripheral type of settlement. It's also a qualitative thing. It's not just the numbers that add up. It's also the fact that we live different kinds of lives than those lived by the urbanized masses of the 19th or 20th century.

    Remember that in 1900, only 10% of the world was urbanized. There was a particular form of industrial urbanization. When we now move to the urban or sub-urban century, we don't live those industrialized... Most of us don't. Of course, we know the factories of the world in China and other parts of the world are still operating as if it was Manchester in the 19th century. But we still have to look at a different type of urbanism.

    In that context, we need to ask those questions, again, that we asked our forefathers and mothers in medical and other sciences, asked in the middle of the 19th century as epidemics first arose. What was significant is that, throughout the 20th century as the famous Canadian/American urbanist Jane Jacobs once said, that cities were once the font of diseases. When you lived in the city, you were about to die earlier than if you lived in the countryside, particularly in those early days of industrialization.

    Over the course of the 20th century, particularly in the West and the North of the planet, which includes, of course, strangely Australia, this was turned around and cities became healthier places than the countryside. But we now think that this may be reversed to some degree as the forms of urbanization that we now see around the world are different from the ones that we saw in the 20th century.

    There's less security around the type of urbanization, the institutional development, the infrastructural development, the public health institutions. Those kinds of things that we associated with mature urbanization are not necessarily around for those new sub-urbanized or urbanized, those new peripheral dwellers.

    That could be the same in, again, in the wealthy countries, as it is definitely the case in the not so wealthy countries. Remember that Africa is the fastest urbanizing continent in the world now, and there will be at least 500 million people in Africa will be urbanized in a generation. These kinds of things need to be considered.

    We are thinking then that perhaps... Given that I'm a political scientist and I'm working with colleagues in urban sociology or the sociology of health like Harris Ali at York University, Creighton Connolly at Lincoln, on thinking about the connections in this situation that we need to make between urbanization and the spread of these emerging infectious diseases.

    What we have come up with is the idea that in order to understand that we need to look at the political ecologists of disease, which means we don't see the disease just as a medical issue, but we're looking at disease in a landscape of political ecology. That could be urban political ecology, or regional political ecology, or sometimes national political ecology.

    I can expand on that perhaps later when we continue the conversation, but I perhaps will leave it at that. Perhaps, just point out, that currently, we're doing some research to test our ideas of how this all hangs together on the ground research that we're doing in West Africa in the Democratic Republic of the Congo where there's an ongoing Ebola outbreak, which is one of those threatening emerging infectious diseases that we now have to face.

    Michele Acuto:

    Thanks. Jodie, so what does the story look like in an increasingly urbanized world?

    Jodie McVernon:

    Thanks. Thank you. I'm basically coming to this from the perspective of a public health physician and quantitative epidemiologist. Epidemiology is the study of health and health related states that determine disease outcomes. Those states clearly involve social processes, and the social determinants of health and housing is critical there, as is urbanization.

    In just thinking numerically about what urbanization means, when we think about the density of people living within households, when we think about the density of households clustered together, when we think about the availability or absence of sanitation, running water. These basic hygiene hardware infrastructures and other things that are associated with improved health states in high income countries, all of those things become problematic in the kind of sub-urbanization that you're talking about.

    We talk about something called the reproduction number, which is the number of secondary cases that each individual produces over the course of their infectious disease, and that relates both to the infectiousness of the pathogen itself, but also to the effective contact rate of the individual. How many people they see, how intensely they're associated with them? Things bed sharing when there's one bed for the whole family clearly amplify the spread of infectious diseases in a highly quantitative way. All of those things clearly enable and facilitate the spread of infection.

    I guess the other issue of urbanization, and you've nicely alluded to Ebola is that, not only are these urban settlements dense within themselves, but they're closely and intimately connected to many other rural and urban areas. The devastating spread of Ebola in the recent West African epidemic has clearly demonstrated to the world the power of human mobility between these settlements, center of commerce and trade, and transport, and visiting family, and all of those other things that connect people between centers to be quite critical.

    From the health perspective, we talk about a whole of society response to infectious diseases rather than purely a health response. Obviously, in the Ebola crisis, it was the UN more than the WHO were able to bring to a halt the spread of disease in many months. All of those things together clearly amplify risk.

    Globally, there's been a recognition from funders and NGOs and others of the importance of the social and political sciences in understanding these threats, and large funding calls for social science networks and others, and a strong call for quantitative epidemiologists like myself to engage effectively to better understand how these factors interact and influence disease risk.

    Michele Acuto:

    Let me poke you quickly on that kind of issue. I guess that you alluded to that as well, Roger. 1918, anyone who works in sort of pandemics would be familiar with, I guess, sort of the last or the first great pandemic of the previous century now. 5% of the world's population infected and affected. We're talking about a context of limited urbanization, a context where getting to Australia from Europe might take a month on end. Now, we fast-forward to Ebola, 2014, 2015, we're talking about a context where getting from any of the effected countries to Europe, or in fact from Europe to Australia would take in the order of 20 to 30 hours at the most.

    I guess, the question there is, then what tangibly does that tell us about the change and the urgency of infections globally? What does a heavily interconnected world, and I guess sort of there, I take the term from Roger's book with Harris Ali, Networked Disease. What does a networked disease landscape look like now? Is it more dangerous? Have the dangers changed fundamentally? How does the world look like? Are we better or worse off? Is it just simply different? Jodie.

    Jodie McVernon:

    Clearly, the ability of infectious diseases to travel around the world is unprecedented in terms of our global mobility and travel. That's probably most problematic for diseases with a long incubation period where the period of travel is far less than the period of disease risk or incubation. The interconnectedness of the world, the importance of the international health regulations is clear, and WHO has recently gone through a process of joint external evaluation of all countries to assess their compliance with the international health regulations, which are all about their ability to detect, and contain, and report emerging diseases. I guess in thinking about that, the risk assessment must bear in mind that all countries do not have equal ability to detect an infection or to contain it at source.

    We have kind of an unevenness in our information on how those risks are transmitted, and we have global patterns of travel that certainly I hadn't considered before. We were involved in doing some regional risk assessment work for Ebola for Australia for Department of Foreign Affairs and Trade. I hadn't realized before, there's a very large migrant worker population from East Asia to Africa, to West Africa. We have these new patterns of mobility for economies that actually connect parts of the world in ways that aren't immediately apparent.

    I think the onus is on rich countries to enhance and strengthen health systems in other parts of the world, if not for the altruistic good of others, then at least for their own selfish risk reduction, which is often a very motivating driver.

    Michele Acuto: Roger.

    Roger Keil:

    I think this is very important to put it into that context. What I would like to add to that is perhaps two things. One is that, we are of course living in a world where it isn't always so clear to figure out what is really threatening and what is not. Fake news and the context of the politics in which this takes place is really important. The idea of a health panic is really important in that context. What may not be a threat to Americans may be built up to be a health panic to Americans. People don't understand. I don't understand. I did not understand before I started getting into this, as a citizen of a country, what are the diseases that are actually threatening at a level of a possible pandemic? So it is very easy to blow something up into something that it isn't.

    On the other hand, it's surprising to me that many things are so unrecognized as a threat. To give you an example that when I moved for a year from Canada to France in 2008/9 at the height of the Swine Flu scare, which is what it was, people in France, the press, the media in France, laughed about Americans being in a panic about the flu, and about the measures taken in Mexico and in the United States to fight that. So you see the cultural differences are really important in that context.

    In the history of the 1918 flu, it gives us a lot of lessons on how differently it was perceived and acted upon by national governments. It was also at the end of the war, which is very similar to the context in the Congo right now.

    I wanted to say that because it's important that we're not talking about objective measures here. We're talking about something in a fluid political field. The other thing that's important about this notion of a networked disease, when we came up with that book title... In fact, the book was supposed to be called Networked Deaths, but Mike Davis talked me out of that, and he said Networked Disease might just be fine with a very rudimentary understanding of what that network was all about.

    Michele and I have done a lot of work separately and together on the idea of a global cities network. The idea there was in the 2000s, that these large global cities, the financial centers of the world would be connected through increasing flight aviation activity, and increased exchange of particular types of populations, particularly managerial people, but also diaspora populations. But it would really be focused on this notion of the global city, these 30-plus centers of the global economy.

    Now, that was a very, let me call it infantile understanding of the global economy. We have long moved away from this idea of a network, and it's now much more important to understand sort of the capillary system of the global economy.

    If you look at a place like the Eastern Congo, everybody's there. These are not the hinterlands of the global economy. There's a mining economy going on. The Chinese are there to to build a Belt and Road, and part of the Belt and Road initiative. It is, of course, a place of civil war where there are various parties supported by a number of political interest groups. So it is an international place. It's a place completely unlike New York, or Tokyo, or Toronto, or London, but it's still part of a global economy, and the kinds of networks that you see there are both hyper-global and connected. At the same time, local and regional in a way that we tended to overlook when we talked about global cities as financial centers.

    This is family connections. People traveling on buses across unsecured borders. People just crossing the borders. People going to family events like funerals and weddings where there is physical contact. Managers don't have a lot of physical contact when they are in meeting rooms. They are not really at risk, but if you visit a family for a burial, you have a completely different set of risks that you need to deal with. It's these kinds of changes, you mentioned mobility, that we are now taking to account to a degree that we hadn't in the past.

    Jodie McVernon:

    I just started to make a comment about the smaller scale networks that result in urbanization as well. There was a lovely paper that came out of Singapore that actually followed people's transport card usage, and identified networks of what they called familiar strangers. As a public transport user, I know all my familiar strangers. I have no idea who they are, but there are lots of people that I recognize every day. So we also interact in complex non-random ways with large groups of people on a daily basis.

    One of the kind of slightly, well, I'm using slash- horrifying stories about the overreaction to Ebola in the US was, the first Ebola case in the US who was missed in the emergency department for several hours, finally was identified, but sent home for quarantine. The first thing the family did was go out to a supermarket and shop for the week having been quarantined.

    The way in which our patterns of living, and eating, and shopping and all of these sorts of things, amplify our risk of contact with others, and the way in which those have to be thought through quite carefully in infectious disease preparedness is kind of another aspect of just the way we live. There was an SBS Insight special on pandemics a few years ago, which was great because we had the funeral directors, and the supermarkets, and all of these other people talking about how they would manage the everyday events of living in a pandemic to keep social-distancing and have safe funerals, and all these things. The intensity of our connection through other mechanisms of life is also a risk.

    Michele Acuto:

    Let me pick on that one for sort of one last comment and sort of question on that. Now, if we rewind back to SARS, for instance, that prompted the world to react with establishing international health regulations to do something about this kind of situations when they happen. Now, we go back then to 2014, 2015 Ebola, and the WHO and the world sort of health community establishes an health emergency program. Routinely, when these things happen, it seems like the international system or the global health system adjusts itself. Now, I guess my question, listening to your conversation about the familiar strangers, the issue of understanding this in an urbanized world that isn't the global city type world that perhaps states are a bit more familiar with. Are we doing enough? Are those reactions enough? Is the system changing fast enough? Is the system of states sufficient enough to deal with these kinds of threats? If not, what would you do about it? Roger.

    Roger Keil:

    My pleasure. Yeah, right. I think, for me, this is a crucial question. In the SARS outbreak, what happened was, for the first time, the World Health Organization and other internationally scaled organizations understood that they had to find ways to upend the state-based system of governance. To give you an idea, an infection was recorded, and now, of course, this is 24 hours around the clock. There are monitoring systems particularly in risk areas that when a case of anything, the Swine Flu, I mentioned that, is being reported somewhere in Thailand, let's say, then all of a sudden, that will be reported immediately to a local, and then the regional national health agency, and then to the WHO. The reaction will come back the same way. Normally that's normally how it is, because the autonomy of states must not be questioned.

    Roger Keil:

    All United Nations organizations operate on the autonomy of the sovereignty of national state. During the SARS outbreak, this sort of national sovereignty principle was perforated. For the first time, for example, some larger states like China allowed the exchange of information outside of that hierarchy, which then led in 2009 to a document, I can't remember the exact name of it now, but it was passed after a consultation in the WHO in Lyon on bringing municipal urban institutions into the picture to the front.

    As far as I know, this is the last big initiative done by the WHO. It is 10 years ago now, to pay tribute to the significance, that rising significance of sub-national governments and sub-national public health institutions in that context. There's a lot more work needs to be done to bring those actors that are very close, particularly in public health, very close to the people that actually are affected by these pandemics into the play in terms of global health governance.

    At the same time technology moves on. We have now different modes of communicating than we had even 10 or 15 years ago, as everybody is on social media. A lot more now particularly in the Ebola outbreak. Following a few non-state actors on Twitter, it gives you a completely different image of what is going on in the conflict zone in the Eastern Congo than if you just follow the communicates of the usual governance actors at the global scale.

    Jodie McVernon:

    I think one of the residual forms though in all of these processes, the need for global information sharing and the need for global awareness, but the absence of global equity. Certainly, in the influenza space, very notable challenges with many countries having wanted Indonesian Avian influenza isolates, but Indonesia saying, "Well where's the benefit to us?" We have a global influenza, there's a system, it's called [inaudible 00:27:49]. I cannot remember the name, but it's the most awful acronym.

    This whole mechanism was set up to try to overcome this barrier to information sharing that the countries who were providing the information were not necessarily benefiting from having done so. For influenza, for example, they are now in the influenza vaccine development process. There is an undertaking that companies will donate a proportion of the vaccines provided, and that they will then be allocated by WHO to countries with the greatest need who can't afford to buy them.

    There has to be this return for information sharing to be open and accessible. When you're talking about social media and other things, we're also seeing globally a move to community-based reporters for infectious diseases and other ways of getting around the fact that we simply do not have adequate health infrastructure or surveillance or public health systems in many countries. But clearly, that's no...Antidote to the fact that we still need to improve that health infrastructure. In the Ebola crisis, we had countries where doctors numbered in the hundreds, and when half of them die, there isn't an effective response. I think that ongoing agenda is essential to remediate the problem.

    Michele Acuto:

    Yes. So very much an ongoing agenda and a jury. Definitely still out, hopefully not completely threatening in a negative agenda, whether in our usual coffee metaphors, that's very much just a matter of a bit of a correcto espresso, injecting a bit of urban governance and urban data, whisking it and giving us that boost to uplift that kind of capacity. Or, in fact, the challenges of inequality, the challenges of a completely different urbanized world is a bit like the scary and threatening espresso Romano where a sudden dash of lemon that we don't expect popping up in our espresso will throw us off and we will simply not know what to do.

    The jury is still out. Hopefully, this was, again, informative and a bit challenging. Until the next episode, again, thanks a lot to Jodie and Roger for indulging us in our format. Thank you.

    Kate Murray:

    Hi. Kate again here. I usually dip in at the end of an episode to tell you that you can find more about connected Cities Lab, our research and our events on our website, research.unimel.edu.au/connected-cities. Or, I'd tell you that you can find us on Twitter @networkcities, or that the music was by Coffee Music, and also remind you to subscribe to this podcast for more conversations and content on urban research. But after listening to the reflections from Roger and Jodie, from their respective places in the world in quarantine, I thought I'd rather end this episode with their words.

    Jodie McVernon:

    It was uncanny to listen to a podcast recorded on the 13th of December and realise that the coronavirus was already silently spreading in another part of the world when we spoke. Since that time, our world has changed dramatically, and so much of what we said has indeed come true, but so much of what we never considered has already happened. The way in which we in cities live our lives has changed possibly for many months or years to come.

    My own reflections are that coronavirus has exposed many things about our cities, and as Roger says, we shouldn't exoticize the emergence of these diseases, because humans are the vectors who have spread this disease. In many cases, those who are most affluent have actually been most influential in its spread, travelling long distances from ski holidays and other parts of the world bringing this infectious disease into our midst. Of course, this disease has revealed the inequities in our cities, and nowhere more perhaps than a place like Singapore with exemplary early control undermined by crowded squalid housing, which are the conditions in which many migrant workers live.

    The importance of home as a place of shelter has never been more apparent. We are cocooned within our homes as we are locked down. For many of us, those are places of comfort and warmth. For others, they are places of fear and violence, and for some, there is no home at all.

    These events have also revealed our dependence on the silent workers of cities. Sally McManus the ACTU President reflected on this the other day quite beautifully, "That the people who are our heroes now are the silent workers. The supermarket workers, the teachers, the bus drivers, waste disposal services. So many people who go uncelebrated in their everyday lives are now sole sources of dependence to enable us to live in our cocoons, in our cities, where the link between our work and existence are so disconnected."

    As we come to terms with this coronavirus and work out how to adapt to it, once again, our powers of evolution and adaptation will be stressed. Many of our relationships are intensified, and others torn. I hope that as we work together to see how our cities can adjust, that we will not forget the hidden people that we will work together collaboratively, and use this opportunity to reimagine our cities and their lives in ways that will be more sustainable and equitable into the future.

    Roger Keil:

    It is eerie to listen to this now. It's almost four months since we recorded this on a sunny morning in Melbourne. Four months later, it's now a completely different world. I'm in a different world, I'm in isolation in Toronto, Canada in my house. As most people, I have spent the last month or even more inside. I've gone through various learning processes of dealing with this. When we talked in December, things were not quite imaginable at the scale at which we now have experienced the COVID-19 outbreak.

    I am going to resist the impulse to say, "I told you so," which some of us who've been dealing with this and all of us at the panel on that morning in Melbourne certainly could have said, because we, I think, covered a whole number of topics that are now on everybody's mind. A lot of the language that was used by us at the time during this discussion is now in every newspaper and every media outlet.

    In a way we had anticipated that. The date, Friday the 13th, was of course, uncanny, because at the time, when we sat down to have coffee and to exchange thoughts on this, the COVID-19 was already amongst us. On December 8th, the first case apparently had appeared in Wuhan, and on December 31st, just a couple of weeks after our recording, China notified the World Health Organization of an untypical pneumonia cluster in Wuhan, and you know the rest of that.

    I am not in the business of saving lives directly. I'm not a medical doctor or a medical person in any way, and I have not participated physically in the enormous effort that people have put into saving lives around the world over the last three or four months. As a social scientist, I'm humbled and I'm happy to some degree that people like us are able to contribute to a better understanding of what is happening out there right now, and to also perhaps contribute to better preparedness in the future.

    In that context, I was a little bit proud and very, very happy to see that our paper with Creighton Connolly and Harris Ali that was talking about exactly the sort of things that we are now dealing with in terms of societies dealing with the emerging infectious disease, that this paper was published by the Journal, Urban Studies actually in March, a month ago. In that paper, we argued that we need to look at the extended urbanization as one factor through which to understand COVID-19.

    I would double up and double down on this now and say that, in fact, COVID-19 has shown, to some degree at least, that it is the disease of the periphery. SARS was the disease of the global city. COVID-19 is the disease of the periphery. In that sense, I don't mean it because outside of the city or in the suburbs of the city, it is a disease that is in the periphery of all of our societies. In those places, it's particularly ravaging in those places that are at the margins of society that we have chosen to peripheralize through our policies and actions, and through our forgetting. It is the long-term care homes. It is the poor and racialized neighborhoods of our cities that have taken the brunt of this disease in many parts of the world.

    COVID-19 also reproduced the idea, unfortunately, that the virus has escaped from somewhere exotic like the heart of Africa as people have been saying about HIV-AIDS or Ebola, or a wet market in China as people said about SARS and now COVID-19. This myth is not helpful, and we have noticed this right away over the last two or three months. We need to understand that those risks of zoonotic diseases coming from anywhere can in fact come from anywhere.

    Viruses are not aliens that come from exotic locales, or far away stars and places outside of our world. Viruses can come from anywhere. The people who carry the viruses are also not aliens. One of the lessons that we learned very fast and learned the hard way is that racialization, racism around COVID-19 raised its ugly head all over the world, but it particularly, of course, initially against the Chinese population in North America and other places where the virus turned up.

    Now, this is a complicated issue and we need to do more work on this. We need to train our societies, for any future outbreak, to be more sensitive to this particular issue around racialization and scapegoating. Here's where I'd like to end my comments. Thank you very much.

More Information

Kate Murray

kmurray@unimelb.edu.au

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