Urban Design In An Antibiotic-Resistant World: Lessons From Mumbai

In an eerie foreshadowing of the present-day pandemic, the 1896 arrival of the bubonic plague in Mumbai — then under British rule and known as Bombay — brought life in India’s financial capital to an abrupt standstill. Within months, the disease had spread across the country, with Bombay at its epicenter; an estimated 50,000 died in the city alone.

As with Covid-19 a century later, the catastrophe highlighted a drastic need to rethink the role that cities play in facilitating the spread of disease. The government established the Bombay Improvement Trust (BIT), which was tasked with introducing new building regulations to improve living conditions, open out crowded neighborhoods, and optimize ventilation. The policies reshaped the city and aided its recovery, with the eventual arrival of a vaccine and antibiotics relegating the plague to the annals of the past.

But as Mumbai expanded over the coming century, it also forgot. Today, high rises dominate the skyline, and the city is among the most densely populated in the world. Old building codes regulating light and space have ceased to exist. In an increasingly interconnected modern world, with pandemics and antibiotic resistance on the rise, experts now worry that this architectural amnesia may prove devastating.

“Covid was a reminder that we’ve forgotten some of these lessons that we learned back in the early 1900s,” says Sameep Padora, an architect and historian based in Mumbai. His recent exhibition and upcoming book, “(de)Coding Mumbai,” charts the evolution of building and development codes in the city.

As cities grow and land skyrockets, says Padora, “what tends to happen over time is that the initial intent of the building codes being connected to human well-being is forgotten, and it eventually becomes a means to fortify real estate.”

Khadija Ansari has witnessed the devastating impacts of this first-hand. She lives with her mother and five siblings in a one-room apartment in M-East ward, in a housing complex known as Natwar Parekh. A year ago, the 19-year-old was diagnosed with tuberculosis — a disease the family says is rife in the community.

“This area is very risky to live in. Most of the people here are suffering from TB,” says her mother, Yasmeen. “In this building there are around six to seven people who have TB.”

The family was moved to Natwar Parekh after the slum they were previously living in was demolished to make way for a new railway station. When infrastructure projects displace those living in informal settlements, the Slum Rehabilitation Authority (SRA) is obligated to provide alternative accommodation, often resettling residents in multi-story apartment complexes.

But a 2020 study published in the journal Cities and Health found that many of these slum rehabilitation projects were poorly designed, leading to high rates of tuberculosis. The report compared three housing complexes, finding that in the blocks with the highest density and poorest ventilation and sunlight exposure, 10% to 11% of residents reported having had tuberculosis within the past 10 years. This compared to just 1% in some of the blocks with better designs.

“It was in hindsight that people realize you need to design not just to provide shelter, but also better quality of living,” says Dr. Ronita Bardhan, an architectural engineer and associate professor at the University of Cambridge, and one of the study’s authors.

Khadija’s housing complex, Natwar Parekh, was found to have the highest rates of tuberculosis in the study, which the authors attribute to a gap of just three meters between buildings, and a design that allows for very little light and ventilation. The incidence of tuberculosis was also found to be disproportionately high on lower floors, which receive so little sunlight that they require artificial lighting even in the middle of the day.

Sunlight has been shown to play an essential role in mitigating the spread of tuberculosis, not only making it more difficult for the bacterium to survive outside of the body, but also aiding in the production of vitamin D, which helps to fight off infection.

To make matters worse, the design of the blocks, which feature peripheral public balconies on every floor, compromise the privacy of each apartment, causing residents to section off their balconies with curtains and leave windows closed even in the peak of summer.

The result is a further reduction in air circulation and light inside the apartments, “creating a perfect breeding ground for tuberculosis bacteria,” says Bardhan. She finds these design oversights particularly frustrating in a country like India: “You have this abundant natural resource, and we are just not using it,” she says.

Growing City, Shrinking Regulations

The idea that sunlight and ventilation can help to mitigate disease isn’t new. In the aftermath of the bubonic plague, the BIT built new, wider roads to channel in the sea breeze, demolished overcrowded slums, and introduced a new bylaw called the 63.5 degree light angle rule, which mandated the height-to-setback ratio of buildings in order to optimize light and ventilation.

“Post the plague, the way that cities were organized was through the lens of the medical practitioner,” says Padora.

This was particularly evident in the chawls, one-bedroom apartments in communal blocks designed to house the city’s workers. Each block was centered around a courtyard, with wide windows and an inner-looking corridor that protected the privacy of residents.

“You have an incredible amount of open space,” says Padora. As well as increasing light and ventilation, these open courtyards also foster a sense of community, he says, meaning that many social functions take place in the open rather than in enclosed spaces. “The idea of housing being also about these spaces that lie beyond the beyond the unit itself is something that’s been completely lost,” Padora says.

As bylaws were rewritten over the years, the 63.5 degree rule was scrapped, with the state compromising on regulations in order to house a growing population, says Bardhan. When economic demand is given precedence, “the whole aspect of design as a guiding principle gets lost,” she says.

And although the national building code still mandates maximum densities and the height-to-setback ratio of buildings, Slum Rehabilitation Authority projects have their own set of rules, with no maximum density and a required setback of just three meters, regardless of the height of the building.

With space in Mumbai in short supply, “what tends to happen is that the slum redevelopment project is cramped on a very, very tiny plot of land,” says Padora, who describes the dense building projects as reminiscent of “warehousing people — building these boxes for them to live in.”

The result has been housing complexes like Natwar Parekh.

“It was not like they were doing something illegal — it was built to code,” points out Padora. “But [the code] creates environments that propagate disease.”

Urban Design After Antibiotics

What is particularly concerning to medical experts is the level of antibiotic resistance in the area, with up to 20% of the city’s drug-resistant tuberculosis cases in M-East ward

Dr. Vikas Oswal, a Mumbai-based pulmonologist who runs a TB clinic in the ward, says that case numbers of drug-resistant tuberculosis are “significantly higher” there than the city average.

“Many of them have never been exposed to [tuberculosis] drugs in the past, but still they are directly diagnosed as having drug-resistant TB,” he says, meaning that there is a high level of community spread of drug-resistant variants.

Tuberculosis that’s resistant to all first-line antibiotics, known as MDR-TB, is increasing globally, and poses a huge threat to the fight to eradicate the disease. India has the highest number of MDR-TB cases in the world, contributing a quarter of the global burden, and Mumbai is a hot spot.

For Khadija, who has MDR-TB, this means that she has been on a cocktail of antibiotics for over a year in an attempt to treat the disease. At one point, she says, she was taking 30 pills each day. The side effects were so severe that she suffered short-term memory loss, causing accidents on more than one occasion when she started cooking and then forgot to remove the pan from the stove.

“In the pre-antibiotic era, we focused on ventilation and direct sunlight,” says Oswal, warning that a return to an era without effective drugs necessitates a “rethink” in strategies to fight disease in urban spaces.

Last year, Prime Minister Narendra Modi announced a target to eliminate tuberculosis by 2025. However, Bardhan believes that the goal is fundamentally at odds with another national initiative, to provide housing for all people in urban areas by 2022. The latter policy, she says, has resulted in bylaws such as those which govern Slum Rehabilitation Authority projects, which prioritize density over good design. (The Slum Rehabilitation Authority did not respond to requests for comment.)

“From the purpose of providing houses, this policy works perfectly, because it allows you to build more and more units in a hyper-dense situation,” she says. “But nobody is looking at what is the expenditure or the cost of living in these houses.”

Despite the specter of rising drug resistance, however, Bardhan is hopeful that authorities are becoming increasingly aware of the problems — and some of the design solutions which could help to solve them.

“Our work, what it has done is actually made the problems more visible. And I’m very hopeful when a problem is visible, it’s very hard for public policy makers to overlook it,” she says, adding that the Covid-19 pandemic has brought renewed attention to the importance of design in mitigating airborne diseases. “Post-Covid, a lot of people actually came back to me and said that our work seems so relevant in today's context,” she says.

For Khadija, however, any changes will come too late. At the height of her illness, according to her medical records, her weight plummeted to just 26 kilograms (57 pounds), and she was so weak she was forced to drop out of her final year of school. Although the drugs she is now on show signs of working, with her health slowly improving, she wishes that the family had never moved to Natwar Parekh. In her old neighborhood, she says, she never used to get sick.

“Our old home was not like this. It was a better place,” says Khadija. “I used to feel free there.”

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