All Together: Summoning Ideals During a Period of Crisis

November 23, 2020

Principal, NBBJ

Editor’s Note: This essay was originally published by Alex Krieger for the Harvard Graduate School of Design here

 

Optimism in America can be in short supply. A fearsome pandemic has taken an intolerable number of lives, with many more people succumbing daily. Livelihoods are at stake as millions remain out of work, and the economy is suffering. The particularly shocking murder of George Floyd, a Black man, at the hands of white police officers—and shootings since—have awakened wide-ranging cognizance of persistent racism, a much longer national crisis than the pandemic. And some political leaders shamelessly stoke divisiveness rather than speak out for tolerance and unity.

In truth, national unease was present prior to the arrival of COVID-19. Among a gathering of worries was climate change inaction, growing environmental harm, housing unaffordability, health care insecurities, and accelerating economic and social inequalities. Unlike prior generations—who trusted in a better future for their kids — today’s parents believe that the prospects for their children’s lives seem not as promising as were their own.

Along with optimism, expressions of ideals are in remission. Yet even amidst individual anxieties and the anger of the multitudes, one can sense a desire to reassert certain ideals. Let’s look again to the ones embodied in the opening sentence of the Constitution, “to form a more perfect Union,” and in our oldest motto, e pluribus unum. Would not the desire for equality, well-being, respect and acceptance of others, shared prosperity, valuing those who serve, caring for the environment, and access to health care be embodied in such aspirations? Add happiness, too, as in “life, liberty and the pursuit of happiness.”

Ah, but you are thinking that such hallowed statements — voiced by the privileged — were not actually intended for all, despite the phrase “All men are created equal.” No, we have never fully met the challenge of America’s lofty aspirations. But should we not continue to try, especially now? That oft-repeated phrase — We are all in this together — heard both in relationship to fighting the pandemic and among the marchers for justice, is not unrelated to an intention to form a more perfect union.

Can we all together transition from marching in protest to overcoming racism and other inequalities? And while we’re at it, can we all insist that fresher air remains over our cities once the pandemic is conquered? Can we collectively distribute less carbon into the atmosphere? Continue to enjoy congestion-free, pedestrian-friendly streets throughout urban America? Keep a healthier balance of work and life? Prolong that respite from incessant travel demands? Continue spending more time with family? Maintain daily walks with a loved one when social distancing mandates abate? Why not commit to keeping those Himalayan peaks visible from broader regions of India? Such shifts have been, pardon the expression, breaths of fresh air, illuminated by a crisis.

Throughout American history, a reconfiguring of society following a crisis often catapulted the nation forward. Shouldn’t today’s interrelated crises do so as well? For inspiration, recall the earliest colonists, finding not the Eden they imagined while sailing to a new world, but confronting a harsh wilderness instead. They persisted to fashion a version of Eden in which to prosper. Against odds, their descendants defeated a mighty empire standing in the way of life, liberty and the pursuit of happiness. Now remember the establishment of a Homestead Act in 1863, enabling any citizen to acquire a quarter-section of America—160 acres—at minimal cost, simply by occupying it and providing minimal improvements. Talk about affordable housing! Or, recall the Morrill Act, also passed in the midst of the Civil War. It required states to establish a public university with the proceeds from the sale of land granted by the federal government. Sixty-nine such land-grant institutions were founded, greatly expanding access to education and the “useful” skills necessary for a modernizing society. Among these were Texas A&M, the University of California, Cornell University, and MIT.

Now consider the determination to overcome distance: Construction of a transcontinental rail system was completed within a couple of decades during the second half of the 19th century. Concurrently, thousands of acres of parks and greenswards were “planted” in rapidly industrializing and increasingly harsh cities, in order to make them more humane for all those arriving from subsistence farms and across oceans. Remarkable environments such as New York’s Central Park and Boston’s Emerald Necklace were the result.

And we haven’t yet gotten to the 20th century, during which America prevailed in two world wars; invented a social security system and Medicare for the elderly; reconnected the country with roads, telephones, and the internet; increased the percentage of families attaining their measure of the American dream; and finally established civil rights in law (if not always in reality). We even landed a person on the moon, and even more remarkably returned him safely to Earth—a catalyst for major public commitment to scientific research in multiple fields.

To summon either aspirations or accomplishments of American culture is not to ignore, much less excuse, the many dystopic aspects of American history: the near total destruction of Indigenous cultures; the horrors of slavery and systemic racism; the conceits of Manifest Destiny and American exceptionalism; the continued corporate and political restraints on economic parity; the despoiling of the environment in the name of progress. Mere voicing of ideals have not led to their attainment. But to live and flourish in company with others — in more perfect union — requires shared ideals.

Summoning ideals during a period of crisis is hardly naive. Re-read John Lewis’s letter written right before his passing, imploring us to pursue “the next chapter of the great American story.” A lifetime of struggle against racism and for civil rights did not lead Lewis to abandon America’s ideals. And back in 1859, at an event in Boston’s Faneuil Hall, scene of revolutionary foment a century earlier, Carl Schurz — senator from Missouri, 13th secretary of the interior, and an immigrant appreciative of his adopted country — spoke to the value of following national ideals. “Ideals are like stars,” he said. “You will not succeed in touching them with your hands, but… you choose them as guides, and following them will enable you to reach your destiny.” Sound advice.

The pandemic will be conquered, vaccines are on the horizon and the economy will gradually rebound. An incoming administration promises to address partisanship and social discord. Many are hopeful for that effort’s success. Still, rather than pining for a return to a prior normal, lets commit, all together, to a destiny that enjoys the necessities of clean air, justice and equality for all.

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Rethinking Healthcare Hubs In The Post-Covid Era

Three ways technological advances will shift healthcare delivery, from the traditional hospital to at home services.

November 2, 2020

Principal, NBBJ

Editor’s note: Our healthcare clients are on the front lines of the coronavirus crisis. We seek to support them as they courageously care for the sick. So we’re posting design ideas based on work with them, in the hope that we can contribute from our base of expertise to help combat the epidemic. From all of us at NBBJ to the many doctors, nurses and support staff in hospitals and clinics, thank you from the bottom of our hearts.

This post initially appeared on Forbes. It was co-authored by Sarah Markovitz and Ryan Hullinger.

 

The explosion of telehealth prompted by the COVID-19 pandemic has accelerated a shift in care delivery away from the hospital and clinic and into homes and communities. While hospitals have historically been the main hub of care, technology and new care models are enabling a different approach to care delivery. Rather than episodic preventative care, in which a patient periodically goes to a physician or hospital with a health concern, this new model of care is continuous and ubiquitous — with ongoing care reinforced in the home, office, school and throughout the community. There are three key aspects to this shift: advancing technology, new care settings, and the future evolution of hospitals.

 

Advancing Technology

Healthcare may follow a familiar path blazed by online retail. It was not that long ago that virtually everyone preferred in-person retail experiences to shopping online. The technology that would later make online shopping experiences superior to brick and mortar just didn’t exist. Telehealth, by comparison, is still in the dial-up days. It’s difficult to imagine now, but based on the patterns we have seen clearly in other technology sectors, it’s probable that some healthcare experiences will be better remotely than in-person—more convenient, and less stressful and time consuming. The technology that will transform telehealth is on the horizon. It will take several R&D cycles, but it will come. In fact, there’s evidence that in areas like behavioral health telehealth is already comparable in efficacy to in-person care.

What might the next generation of telehealth look like? For one, rather than sequential visits with separate specialists, patients may be able to connect to a suite of caregivers, all working collaboratively to provide more coordinated, effective care. The type of continuous, convenient touch-bases and flow of information enabled by telehealth and wearable devices could be particularly effective for the elderly and those with chronic conditions, where communication and ensuring compliance with medication and preventive care are often an issue. There will also likely be an expansion in the types of care and services that can be provided, including everything from post-surgical appointments, to ED triaging, and eventually more complex tests as new diagnostic technologies emerge.

Automated technologies and artificial intelligence will also play an increasingly vital role in improving health throughout the community. AI technologies are being used to scan patient records, identify patients with hypertension and diabetes, and remind physicians to check in regularly with them. Hospitals have already shown good results using telehealth, texting and improved monitoring to help vulnerable populations and those with chronic conditions. Improved telehealth and health data capabilities could extend widescale efforts like these, improving population health efforts.

 

New Care Settings

With technology acting as a facilitator, more and more forms of care, especially routine procedures, will migrate away from hospitals and clinics. The home could become the new healthcare hub, with prefabricated telehealth units for the home that integrate medical technologies with telehealth capabilities. The explosion of smart home, home health and health monitoring devices, encompassing everything from sensors that detect sudden falls to smart watches that monitor heart rate and O2 levels, is only the tip of the iceberg. With the ability to monitor health data and communicate effectively with caregivers, the home could be a crucial site for preventive medicine, chronic disease management and ongoing care.

The home health model is only one possible model—the technologies that enable it may have shortcomings, or prove unaffordable to large segments of the population, further exacerbating health inequities and the digital divide. But healthcare can still be provided in a wide range of locations distributed throughout communities. Libraries, schools, community centers, homeless shelters and pharmacies could become hubs for telehealth resources and care, serving a vital role in improving the health of communities. A key consideration will be access and location—ensuring that healthy equity and care for vulnerable populations drives where these new care hubs emerge.

 

How Hospitals May Evolve

As care becomes increasingly continuous and ubiquitous, the role of the hospital may evolve. Rather than serving as a destination for all patient types, it will become increasingly specialized and streamlined, focusing on high acuity cases. They may expand their capabilities and efficiency in areas like perioperative and high-end imaging that are not available in community settings. In the process, hospitals are likely to become more compact, high performing and efficient by narrowing their focus. As part of this evolution, hospitals may also need to bolster their ability to expand capacity by 50-100% in anticipation of emergencies like epidemics, mass casualties and weather-related crises.

In the last 20 years, many hospitals have invested heavily in improving patient comfort and satisfaction, and have even borrowed processes and designs directly from the hospitality industry—creating patient environments that nearly resemble hotel lobbies and guestrooms. Patient satisfaction will continue to be a driver, but the environments that promote satisfaction are likely to change drastically. New environments that convey a sense of safety and cleanness will begin to feel more comfortable than the hospitality-informed designs of the past.

As this shift and gradual downsizing takes place, there may be opportunities to adapt existing space for other uses. The COVID-19 pandemic has demonstrated the dramatic impact of stress on healthcare workers. Hospitals now have an opportunity to provide sufficient and appropriate space for staff, helping to build resiliency to counter staff burnout and ensure the well-being of these truly essential workers. Hospitals could also aim to provide more community, patient and staff resources, such as spaces to demonstrate telehealth technologies and how to use them, or new hybrid offices equipped for telehealth.

As technologies, new care settings, and hospitals evolve, care will become more embedded in our daily lives. The pandemic may have spurred new interest in telehealth, but the trends shaping the future of care predate social distancing. They will continue to transform how and where care is delivered, ushering in a new era of ubiquitous healthcare.

 

How are you and your healthcare organization dealing with the coronavirus? We’d like to hear from you. Drop us a line at socialmedia@nbbj.com.

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In Defense of Cities

Despite the pandemic, history shows that urban growth is likely to continue because cities provide benefits that cannot be replicated elsewhere.

October 6, 2020

Principal, NBBJ

Editor’s Note: This essay was adapted from a recent presentation Alex Krieger gave to the Harvard Graduate School of Design. Watch the presentation here.

 

The pandemic (somewhat understandably) and the protests for justice (sadly) are leading to a partial withdrawal from our cities. Of course, such departures have occurred a number of times over the course of American history. Americans have not needed much encouragement to seek a bit of space between themselves and the “rasping frictions” of big city life.

Prior to the pandemic, American cities were on a roll. Since the turn of the millennium at least, America was actually witnessing an urban revival. Suburbia had lost much of its appeal for the generations that grew up in it, and memories of mid-century urban decay had largely faded. Editorials in urban newspapers announced “the cachet of a city zip code.” Pundits welcomed the arrival of the creative class, and promised an extended era of urban fortune assured by the commitment to city life by the millennial generation. Even some empty nesters were happy to part with lawn mowers in exchange for more convivial urban contexts.

Now in 2020, many people are again falling prey to anxieties about cascading urban problems: spreading of disease, street protests — even on behalf of just causes — urban crime rates and cost of living.

Then comes a new possibility: the untethering of work from the places designated for work. Some companies forced to vacate offices due to the pandemic are beginning to question the necessity of ever fully returning to downtown office towers, but especially between now and the development of a COVID-19 vaccine. Employees are assessing the personal and financial benefits of cutting out commutes, having greater daily flexibility, and enjoying more family time while working from home.

Should we succumb to urban anxieties? Or, will cities recover their appeal (unaffordability aside) when the pandemic is conquered? History makes those of us who love cities maintain some optimism. Neither devastating fires when cities were made of wood, nor the cholera of Dickens’s London, nor the urban bombardments of World War II, nor the postwar fears of nuclear holocaust, nor even the shock of 9/11 fundamentally altered the pull to urbanize. Neither will COVID-19 over the long term (barring arrivals of COVID-20, 21, etc.). Cities have been, and will remain, in Claude Lévi-Strauss’s memorable phrase, “the human invention par excellence.”

There are advantages to living in a city that are not replicable with digital software. Days filled with Zoom calls and on-line shopping are not an adequate replacement. Today’s global institutions and economies advance with a metropolitan bias — powered by the concentration of innovation-minded talent and entrepreneurial zeal. Some 60 million people have been annually migrating to the world’s cities. They do so, as people have done for centuries, in search of opportunity, economic security, and the promise of a better life. Today’s anxieties will not lead to half of the seven billion inhabitants of earth who currently live in urban regions to all flee to exurbia, or Montana, or the steppes of Russia. (But some rebalancing between immense urban concentrations and smaller and mid-sized cities may be a good thing.)

Will there be adjustments as a result of our current crises? Absolutely. Since the Industrial Revolution—and the accompanying prodigious migrations to urban areas from subsistence farms and across oceans—Americans have viewed cities as sources of congestion, pollution, crime, undue class competition, the spread of infectious diseases, and too harried a daily life. The idea of the garden suburb emerged in reaction to the squalor unleashed by industrial urbanization. And at least since the Transcendentalists, a bucolic setting has been considered ideal for family life.

Now that the possibility of enjoying a hospitable setting while remaining connected to jobs and centers of enterprise has finally become a reality (after having been predicted since the earliest days of the digital revolution), decisions about where to live and commercial investment in city centers will surely be affected. But even as we’re discovering that we can live and work “anywhere,” the inadequacies of life tethered only to home and computer monitors are being revealed. A rebalancing of the domains of work and life will continue, and will affect the planning of cities, especially with regard to density, but to what extent remains uncertain. Predictions about the future rarely come to fruition.

Oscillation between the allure of the city and the allure of living free of city stress has recurred throughout American history. The pandemic will certainly cause some people to seek a haven away from the hustle and bustle, or over anxiety about future pandemics. Still, since global institutions and economies will continue to advance with that metropolitan bias, many more people will continue to partake of all of the cultural riches found in great city centers than will flee for the promise of a safer, if less full, life.

 

Alex Krieger, Principal, NBBJ. Professor of Urban Design, Harvard University. Author of City on a Hill: Urban Idealism in America From the Puritans to the Present.

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