Over the course of the coronavirus pandemic, there has been a lot of hand-wringing about the fate of cities and urban living. The argument goes that dense populations lead to more sickness and more death.
But how true is that?
It turns out that suburban sprawl, not density, contributes more to death and spread of COVID-19, according to a new study from Johns Hopkins University.
Knoxville’s metro region is a textbook example of suburban sprawl — the expansion of living areas far outside a city’s core. A 2014 assessment by Smart Growth America, an urban planning think tank, places Knoxville and Chattanooga in the top 10 most sprawling midsized metro areas.
Reid Ewing, a professor of urban planning at the University of Utah and study co-author, explained in an interview with Knox News that deaths and case counts correlated closely with the square mileage footprint of commuters and suburbs around a city, not the population density of the city itself.
“Right now, one of the epicenters is Los Angeles. It’s the opposite of New York,” Ewing said. “It’s really huge and it goes on forever, and it’s just medium density everywhere.”
Ewing’s team believes these counterintuitive findings are related to two things: risk perception and access to good health care.
“People in dense places are more likely to take ‘stay at home’ orders seriously or are more likely to wear masks just because they are more aware of the threat,” Ewing said. He explained that it was possible that people in suburbs might not perceive themselves to be at risk and so would take fewer precautions.
And because people living in suburbs travel greater distances, this means that the virus has more of an opportunity to spread.
Sprawl and lack of access to health care have long been associated with bad health outcomes, both in rural and suburban areas. Studies have shown that less dense areas tend to have less developed health care infrastructure.
“We explain the higher death rate in sprawling areas in terms of inferior intensive health care,” Ewing explained.
But how does this work locally? Take the case of Knoxville.
Knox County has 4,784 confirmed cases of COVID-19 and 46 deaths. Knox County is home to 465,289 people. The metro area, which includes nine nearby counties, is home to 882,598 people and has had 8,147 cases and 60 deaths as of Aug. 7. The whole area is roughly 3,500 square miles in size.
Now compare this to the hyper-dense city of Hong Kong, population 7.5 million. Hong Kong is spread over an area of 405 square miles, or less than a quarter of the Knoxville metro area. The total number of COVID-19 cases is 4,148 with 55 deaths, according to the Johns Hopkins Coronavirus Dashboard.
Importantly, Hong Kong had neither a South Korean-style test-and-trace response, nor a Wuhan-style lockdown. According to reports in The Atlantic and other outlets, Hong Kong’s containment of COVID-19 was led by mass movement of volunteers who distributed masks and sanitary supplies to the poor and older adults. In contrast, the government response was disorganized.
If COVID-19 was strictly spread via density, Knoxville should have nowhere near the number of cases that a megacity like Hong Kong has. Instead, the two are comparable in case counts but not in physical size. Knoxville fairs similarly when compared to other dense metropolises like the South Korean capital city of Seoul.
Ewing’s research team examined the confirmed infections and deaths from COVID-19 at the county level from the beginning of the pandemic. They controlled for possible cofactors like poverty, the number of health care facilities, race, sex and air quality. They also examined connectivity between cities by factoring in air travel and commutes. The team also factored for crowding in public areas like restaurants. It did this because many politicians had been making comments that compared New York City directly to all other places erroneously.
“So, instead of just looking at New York City, we studied data from 913 counties located in metropolitan areas across the country to come to more generalized conclusions,” Shima Hamidi, a professor of public health at Johns Hopkins, said in an interview with Common Edge.
They found that outlying counties within spread-out metropolitan areas had statistically significantly high rates of infection. They also found that dense counties had significantly lower death rates.
Knoxville isn’t unique. Nashville and Atlanta were in the top 10 for most sprawling major metro areas.
The study authors readily admit that this is the first, not the last, word on density and COVID-19. As the pandemic continues, more localized studies can shed light on each community.
Even if this early correlation between COVID-19 and sprawl turns out not to be true in every case, there is ample evidence that sprawl makes health worse in other ways. Sprawl has been linked to air pollution, obesity, heart disease and mental health issues, all of which make people less healthy and happy.
“There are many studies over the past decades on how compact development can improve the quality of life: from economic aspects, to environmental sustainability, to public health,” Hamidi said.
The study authors hope that these factors are not forgotten as people adjust their lives in the fallout from COVID-19.