1.2.3. Weak spots

While São Paulo has the highest population density (7,216 per square kilometre) of the three cities, followed by Manaus (158 per square kilometre) and then Boa Vista (74 per square kilometre), it is clear that the relationship between density and health outcomes is by no means linear or decisive: despite its lower density, Manaus has a higher rate of infections per 100,000 inhabitants than São Paulo. At the same time Boa Vista, the least dense of the three, also had the lowest infection levels. These disparities could be due to many reasons, such as social behaviour, the nature of work or mobility patterns. There may also be discrepancies in how the figures are estimated. For example, in view of mortality rates, both São Paulo and Manaus have had similar mortality rates that are higher than the country average. While this could be due to multiple factors, it is important to note that the two cities serve nearby suburban and rural areas due to their relatively high number of medical facilities, leading to higher recorded deaths in cities.

In fact, vulnerability is ultimately a more significant determinant than either density or population size. A city-level measurement, the Social Vulnerability Index, has been specifically designed specifically to assess this. Based on 16 indicators looking at three dimensions — urban infrastructure, human capital and income and employment — the scores are represented on a scale between 0 (ideal) and 1 (critical), with a range of indicators (0-0.2: very low, 0.2-0.3: low, 0:3-0.4: average, 0:4-0.5: high, 0.5-1: very high) in between. The higher the index, the greater the vulnerability of a city. The dimension of urban infrastructure is based on access to basic services and urban mobility, as these aspects are related to place of residence and affect quality of life. The dimension of human capital is based on health conditions and access to education as they determine the prospects of an individual. The dimension of income and labour considers families’ insufficient income as well unemployment rates, informal occupation and child labour.56

For the cities in this case study, the Social Vulnerability Index was available for both São Paulo (0.291) and Manaus (0.387), but not for Boa Vista. A breakdown of the index based on the three dimensions reveal that not only was urban infrastructure in Manaus more precarious, but also that its human capital was at greater risk than in São Paulo, relating to health conditions and access to education. With the current pandemic, this dimension played a critical role in exacerbating the vulnerability of individuals.

1.2.3. Weak spots

Urban “weak spots” can be understood as parts of metropolitan regions and cities that have a harder time responding to shocks or stresses due to their physical form and the availability of services. A number of characteristics define these settlements, including:

ƒ Overcrowding: High population density is not matched by service delivery or adequate living and circulation space.

ƒ Limited or poor connectivity: Homes and communities are cut off from neighbouring parts of the city and their accompanying benefits by a lack of public transportation or even physical barriers.

ƒ Vulnerable locations: High-risk areas such as floodplains, riverbanks or dumps pose a range of health and environmental hazards for residents living in them. These are all issues that many informal settlements face, leaving them more exposed to natural disasters, food shortages and other crises, including COVID-19. They are also exposed to a range of other risk factors that accelerate the spread of infection, including overcrowding, inadequate sanitation, lack of access to clean water and other issues. Besides the difficulty of complying with physical distancing at home or on the street in cramped or crowded conditions, many residents have to commute between different parts of the city for work, exposing them to overcrowded public transportation. The multidimensional inequalities faced by informal settlements in terms of poverty levels and lack of service provision, discussed in more detail in Chapter 2, are also reinforced by the spatial dimensions of their exclusion, with many located in peri-urban areas that are far removed from hospitals and other facilities.

Although not traditionally associated with poverty or lack of services, suburban areas and Informal settlements are also exposed to a range of other risk factors that accelerate the spread of infection, including overcrowding, inadequate sanitation, lack of access to clean water and other issues

their inhabitants can also be at a disadvantage when responding to and recovering from crisis, in part because of their spatial typologies. One reason for this is because they often lack amenities that support alternative use. Because parts of metropolitan areas that are not mixed-use are more prone to relying on private motor vehicle use and usually have only a few types of building and block typologies, flexible street design and adaptive re-use or temporary re-purposing of buildings and public spaces are not as easy to implement as in more heterogeneous urban areas.

Another aspect is that suburban areas patterned after single-family houses with yards might not have the same acreage of public space and infrastructure for public transport and nonmotorized transit per person as in urban areas. During lockdown, outdoor recreation and leisure facilities such as public parks, boardwalks and nature reserves were considered safe zones for play, physical activity and psychological reprieve. However, infrastructure for recreation and leisure is often missing or not within walking distance for many suburban families, which, under restrictions to stay within a certain distance of one’s home, can make access to such spaces difficult. The importance of designing and advocating for neighbourhoods where most daily needs can be met within a 15-minute walk from home is discussed further in relation to pandemics at the neighbourhood scale in section 1.3.

Access to other functions is also typically limited in suburban areas where low-density single-family homes constitute the primary land use. Whereas in higher-density mixed-use areas, markets, pharmacies, post offices, schools, offices, recreational facilities and open spaces can all be found in the same neighbourhood, single-use areas typically require personal motorized vehicle in order to carry out daily functions. Moreover, because of their auto-centric morphologies, they also direct large groups of consumers to the same destinations. For example, in well-planned cities small markets where neighbourhood residents can purchase basics like milk, rice, bread and beans throughout the day can typically be found at almost every street corner. In areas designed around cars, on the other hand, much larger grocery outlets concentrate hundreds of shoppers in the same space, typically during peak hours, when people find the time to drive out of their way to shop for groceries. Aside from further contributing to road congestion, pollution and a relatively sedentary lifestyle, these suburban development models serve as a “petri dish” for the spread of the virus.57

The health implications of living in areas associated with suburban sprawl can also put residents at a disadvantage. Findings from one of the first significant reports on this issue concluded that “the most obvious mechanism through which a sprawling environment affects health is as an opportunity structure that constrains the amount of physical activity that people routinely exert on a daily basis”, impacting particularly on the elderly and the poor who may have less access to private vehicles to overcome the spatial challenges of suburban living.58 By limiting or disincentivizing physical activity, suburbs can have a deleterious effect on physical health.

This is borne out by another survey, conducted by RAND using data from a nationally representative US household phone survey, which found that people living in more sprawling areas had higher rates of hypertension, arthritis, abdominal complaints and headaches, as well as significantly higher rates of breathing difficulties. Crucially, these results held even after other factors such as income and ethnicity were accounted for.59 Limited street accessibility seemed to be one of the core factors in the decision and ability of respondents to walk, with a significant association noted with elevated hypertension and heart disease. Breathing difficulties, meanwhile, are also likely to be the result of air pollution as a result of increased motorized transport to navigate the low-density, physically dispersed urban form that typically characterizes suburban areas. This is particularly relevant to the current pandemic as both hypertension and respiratory diseases may put