Debates paper

Urban Studies
2021, Vol. 58(2) 245–263
Ó Urban Studies Journal Limited 2020
Extended urbanisation and the Article reuse guidelines:
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spatialities of infectious disease: DOI: 10.1177/0042098020910873
journals.sagepub.com/home/usj
Demographic change, infrastructure
and governance

Creighton Connolly
University of Lincoln, UK

Roger Keil
York University, Canada

S. Harris Ali
York University, Canada

Abstract
This paper argues that contemporary processes of extended urbanisation, which include suburbanisa-
tion, post-suburbanisation and peri-urbanisation, may result in increased vulnerability to infectious disease
spread. Through a review of existing literature at the nexus of urbanisation and infectious disease, we
consider how this (potential) increased vulnerability to infectious diseases in peri- or suburban areas is in
fact dialectically related to socio-material transformations on the metropolitan edge. In particular, we high-
light three key factors influencing the spread of infectious disease that have been identified in the litera-
ture: demographic change, infrastructure and governance. These have been chosen given both the
prominence of these themes and their role in shaping the spread of disease on the urban edge. Further,
we suggest how a landscape political ecology framework can be useful for examining the role of socio-
ecological transformations in generating increased risk of infectious disease in peri- and suburban areas.
To illustrate our arguments we will draw upon examples from various re-emerging infectious disease
events and outbreaks around the world to reveal how extended urbanisation in the broadest sense has
amplified the conditions necessary for the spread of infectious diseases. We thus call for future research
on the spatialities of health and disease to pay attention to how variegated patterns of extended urbanisa-
tion may influence possible outbreaks and the mechanisms through which such risks can be alleviated.

Keywords
demographic change, extended urbanisation, governance, infectious disease, infrastructure, urban
political ecology
Corresponding author:
Creighton Connolly, Asia Research Institute, National
University of Singapore, 10 Kent Ridge Crescent, AS8, 07-
49, Singapore 126818, Singapore.
Email: cconnolly@lincoln.ac.uk
246 Urban Studies 58(2)

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Received May 2019; accepted February 2020

Introduction urbanisation, paying particular attention to

the socio-ecological flows and disruptions
To date, the literatures on urbanisation and leading to an increased incidence of infec-
globalisation have focused primarily on eco- tious disease in peri- or suburban areas.
nomic and demographic flows to, from and This paper, then, will focus on the impact
through cities and their regions (Brenner, that more extensive forms of urbanisation
2014; Ren and Keil, 2017). More recently, worldwide have on increasing susceptibility
there has been a growing academic and pol- to infectious disease, especially emerging
icy interest in connecting challenges of a infectious disease (EID), that is, ‘an infec-
majority urbanised world to questions of tious disease whose incidence is increasing
health and disease, including Ali and Keil’s following its first introduction into a new
(2008) edited collection, Networked Disease: host population’ (Quammen, 2012: 43), and
Emerging Infections in the Global City, as a zoonosis, which is ‘an animal infection
ground-breaking publication (see also Elsey transmissible to humans’ (Quammen, 2012:
et al., 2019; Moore et al., 2003; Wu et al., 14). Notably, ecological pressures coupled
2017). Meike Wolf’s (2016) research on with social and spatial change have led to
urban epidemiology also takes forward the new forms of disease spread that have like-
debate surrounding the role of changing wise contributed to the rise of EID epi-
geographies on urban health and disease. demics. These include changes in water-
Furthermore, a recent article by Bollyky borne EID spread, as was the case with E.
(2019) has more explicitly noted that the coli 0157:H7 (Ali, 2004); changes in food-
future of global health is urban health. borne EID transmission as brought on by
Recognising these emerging conversations, changes in global consumption patterns
we are specifically interested in this paper in (Hoffman, 2014); as well as changes in the
new ways in which infectious disease is distribution of vector-borne diseases such as
bound up with processes of extended malaria, wherein the distribution of
Connolly et al. 247

mosquitos has been affected by global cli- of infectious disease burden that have been
mate change (Brisbois and Ali, 2010; identified in the literature on this topic
Epstein, 1998; Nading, 2014). within various strands of urban studies.
In examining these relationships between These interrelated dimensions are mobility
extended urbanisation and infectious disease and demographic change, infrastructure and
we suggest how a landscape political ecology governance. There are certainly more factors
(LPE) framework can be useful for integrat- that could be identified (e.g. deforestation
ing the key themes of spatiality, socio- and climate change) but these three themes
natural metabolism and power relations cen- have been most prominent in the literature
tral to undertaking such an analysis. As we on urbanisation and infectious disease, and
discuss, LPE approaches are crucial to also relate closely to processes of extended
understanding the metabolic processes and urbanisation.1 We have kept these themes
socio-environmental implications bound up intentionally broad to capture as much of
with extended forms of urbanisation. The the disparate work that exists on this topic
concept of metabolism refers to the combi- as possible. Moreover, we consider how
nation of social and natural processes to these factors influence different phases of
form socio-natural landscapes (Swyngedouw infectious disease management, from disease
and Heynen, 2003). We posit that, while prevention to mitigation and control of out-
rapid and intensive forms of urbanisation breaks, and possible responses.
(densification) are seen as enabling factors In what follows we will first establish the
for the spread of infectious disease (Munster context for this paper, outlining why the
et al., 2018), it is important to study relationship between extended urbanisation
extended urbanisation because patterns of and infectious disease is important to study,
urban sprawl and expansion are more likely and how this differs from existing work on
to lead to infectious disease outbreaks, as the relationship between urbanisation and
opposed to cities, which are generally disease. Subsequently, we introduce the con-
assumed to reduce the incidence of infec- ceptual framework of landscape political
tious disease for inhabitants (see Wood ecology, indicating how this relates to (but
et al., 2017). This is, in part, because urban differs from) urban political ecology and
expansion might expose sub- and ex-urban how this is a useful lens through which to
areas to higher levels of biodiversity (and understand the emergence of infectious dis-
disease sources) than are found in central ease in peri-urban areas. We then survey the
urban areas (Kaup, 2018). Cities also have three themes of mobility and demographic
better health facilities and resources which change, infrastructure and governance, in
can enable faster response times and turn, discussing their importance for addres-
enhance containment of disease outbreaks. sing emerging urban challenges related to
In other words, the new and evolving glo- extended urbanisation. Finally, we reflect on
bal peripheries have been particularly sus- how the expansion of the city can influence
ceptible to diseases that jump the animal-to- the spread of disease and how this can be
human species boundary (zoonosis); have addressed in future research.
seen the introduction of new disease vectors;
and have seen dynamic changes to urban Extended urbanisation and
and spatial morphology and transforma-
emerging infectious disease
tions over time (Brisbois and Ali, 2010). In
demonstrating this argument, we highlight Contemporary patterns of extended urbani-
three key factors influencing the distribution sation fundamentally shift the vulnerability
248 Urban Studies 58(2)

of cities to infectious diseases in ways that and the informal communities that character-
differ from those that have historically been ise much of today’s urbanisation without
associated with urbanisation. Such processes being necessarily spatially on the margins (e.g.
of urban expansion are linked to the ubiqui- refugee settlements, mining camps and indi-
tous reordering of the global urban periph- genous reserves near urban centres) (Caldeira,
ery through complex processes of 2017; Güney et al., 2019). Finally, extended
displacement of central populations to the urbanisation refers to new and existing urba-
margins and the creation of new functional nisation and urban settlement in the periphery
centralities (jobs, infrastructures, densities) of cities and relations that condition these
away from the traditional core. As indicated, spaces but also reach beyond them (e.g.
we use the term extended urbanisation as a mines, factories and infrastructures) (Keil,
summary concept for these developments. 2018a).
The processes captured under this term, Such patterns of urbanisation – including
originally informed by the urban theory of connected processes of globalisation and
Henri Lefebvre (2003), predict what he neoliberalisation – can increase the qualita-
called ‘the complete urbanisation’ of society. tive conditions and the statistical odds that
This phenomenon is partially caused by the microbes are being spread, which has
rapid growth of the human population and resulted in a tripling of the total number of
the expanding geographical reach of capital- disease outbreaks per decade since the 1980s
ist accumulation over the past century, (Ali and Keil, 2007; Haggett, 1994). As
which have brought about an ‘urban revolu- Wald (2008: 14) has put it, cities have been
tion’ and the creation of an ‘urban society’ known by public health officials as ‘promis-
at the planetary scale (see Keil, 2018a). cuous’ social spaces, with people ‘literally and
Relatedly, various scholars have argued that figuratively bumping up against each other in
we are now witnessing a process of planetary smaller spaces and larger numbers than ever
urbanisation, which is premised upon before’. Additionally, the most significant glo-
expanding infrastructural networks and bal disease outbreaks in recent years have ori-
human settlements (Brenner, 2014). ginated in China and Africa, which are also
In this broader context, we are specifi- amongst the most rapidly urbanising regions
cally interested in what Lefebvre (2003) calls (Alirol et al., 2010). Both SARS and Ebola
the spread of ‘the urban tissue’ across the originated in urbanising hinterlands before
planet, which refers to the fluid relationships travelling to and spreading in and between
between urban and rural environments. major cities such as Hong Kong and Toronto
Forms of extended urbanisation – such as or Freetown and Monrovia, respectively (Keil
suburbanisation – are an empirically recog- and Ali, 2007). As such, how and why the
nisable process in this context. In many proliferation of suburban or peri-urban areas
parts of the world, particularly in the Global is conducive to disease spread is an important
South, peri-urbanisation is the preferred term question to explore.
for extended urbanisation (de Vidovich, While other approaches situate commu-
2019). Some scholars have called the current nicable disease as a function of social inter-
phase of urban extension ‘post-suburbanisa- actions, we focus on changing spatial factors
tion’, which leads to an increasing complexity that drive changing patterns of disease. This
of structural form and daily life in the periph- can be cast as part of a general concern with
ery of cities (Charmes and Keil, 2015; Wu the spread of risk as processes of peri-
and Phelps, 2011). In this context, ‘peripheral’ urbanisation and suburbanisation are argu-
can also refer to both the self-built structures ably the defining forms in which global
Connolly et al. 249

urban society is taking shape in the 21st cen- One of the key points of emphasis in
tury. In this context, Bloch et al. (2013: 96) approaches based on this premise is a focus
observed that ‘current urban growth pat- on the physical environment found within
terns appear to have significantly amplified such contexts. Much of the health research
the exposure of urban populations to hazard on the built environment reveals that the
risks, markedly but not exclusively those health of those in urban areas tends to be
broadly characterised as the urban poor’. worse than that of those residing in less
Therefore, identifying areas where the con- urbanised areas – a disparity referred to as
vergence of risk factors is occurring with the urban health penalty (Freudenberg
greatest intensity, and at the largest scales, is et al., 2005). However, such findings are not
a logical first step in the development of a wholly conclusive, as research has also
mitigation strategy. pointed to certain features of urban life that
benefit the health of urban dwellers, includ-
ing the availability of social support and bet-
Chronic and (emerging) infectious disease ter access to health and social services
(Bollyky, 2019). Current health research
Before we continue, we need to acknowledge
does conclusively demonstrate, however,
that much of the debate about urbanisation
that one aspect of the built environment
or, more precisely, extended urbanisation
is detrimental to good health, namely, living
and health/disease is occupied by a burgeon- in sprawling suburban neighbourhoods
ing interest in chronic diseases associated (Freudenberg et al., 2005; Frumkin et al.,
with a lifestyle that is ascribed to suburbani- 2004). What has made this question more
sation, auto-mobility and related technolo- complicated is exactly the tendency, invoked
gies. At the top of the list of these concerns in our usage of extended urbanisation and
are usually obesity (especially amongst post-suburbanisation, of blurring the classi-
young people), diabetes and heart disease cal lines of distinction of city and suburb,
(Hamblin, 2014). Importantly, attention has town and country. It appears more impor-
now also shifted to mental health related to tant for the health of communities and indi-
suburban life, for example in emerging work viduals where in the world and, indeed,
on people living with dementia in suburban where in the urban region they are located
environments (Biglieri, 2018). Much of the and how those particular areas are changing
literature on chronic disease has, as the tacit in relation to their natural and social envir-
starting point, the notion of ‘epidemiological onments (Wilson et al., 2008).
transition’. That is, the argument that in As alluded to above, the tendency to
Western, industrialised societies, more indi- date not to have focused concerted attention
viduals are living to older ages, which conse- on infectious disease may have to do
quently leads to increased incidence and with the ‘epidemiological transition’ model.
prevalence of chronic diseases associated According to this perspective, Western soci-
with (sedentary) ‘lifestyle’ and ‘ageing’, as eties have undergone a health transition
opposed to infectious diseases. Bloch and whereupon infectious diseases were no lon-
co-authors (2013: 96) of course warn: ‘A ger to be considered as major causes of mor-
closer examination of urban risk shows, in tality and morbidity (Omran, 1971). Thus,
fact, that ‘‘sprawl’’ is not the problem, but for example, it was in this light that in 1967
rather the lack of adequate land use plan- the US Surgeon General publicly declared
ning policies and infrastructure provision in that it was ‘time to close the books on infec-
rapidly growing and expanding settlements.’ tious diseases’ and to shift all national
250 Urban Studies 58(2)

attention to chronic diseases such as cardio- Robbins, 2012). This is because of its deep
vascular disease (Garrett, 1994: 33). Recent concern for human/environment relations,
developments, however, appear to indicate and for its systematic study of the unequal
that this may be premature as we now distribution of socio-environmental harms
appear to face an onslaught of what are and risks. More specifically, Connolly
referred to as new and (re)emerging diseases (2017) suggests that a landscape political
(Garrett, 1994; Haggett, 1994; Mayer, 2000; ecology (LPE) perspective can be a useful
Morse, 1996). approach for examining the political ecolo-
Emerging diseases are those which have gies of disease. This is because both political
become more prevalent during the last quar- ecology and health geographies draw on
ter century, while ‘new diseases’ refers not ideas of place and landscape and utilise an
only to newly appearing ones but also to understanding of place as a socially (re)con-
those that are spreading to new geographical structed phenomenon (see King, 2010).
areas (Mayer, 2000). Some examples of these The concept of landscape is useful for
include: yellow fever, the Marburg virus, studying processes of extended urbanisation,
Legionnaires’ disease, the Ebola virus, Lyme given the hybrid nature of the term, which
disease, hepatitis C, HIV/AIDS, Hantavirus allows for blurring distinctions between the
pulmonary syndrome, West Nile virus and urban and rural. This is one way in which
Severe Acute Respiratory Syndrome sub/urban political ecologies have moved
(Drexler, 2002; Garrett, 1994; Heymann and beyond critiques of ‘methodological cityism’,
Rodier, 1997). On the other hand, re- by exploring socio-ecological processes on
emerging diseases, or those thought to have the urban periphery (c.f. Angelo and
been eradicated through aggressive antibio- Wachsmuth, 2015; Connolly, 2019). The
tic vaccination campaigns, have also begun landscape lens is also important to under-
to reappear with greater frequency in the stand how spatial factors and the physical
population in recent years (for example, ordering of the urban environment can
tuberculosis). directly influence the incidence of disease
outbreaks and possible responses to them
(Lambin et al., 2010). Moreover, Kearns
Landscape political ecologies of
and Moon (2002: 611) have argued that
health and disease landscape serves as a metaphor for ‘the com-
Spatialised political ecology of health plex layerings of history, social structure and
approaches – paying specific heed to interac- built environment that converge in particu-
tions between urban, suburban and rural lar places’. This can be seen in the infrastruc-
landscapes – are important for their focus tural (dis)connections and changing nature–
on the interaction between political interests, society interactions that are associated with
social institutions and the human–non- urban expansion. As such, we posit that par-
human environment, which can bring about ticular landscapes themselves can be struc-
a greater systemic understanding of health tured in such a way that they influence the
and disease (see Connolly et al., 2017; likelihood of disease transmission.
Jackson and Neely, 2015; King, 2010). Some scholars working on the political
Given the interdisciplinary nature of health ecology of health and disease have used
studies, political ecology is an ideal frame- landscape as an analytical lens to consider
work that allows for the use of mixed how various health discourses can become
research methods and incorporates a range materialised in particular places (Mulligan
of conceptual approaches (King, 2010; et al., 2012; Parizeau, 2015). For example,
Connolly et al. 251

Wald (2008: 2) has described how ‘the circu- are now commonplace in the literature on
lation of microbes materialises the transmis- urban political ecology and in the social
sion of ideas’ regarding theories about how sciences more broadly.
diseases spread, and attitudes toward social Braun (2008), for example, has argued
change. In this way, disease is not only deter- that infectious diseases emerge from human–
mined through biophysical factors but also non-human relationships, circulation and
constructed out of a particular set of social exchange at a variety of scales from the
and spatial relations which are mediated molecular to the global. This has caused var-
through the landscape. As we will discuss ious non-human animals including rodents
later in the paper, processes of extended urba- to enter human settlements, which is partly
nisation can increase risk from infectious dis- to blame for the first Ebola case in Guinea.
eases – which are themselves rapidly evolving Processes of extended urbanisation have also
– as the nature and mode of transmission are facilitated the expansion of human settle-
often neither well understood by science nor ments into former rainforest areas, exposing
properly regulated by government, particu- humans to new possible sources of disease
larly in informal peri-urban settlements com- (see Yong, 2018). Deforestation and human
mon in the developing world. Lambin et al. encroachment on wildlife habitats have
(2010) have examined specifically how land- increased interactions between wildlife,
scape attributes and land use change can have human beings and livestock, thus heighten-
a significant impact on re-emerging infectious ing the potential for pathogens to cross the
diseases and/or zoonoses. species barrier (Coker et al., 2011). As Yong
Others have used a landscape lens to (2018: n.p.) has explained, such patterns
examine the interconnections between social have now become the general context for the
and environmental systems (Fairhead and spread of infectious disease resulting from
Leach, 1996; Walker and Fortmann, 2003). zoonotic infection, noting that: ‘wherever
In this regard, Wald (2008: 2) has observed people push into wildlife-rich habitats, the
how interactions between microbes, bodies potential for such spillover is high’ (Yong,
and spaces have the tendency to blend 2018). Such processes have been facilitated
together as they ‘animate the landscape and by the greater and more rapid movement of
motivate the plot of the outbreak narrative’. people, exposing human populations to a
Such analyses draw upon a wide body of lit- host of microbes, insects and other non-
erature in science and technology studies human organisms which were previously
(STS) and are influenced by assemblage the- largely undisturbed by urbanisation.
ory exploring the agency of non-humans in Maria Kaika’s (2005) city of flows ana-
shaping urban environments and the regula- logy, born out of the urban political ecology
tion of public space (see Braun, 2008; (UPE) literature, is also useful for concep-
Jackson and Neely, 2015; Rose, 2007). tualising the relationship between extended
Urban political ecology has also mobilised forms of urbanisation and disease. UPE
insights from STS to analyse the role of examines the multitude of socio-natural
non-humans in shaping human health (see flows into and out of the city, often referred
Jackson and Neely, 2015). This has been to as ‘urban metabolism’, including bio-
achieved through the use of analytical and physical, technical, social and economic
heuristic concepts such as Haraway’s exchanges (Gandy, 2004; Loftus, 2006;
‘cyborgs’ (Haraway, 1991) and Latour’s Swyngedouw, 2006). Kaika and colleagues
‘quasi-objects’ (Latour, 1993) – terms that have also recently proposed a distinctive
252 Urban Studies 58(2)

suburban political ecology lens which has infrastructure and governance. As we will
considerable overlap with the perspective demonstrate, these concepts are well suited
put forward here in our combined use of to a landscape political ecology approach
landscape and urban political ecologies and are crucial for identifying spatial pat-
(Tzaninis et al., 2020). As Coker et al. (2011: terns and political-economic arrangements
599) have elaborated, cities are home to that influence the spread of infectious dis-
‘dynamic systems in which biological, social, ease in the ongoing, and accelerating, pro-
ecological and technological processes inter- cess of extended urbanisation.
connect in ways that enable microbes to
exploit new ecological niches’. Moreover,
Dynamics of population change
‘the particular sociopolitical contexts and
spatial configuration of urban regions have
strong implications for how these various Dying alone in your hut isn’t an outbreak.
non-human natures are urbanised’ (Khan and Patrick, 2016: 70)
(Connolly, 2019). For these reasons, land-
scape political ecology becomes an extremely This terse statement by former director of
useful tool for understanding the political, the US Centers for Disease Control’s Office
social, economic and cultural relationships of Public Health Preparedness and Response
between urban environments and public points the finger at an obvious truth: pan-
health. demic disease relies on population growth.
Population growth in cities – driven primar-
ily by rural–urban migration – is a major fac-
Extended urbanisation and tor influencing the spread of disease (Coker
infectious disease: Three et al., 2011). This is seen most clearly in rap-
dimensions idly urbanising regions such as Africa and
Asia, which have experienced recent out-
Meike Wolf (2016: 975) has proposed a breaks of Ebola and SARS, respectively.
number of ‘future challenges’ of research Projections by urban scholars hold that sub-
into the ‘messy materialities’ of (extended) Saharan Africa’s urbanisation rates are
urbanisation and (emerging) infectious dis- higher than anywhere else in the world as the
ease research. In summarising her review of urban population in the region ‘is expected
recent developments in the field, Wolf to quadruple, from 295 million to 1.15 bil-
argues that ‘a reconsideration of analytical lion’ (Angel et al., 2017: 169). Twelve million
categories of space, time, climate or nature – people now live in Kinshasa, capital of the
which are of equal importance to both the DRC, which is three times the combined
social sciences and public health – goes hand population of the cities affected by the 2014
in hand with accounts that ramify different outbreak in West Africa (Yong, 2018).
sites and aim to capture new paths of con- Equally, regional towns in the DRC, where
nection and association’ (Wolf, 2016: 976). some of the recent Ebola cases have been
This can be more useful than making over- recorded, have also been expanding, some
arching processes such as globalisation or under the influence of conflict and war.
urbanisation synonymous with increases While the ecological consequences of this
in mobility. With this in mind, we have expansion are beginning to be better under-
isolated three dimensions of possible stood, we are only starting to shed light on
research on suburbanisation and infectious the impact of dramatic and massive sub/
disease: dynamics of population change, urbanisation on health and disease.
Connolly et al. 253

But, studies at the intersection of urba- seven times higher than anywhere else in the
nisation and infectious disease have shown world (WHO, 2015). This migration is dri-
that it is not only population growth that ven by a myriad of social and political-
leads to infectious disease spread but also economic factors that force people to travel
density. Jakarta, to take another example, daily in search of food or work; extended
is projected to become the largest city in families with relatives living in different
the world in coming decades, with much of countries; the traditional practices of return-
the population made up of rural–urban ing to a native village to die and be buried
immigrants. Numerous researchers have near ancestors; as well as travel to tradi-
thus noted that population density – which tional healers who have the trust of commu-
is highest in cities – strongly influences the nity members (WHO, 2015). There are also
likelihood of a disease outbreak (Ali and the effects of civil war that have forced some
Keil, 2007; Alirol et al., 2010; Coker et al., family members to flee their home villages
2011). For instance, Wilkinson and Leach to other, usually more urban areas, for relo-
(2015) have noted that the dense urban cation and resettlement.
areas and slums in Monrovia and Disease transmission in large urban popu-
Freetown, Sierra Leone, have been prime lations can also be affected by heterogeneity
sites where Ebola has thrived. While subur- in health of urban dwellers, increased rates
ban areas are popularly understood as low of contact, and mobility of people (Alirol
density areas, such processes of extended et al., 2010). For instance, Alirol et al. (2010)
urbanisation in developing regions often and Tong et al. (2015) have shown that rural
consist of densely populated ‘new towns’ of to urban population movements can sub-
high-rise flats or peri-urban informal settle- stantially increase risk of transmission
ments with high densities (see Mabin et al., amongst newcomers who may not have pre-
2013). Such cases indicate the importance vious exposure (immunity). It is also difficult
of a landscape political ecology lens in to control migration between cities in many
examining urbanisation and infectious dis- African countries, as Sierra Leone, Liberia
ease, as it is often the lack of physical infra- and Guinea each have 5000 border crossing
structure coupled with political-economic points (Wilkinson and Leach, 2015). Thus,
factors resulting in high density in such the monitoring of rural–urban and inter-
places that provide perfect scenarios for urban migration will be crucial in order to
the spread of microbes. stop the spread of disease in future out-
Research on urbanisation is also begin- breaks. Tong et al. (2015: 11,029) further
ning to consider how mobility patterns add that rural–urban migrants tend to be
between urban, peri-urban and rural areas poorer and less educated than the permanent
influence infectious disease spread (see population in urban areas, live in lower
Herrick, 2014; Wolf, 2016). It should be quality housing with inadequate sanitation,
noted that the first urban Ebola outbreaks have limited access to health services (see
happened in West Africa after almost four also Hynie, 2018). These migrants tend to
decades of rural outbreaks throughout the settle in (often informal) places along the
rest of Africa (WHO, 2015). Why, then, was metropolitan edge. This can be problematic,
there a change from rural to urban out- as Wu et al. (2017: 21) have found that in
breaks after this time and in this particular many Chinese cities, public health manage-
region? One factor is the high degree of pop- ment has not kept pace with demographic
ulation movement on the continent, which is changes in rapidly urbanising areas.
254 Urban Studies 58(2)

As Wolf (2016: 965) has noted, infectious air travel networks. While this has been well
diseases are thus less of a ‘natural’ disaster, documented before, it is relevant here because
but emerge alongside social and spatial airports and other nodes of economic logistics
inequalities in housing, health education or and activity are often located in suburban
financial resources (see Kotsila, 2017). Such municipalities, thus raising potentially com-
processes are particularly well suited to an plex governance and jurisdictional issues with
urban political ecology framework which is regards to who has responsibility to control
not only useful for examining the ‘explosion’ disease outbreaks in large urban regions
of urban societies, but also the uneven (Addie, 2014; Ali and Keil, 2010; McNeill,
and socially unjust power relations which 2011).
amplify health inequalities in particular Ex-urban infrastructures have thus
places, and underlines the issue of govern- become the lynchpin of urban mobility and
ance that we will deal with later (see circulation and of socio-natural metabolisms
Houston and Ruming, 2014; Parizeau, (see Filion and Pulver, 2019; Lin, 2019;
2015). Understanding the root causes of dis- Monstadt, 2009). As Lin (2019: 76) writes,
ease emergence in urban areas will thus be ‘infrastructures often figure as networked
essential to preventing additional rural to landscapes, constituting ‘‘spatial products’’
urban spread and to containing outbreaks that script structural relations between
within urban centres (Fallah et al., 2018: places at the planetary scale’. For this rea-
280; Richards et al., 2015). son, such infrastructures can facilitate the
transmission of infectious diseases and make
urban populations more vulnerable (Keil
Infrastructure and Ali, 2007: 848). Indeed, the spread of
disease is enabled by the same infrastruc-
Viruses have no locomotion yet many of them tures that carry people, resources and goods.
have traveled around the world. (Stephen S For instance, Munster et al. (2018) have
Morse, in Quammen, 2012: 24) argued that road construction for logging,
mining and hydroelectric activities ‘contin-
In many ways, the geographic spread, grow- ues to open access to remote locations’,
ing sophistication and colonising propensities making road development between major or
of transportation networks are the hallmark minor urban centres a key factor in the
of extended urbanisation in general (Keil, spread of infectious disease.
2018a). Specifically, peri-urban (transport) Transportation infrastructure is thus a
infrastructures are tremendously important primary form of ex-urban infrastructure
for the functioning of the entire urban region which can lead to the spread of disease, par-
(Filion and Pulver, 2019). This is due to the ticularly in outbreak situations (Keil and
location of prime network spaces such as air- Ali, 2011: 131). During the recent outbreaks
ports and recreational spaces, in addition to of Ebola in Central and Western Africa the
the noxious or toxic industrial infrastructures increasing quality of transportation infra-
including waste and water treatment facilities structure, connecting African cities with each
and incinerators, which are often in peri- or other and the world, have been seen as a deci-
suburban areas (Keil, 2018b: 132). Diseases sive factor (McNeil, 2011). While Ebola is
can spread rapidly between cities through nothing new to the affected regions, previous
infrastructures of globalisation such as global cases have been contained by poor transport
Connolly et al. 255

infrastructure, making travel between cities receive as much attention as those in rural
very challenging and time consuming. As areas.2
Yong (2018) recently observed, the paving of Therefore, Filion and Keil (2017) have
the road between Kikwit and Kinshasa in the argued that it is important to study suburbs
DRC decreased travel time from more than a in particular because of their rapid growth
week to just eight hours. Affected patients rate, which is often coupled with an insuffi-
would thus leave Kikwit for Kinshasa seeking cient infrastructure development response.
treatment, which could infect more people in This echoes Mulvihill and Ali’s (2007: 356)
Kinshasa. Such connections illustrate the cen- observation underscoring the vulnerability
tral role of landscape in connecting infrastruc- of ex-urban places to an intensifying ‘urban
tures and local environments, and the ‘enviro- shadow’ along the urban periphery. This is
technical assemblages’ that can influence especially true in the Global South, particu-
socio-ecological processes and the spread of larly in informal settlements whose needs are
infectious disease (see Ali and Keil, 2010; overlooked by governments, combined with
Houston and Ruming, 2014; Keil and Young, lower income of residents. For example,
2009). Zhang et al. (2008) have highlighted the pau-
We also need to take into account the dis- city of studies in developing countries which
connections that become apparent as rapid study the relationship between urbanisation
demographic and peri-urban growth is not and disease. However, ex-urban areas in
accompanied by appropriate development of developed regions are also rapidly growing
social and technical infrastructures. The and can likewise be vulnerable if there is little
rapid pace of urban expansion has meant knowledge about how to control a particular
that many emerging and existing ex-urban disease. This was evidenced in the case of an
landscapes contain ‘infrastructure deserts’, American healthcare worker who contracted
especially in the Global South, as infrastruc- Ebola in Dallas, Texas, through treating an
ture development has not been able to keep infected patient who had recently returned
up with the spread of population (Keil, from West Africa (Courage, 2014).
2018b: 139). For example, Wilkinson and
Leach (2015) have noted that the ‘precar-
iously expanded urban areas’ in West Africa Governance
have become populated by unemployed The crucial issues of governance and
young people and lack basic municipal plan- political-economic factors in relation to
ning and services including access to fresh infectious disease have been a topic of scien-
water, or have poor sanitation which would tific analysis since the middle of the 19th cen-
increase the potential threat of water-borne tury, when Rudolf Virschow and John Snow
disease and low health indicators. Coker demonstrated the connection between socio-
et al. (2011: 603) similarly found that popu- economic context, natural resource manage-
lation growth and urbanisation in South- ment and outbreaks of various epidemics
east Asia have meant the number of people (Connolly et al., 2017: 3). Subsequently,
using unimproved sanitation and drinking health and medical geographers have exam-
water systems in urban areas has risen by ined the political-economic factors shaping
20 million between 1990 and 2006. Finally, the spatial distribution of disease in order to
as Kotsila (2017: 99) found, there is a ‘con- achieve a more systemic understanding of
siderable number’ of people in Can Tho health (see Haggett, 1994; Kearns, 1993;
City who lack access to piped water but are Mayer, 1996). In particular, scholars such as
statistical minorities and as such do not Mayer (2000) and Ali (2004) have
256 Urban Studies 58(2)

demonstrated how certain sociopolitical con- environment (Kaup, 2018; King, 2010;
ditions associated with a physical setting can Turshen, 1984). For instance, King (2010:
act as structural causes that play a central 42) has argued that political ecology of
role in the number and intensity of disease health frameworks can illustrate how key
outbreaks in a given area. In terms of actors and institutions and human–non-
extended urbanisation, this means that dis- human relationships can influence the trans-
ease response mechanisms and other forms mission of disease and ability of institutions
of governance may not be as well established to provide effective treatment. It can also
in peri-urban areas, resulting in increased help to understand how various power rela-
vulnerability to disease outbreaks. tionships and government policies at a vari-
One concept through which scholars have ety of scales can reinforce social inequalities
addressed the relationship between govern- that influence vulnerability to disease. Kaup
ance and disease is that of biopolitics, which (2018), for instance, has drawn attention to
refers to the ways in which health and dis- neoliberalisation and privatisation or rolling
ease have historically been closely associated back of government services as a factor
with the modern (nation) state and its poli- influencing disease outbreaks, particularly in
tics of governing (Braun, 2008; Collard, ex-urban areas. As he notes, this results in a
2012; Rose, 2007). We cannot discuss this decreased state ability to respond to out-
history in detail here. However, it has a breaks when they occur and to create condi-
bearing on our discussion directly through tions in which outbreaks are less likely.
its link with settlement, urbanisation and Future studies on extended urbanisation
density. In particular, it describes how the and infectious disease could therefore exam-
state controls populations for various pur- ine how government policies might seek to
poses, including ostensibly for the purpose regulate patterns of sub- and ex-urbanisation
of disease management. Examples include in the interests of ‘healthy cities’. One area
public health, town planning and adminis- of focus here should be on the changing
tration, which seek to ‘improve’ the national composition of ex-urban populations and
population by eliminating risks to its future communities including the phenomenon of
wellbeing (Braun, 2008). As Collard (2012) the ‘suburbanisation of poverty’, which
notes, biopolitical approaches examine how brings new health concerns to areas that had
safe space is made, maintained and unmade, traditionally been seen as privileged and well
and how non-humans (e.g. animals, bac- served by public health agencies and private
teria, zoonoses) matter to the material and providers of healthcare (Kneebone and
semiotic construction of ‘safety’ and space. Garr, 2010). Highlighting spatial inequalities
As discussed above, urban political ecology in healthcare provision and response in
approaches also discuss the ways in which urban areas is a topic which is well suited to
governance decisions result in unequal and urban political ecology frameworks, given
spatialised patterns of disease whereby par- the field’s focus on environmental injustice.
ticular spaces and population groups face a Relatedly, the notion of ‘political pathol-
disproportionate burden of disease for vari- ogy’ has also been relevant in the governance
ous reasons (Rose, 2007; Sarasin, 2008). of infectious disease. David Fidler (2004), in
In this context, political ecology is a use- particular, has put forward the notion – with
ful framework for considering issues of gov- respect to the SARS epidemic in 2003 – that
ernance given that political economy and this ‘first severe infectious disease to emerge
power are central to its analysis of the rela- in the 21st century’ was also the harbinger of
tionships between humans and their a changing global landscape of health
Connolly et al. 257

governance. Fidler argued that ‘SARS is the for the need for a landscape political ecology
first post Westphalian pathogen because its approach that can interrogate the relation-
nonrecognition of borders transpired in a ships between social actors across multiple
public health governance environment radi- spatial and temporal scales.
cally different from what previous border While the governance of disease control
hopping bugs encountered’ (Fidler, 2004). and prevention has often taken place at a
Importantly, governance now had to recog- municipal scale, the increasing porosity
nise that the classical nation-state-centric between urban, suburban and peri-urban
approach to global health had to adapt to places requires a new approach (see Houston
changing realities in a world that became and Ruming, 2014). Cities are thus reconcep-
both more transnational and more localised. tualised ‘as unbounded and polyrhythmic
The debate on global health security has spaces, no longer understood in terms of
since been constantly in the foreground of fixed locations in abstract space, but rather
governance on a rapidly changing planet in terms of a continuously shifting skein of
especially after recent Ebola outbreaks in networks, with their own spatiality and tem-
West Africa and the DRC (Halabi et al., porality’ (Ali and Keil, 2007: 1217). Thus,
2017). the growth of megacities and mega-regions
As Priscilla Wald (2008: 17) has observed, raises the critical question of who has the
drawing upon Rosen’s (2015 [1958]) earlier mandate to control outbreaks in peri-urban
work on the history of public health in areas (see Keil and Ali, 2007). This issue of
Europe, epidemics ‘dramatise’ the need for jurisdictional authority is particularly note-
regulation with ‘terrifying urgency’. They worthy in the context of public health and its
further put in place the ‘administrative connection to the unique type of governance
machinery for disease prevention’ and pro- relationships that may exist between urban
tection of public health (Rosen, 2015: 47). and ex-urban centres. There is a need for
As Keil and Ali (2011) found, it was typically future research in this area, to identify areas
conventional containment strategies, such as for improvement in urban health govern-
isolation and home quarantine, that proved ance, which will assist in preventing future
most successful for controlling the spread of outbreaks.
SARS in affected cities. As they note, this is
based on the view of the bounded city with
fixed, territorialised and restricted access,
Conclusion
which contrasts with the unbounded and This paper has offered an initial attempt to
‘topological’ character of contemporary theorise the relationship between processes
urbanisation processes. The coronavirus of extended urbanisation and infectious dis-
(COVID-19) epidemic that spread just as we ease, while also establishing the basis for a
were completing this paper sparked the ‘larg- future research agenda in this area. The mas-
est quarantine in human history’, resulting in sive increase of the global urban population
the isolation of entire cities and regions over the past few decades has been concen-
(Gollom, 2020). Wuhan’s urban periphery trated primarily in ex-urban areas, which
also became the setting for a ‘pop-up’ con- has posed new challenges to the control of
struction of a 1000-bed hospital facility to infectious disease. This includes processes
deal with affected patients. As Wuhan is such as population growth and movement
locally known as the ‘thoroughfare of China’ between urban, ex-urban and rural areas, as
(Huifeng, 2020), such spatial factors account well as infrastructure provision (e.g. water
258 Urban Studies 58(2)

and sanitation) and land use change. As we be triggered by the expansion of urban settle-
have noted, these processes are especially ments in previously forested or agricultural
pronounced in (but not limited to) develop- areas. For instance, the aforementioned out-
ing regions, which have also been the source break of the new coronavirus (COVID-19)
of recent major outbreaks such as Ebola and first crossed the animal–human divide at a
SARS. We have also noted how the govern- market in Wuhan, one of the largest Chinese
ance of infectious disease is challenging, with cities with 11 million people. As in the
overlapping institutional roles and responsi- SARS pandemic of 2003, the connectivities
bilities in urbanising regions, which poses of accelerated urbanisation, heightened
questions as to who should do the work of mobilities and more extensive zoonotic risks
managing (and preventing) potential out- became immediately apparent (Ali and Keil,
breaks (see Coker et al., 2011). This is par- 2008).
ticularly problematic in developing regions, Such transformations are producing new
which are often faced with (inter)national ecological niches for disease spread, meaning
political tensions and inequalities that can that ex-urban regions are likely to remain a
hinder effective control. hotspot for EIDs into the foreseeable future.
Given the scarcity of research on this This course of events, continuing as we com-
topic, there remains a crucial need for both plete this paper, urges urban researchers to
academic research and that which practically seek new and better explanations for the
informs policy (Coker et al., 2011). In doing relationships of extended urbanisation and
this study, we have identified three key areas the spatialities of infectious disease. This will
on which such research efforts should focus, require an interdisciplinary approach includ-
namely: mobility and demographic change, ing geographers, health scientists, sociolo-
infrastructure and governance. These have gists, while also developing possible
been identified based on existing research in solutions to prevent and mitigate future dis-
these areas, at the intersection of urban stud- ease outbreaks. As we have argued, land-
ies and infectious disease. These three fac- scape political ecology approaches can
tors do not constitute an exhaustive list, contribute to this goal by helping to identify
however, as socio-environmental change – the political-economic and biopolitical fac-
including deforestation and climate change – tors influencing the spread of disease
has been highlighted by authors as a key risk through a range of spatial scales in an age of
factor which could lead to the emergence of extended urbanisation.
new epidemics and should form the basis of
future research (see Brisbois and Ali, 2010; Acknowledgements
Tong et al., 2015). The authors thank participants in a workshop on
We have also illustrated how a landscape ‘Health and Suburbanisms’ who gave insightful
political ecology framing which is more feedback on an earlier draft of this paper pre-
attentive to interactions along the urban per- sented at York University in Toronto in October
iphery, can be useful for examining these 2018.
topics along interdisciplinary lines given the
holistic nature of the landscape concept and Funding
the diverse methodological approaches com- The author(s) disclosed receipt of the following
prising political ecology. The attention to financial support for the research, authorship,
socio-ecological metabolisms also allows for and/or publication of this article: The research
understanding how outbreaks of zoonoses for this paper was funded by a Canadian Social
and other emerging infectious diseases can Sciences and Humanities Research Council
Connolly et al. 259

(SSHRC) Major Collaborative Research Initiative Biglieri S (2018) Implementing dementia-friendly

on Global Suburbanisms: Governance, Land and land use planning: An evaluation of current
Infrastructure. literature and financial implications for Green-
field development in suburban Canada. Plan-
ORCID iD ning Practice & Research 33(3): 264–290.
Creighton Connolly https://orcid.org/0000- Bloch R, Papachristodoulou N and Brown D
0002-4782-2621 (2013) Suburbs at risk. In: Keil R (ed.) Subur-
ban Constellations. Berlin: Jovis, pp. 95–101.
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Notes
urban health. Global Health Program. Council
1. As one would expect, this is a highly interdis- on Foreign Relations. Available at: https://
ciplinary field, with contributions not only www.cfr.org/article/future-global-health-
from social scientists but also epidemiologists. urban-health (accessed 31 January 2019).
2. The same is true for waste management in cit- Braun B (2008) Thinking the city through SARS:
ies, as accumulated waste can be a breeding Bodies, topologies, politics. In: Ali SH and
site for insect-borne vectors (D’Alisa, 2017). Keil R (eds) Networked Disease: Emerging
Infections in the Global City. Hoboken, NJ:
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