Healthcare Architecture Origin and Development

Chapter 1: Healthcare Architecture

History that Time Forgot

To trace back the history of healthcare and hospitals were unknown as there were many evidences of origination for earliest hospitals across different continent, and all historical healthcare serve under as religious influenced. Physicians back than consists of religious figure from gods and witch doctor to monks and priest.

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Around 430BC, temples in Athens were dedicated to “healing gods”, Asclepius for treating the sick spread throughout Greece. These holy temples were known as the very first hospitals in the history of western civilization. Dream interpretations was the process of healing where priests would interpret the dreams visited by the god, is also known as incubation. Priest would take a holistic approach to treatment which include, mud, herbal remedies, psychotherapy massage, bathing treatments, set dislocated bones and opium to calm agony of patient which were prescribed according to the dreams they experience.

One of the oldest architecture evidence of a healthcare centre which dated back to the 9^th century AD at Mihintale, Sri Lanka were Buddhist monasteries. There is evidence of patient ward which measured 4m x 4m. These evidence Medicinal trough roughly 7 feet long and 30 inches wide have been found by archaeologist. It was suggested that it was used with mineral water and medicinal oil for hydrotherapy.

Healthcare influenced by social environment

Roman Warfare Era

“Many of mankind’s greatest discoveries have been made within the frame of warfare.”

The Roman Empire was built upon the success of its legions, and the foundation of that success lies in the innovations and discoveries of Roman medicine in the battlefield. In the first century AD, the Roman Empire was in constant warfare with neighbouring country but the Roman legions did not have any organized medical units. It was only when the Roman Empire expanded to Greece that many Greek physicians came to Italy and Rome, because it was only during warfare that physician are able to practice and flourish their medical skill by performing surgeries and treating wounded soldiers.

“He who desires to practice surgery must go to war.” Hippocrates (c. 460-377 B.C.) a famous Greek physician

During the first and second century AD, Emperor Trajan established the Roman Military Hospitals, or valetudinarium after recognizing the importance of medical treatment to reduce wounded and sick soldiers during long military campaigns. Trained Roman medical officer would travel together soldiers

To the battlefield and set up temporary groups of small tents and fortresses. Over time, the Roman ethic of military improvement reform temporary Military Hospital into permanent facilities. Roman military hospitals were originally built near river for the access of clean water and adequate sewerage for sanitation purposes. Later in order to have an effective army, the military hospital was incorporated into part of Roman fort architecture and were put near the other wall, so that soldiers could get treated and be back into the battlefield.

The architecture of a standard Roman Military Hospitals is similar to most healthcare centre today, rectangular in shape and consist of four corridors connected by an entrance hall. Each corridors consists of number of small ward with ante room and large ward that holds three bed off the end. Other spaces in the valetudinarium include a reception ward, staff quarters, kitchen, dispensary, large hall and medicine facilities.

Religion Influence Era

But unlike modern hospitals, these military hospitals were only reserve for sick and wounded Roman soldiers as Roman soldiers were usually treated with respect and honour in daily life. Unfortunately, the poor receive no sort of medical care which raises the issue social stigma. Even slaves and gladiator receive medical care. After 310 AD, the concept of healthcare available to only soldiers and the rich changes when the Roman’s adopted Christianity as religion, which promoted a caring and social community, revolutionizing morality and social behaviour. Christianity contributed an immense role in expanding healthcare provisions for the public. Many churches and monastery were built not only as place for spiritual worship, but to cater for travellers, the poor and the sick. St. Basil of Caesarea founded the first large-scale hospital in 369 AD. The hospital consists of 300 bed to care for victims of the plague.

It was during the late 8^th centuries in the Dark Ages, which Emperor Charlemagne that a hospital must be built attached each cathedral and monastery. Benedictine Abbey of Cluny was founded in 910 became a dominant factor in hospital work.

“To help them as would Christ” was the principle founded by the monastic hospitals. Patients ward would be placed near the altar

The Cluny order had an enormous influence on the culture and Romanesque architecture during the time. The monastery was form by cloister of buildings to form an open central space. The cross shaped plan in the abbey was where patient ward were place, where light and fresh is easily penetrate into the whole plan. Patients is able to gain spiritual healing in assisting with their recovery in front of the altar.

Danger of bad design Healthcare Architecture

Hotel-Dieu was the oldest hospital in Paris founded in the 7^th century situated next to the Seine river and serve originally as a refuge for the homeless and sick. It was during the 17^th century, Hotel-Dieu became hospices where the poor and sick is treated. With 1,200 beds in total and over 100 beds in some ward, Hotel-Dieu was the largest hospital ever built at the time.

Although being the largest hospital, the hospital was designed poorly. Most of the wards in Hotel-Dieu does not have adequate ventilation, it was also maintained poorly and unsanitary. During plague epidemics, it was the only place that provided healthcare facilities for the sick. The hospital was faced with problem of overcrowding when it requires to house 3500 patients at the same time during the period, which the hospital was inadequately able to provide. Up to six patients were force to share a single hospital bed and infectious airborne diseases were able to spread easily across the hospital. Poor architecture design combined with uncontrollable spread of disease resulted in a high mortality rate of one death in four patients.

In 1785 numerous discussion, design modifications and reformation to the Paris hospital system were made when a large part of the Hotel-Dieu was burned down by fire in 1772. Dr Jacques Tenon was appointed with drawing up proposals for improving the hospitals of Paris. He visited forty hospitals during his time in England to detailed spatial, sanitary and administrative elements of it. During his visit in Greenwich, it was when Jacques Tenon paid unusual attention on the functions and service arrangement. Documenting every architectural element detail from dining rooms, cabins bed, woollen mattress, feather pillow, the distance between the corridors, fire precautions, iron doors, alarm bells and many more. Jacques Tenon’s published the book “Memoirs on the hospitals of Paris” based on his records.

Jacques Tenon and Bernard Poyet (architect) came up for the design for the new Hotel-Dieu in 1785 next to Notre Dame Cathedral after the approval of scheme by the Academy of Sciences. The hospital introduces a circular design with wards radiating from the centre point. The design was prioritized on improving the ventilation and hygiene of the building. Although the radial design for the new Hotel-Dieu receive complimentary for its effort. The death rate remained unchanged in the hospital due to most of the city’s serious accidents were admitted to the new Hotel-Dieu. There are still several issues regarding to the design of it. Radial design provides insufficient space to cater for all patient; ventilation and sun light is unable to penetrate efficiently into most of the wards room.

The Turning Point of Hospital

The modernization of hospital design began to flourish during the age of enlightenments. In the mid-18^th century, hospitals were introduced to the pavilion design. With the improvement of medical facilities and knowledge, isolation and containing airborne infections has been the main focus in reducing mortality rate.

“taking the quest for the separation of pathologies and the desire to prevent contagion effects to the extreme”

The first Pavilion type hospital in England was the Royal Herbert Hospital designed by Sir Douglas Galton which was recommended by Florence Nightingale in 1865. Sidney Herbert which was the leader of War Office wishes to reduce military mortality rate of British veterans of the Crimean War.

The main intention of the pavilion design was to improved sanitation, cleanliness and fire prevention. Semi- detached building separates the hospital into isolated complex. Each complex contains ward connected by a central corridor to all other parts of the hospital. All wards are raised from the ground to maximise cross ventilation (fresh air) and natural lighting (daylight penetration). The central complex is where the administration and services located.

The pavilion plan spatial layout is an excellence respond to the lack natural ventilation and separation of contagious diseases. During an epidemic outbreak in the hospital, it is able to quickly shut down the infected block, isolating it from the rest of the building. The rectangular form of the Royal Herbert Hospital provides better efficiency in plate ratio maximizing number of wards in the hospital. The sharp decline in hospital mortality rates and rise in public health make the “pavilion principle” a trend for modern hospital design.

Political Influence Healthcare Buildings

In 1938 the Finsbury Health centre designed by Berthold Lubetkin was opened with his allegation that “nothing was too good for ordinary people”. The development of the NHS was an essential crossroads in British Social History, and the Finsbury Health Centre was that monument of a socialist idealism. Finsbury was once a thickly stuffed ghetto relieved by green space and filled with epidemic disease. Given the circumstances, local politicians were determined to redeveloped Finsbury into a model of social progress. Things had to be improved, housing, education, hygiene and health. The principle of Finsbury Health Centre was to make healthcare available for free at a single point of delivery and the spatial arrangement of the healthcare building was designed to accommodating many different kinds of medical treatment, as opposed to being scattered all through the borough. After six decades of National Health Service, many of Finsbury principle has been adopted which led to the belief of Berthold Lubetkin that the building serves as an instrument of social improvement.

The form of the Healthcare centre is design in a letter H with public spaces located in the ground floor plan. Core public spaces such as the reception, lecture theatre and services are located in the centre section of the building with ramped services provided from the garden entrance. Both wings on the side of the building are flexibly planned clinical accommodation with different healthcare spaces. The floor plates of the building is extended from ground floor to first floor. Emergency patients can access independently to the basement floor from the rear service courtyard. The building is built from reinforced concrete frame with glass block and curtain wall infill, tiled wall surrounds and asphalt roof.

Built Environment & Human Health

The built environment influences health. As a species, humans need structures for physical shelter, as manifestation of social and cultural values, and as embodiments of spiritual and emotional needs. As population growth accelerates, the production of the built environment becomes more resource intensive, stressing indigenous building materials and methodologies beyond their sustainable capacities. Resource depletion, in turn, negatively impacts human health.

Clinical medicine and public health do not always define health as the mere absence of disease. As stated by the World Health Organization (WHO) that “a person health is define in the state of physical, mental, and social well-being.” Architecture and planning can promote this broader conception of human health and well-being.

In the nineteenth century, infectious diseases such as smallpox, tuberculosis, typhoid, pneumonia, and rubella were responsible for the majority of deaths. To a large degree, these could be, and eventually were, controlled through environmental and clinical public health interventions. Many of these health improvements were achieve through urban planning and zoning mechanisms, reflecting a close partnership among urban planning, public health, and allopathic medicine.

Moving into the twenty-first century, a long-term chronic illness such as cancer, heart disease, and strokes began claiming the most lives. In the last twenty years, chronic respiratory afflictions such as asthma and sick building syndrome have emerged as widespread threats to public health. While we have created a large allopathic medical structure to deal with these issues, growing evidence indicates that a renewed partnership among urban planning, architecture, public health, and medicine will be necessary to prevent these illnesses before they occur.

Case Study

Gaviotas Hospital

“If humanity is to survive, we must move out of the cities, and learn to live sustainably in areas where people have not tried to survive before.” Paolo Lugari

Introduction

Colombia as a country surrounded by strife and harsh condition like violence, drug trafficking, sickness, gun wars and poverty exists a functioning utopia of sustainability and peace. Gaviotas, a village founded in 1971 in the remote savannas of eastern Colombia, Llanos region by Professor Paolo Lugari, is a self-sufficient community of about two hundred. The sixteen-bed, 7,266- square foot solar powered hospital was designed and built by community members between 1982 and 1986. Gaviotas Hospital, elegant in its pragmatic functionality – manifests a humanistic core value that identify as “an oasis of imagination and sustainability”

Utopia to Reality

Gaviotas Hospital started out as an experiment by a group of local engineer, scholars and scientist in attempt to transform an empty and remote plot of land with no arable soil into a rich and self-sustaining productive community. One of the most remarkable process of developing Gaviotas was regenerate the soil (which had a high acidity in the soil, pH4) into growable condition for trees. Scientist found a solution by using Caribbean pine trees, which have a symbiotic relationship with mycorrhizal fungus that helps to keep them alive in acidic conditions. The pine tree help provide shade, reducing the ultraviolet rays penetrating the earth and with the increment of rain fall. All these combinations help created a fertile soil with a pH value of around 6.8. The community is now able to grow different rages of agricultural food.

Key Disease Treatment

Eighty percent of diseases in Colombia are water-related disease which include Hepatitis A, Hepatitis E, Typhoid Fever. All these disease causes the victims to exhibit signs of fever, jaundice, diarrhea, abdominal pain and sometimes death if left untreated. Considering all these diseases, the main causes of suffering for the local population is gastrointestinal disorders disease, which affect seventy- five percent of the population attributable to unclean drinking water. Lugari shifted his attention from curative to preventative medicine by supplying clean water straight from Gaviotas. The hospital’s provision of purified water by using simple solar energy distillation technology to immediately reduced sickness and deaths previously plaguing the villages.

Sustainable and Built Environment

“When a new building is found to show signs of water leakage into the new building, it is immediately seen as a design and construction fault by the architect or contractor and they are force to absorb the cost of repair. On the contrary, if there is excess heat in the building causing thermal discomfort to the user, the user will automatically assume it’s the weather and complain about it without further investigating on the design. Resulting in installing air conditioning systems for their house. Bioclimatic error is neglected in the end.”

The Gaviotas Hospital feed solely on clean energy by taking advantage of nature. Functioning as an off-the-grid structure, the hospital relies on solar, wind power, mini-hydraulics and biomass for the building’s modest energy demands, the hospital is able operate without consuming drops of oil or fossil fuel. All this was made possible by integrating passive design strategies for cooling. A series of underground ducts enabled the building’s interior to maintain cool temperatures by creating a convective loop: cooled underground air entered the building, and warmer air escaped through honeycombed shaped air channels in the double layered corrugated roof. Despite frequent 100 percent humidity, a passive dehumidification system inspired by the workings of a termite mound contributed to comfortable indoor conditions. The surgical room maintained 17 percent humidity year-round the lush landscape was replete with organic produce and medicinal herbs. People were kept connected to the outdoors through operable skylights, daylit spaces, and a retractable galvanized metal roof over patient areas which provide view at the night.

Looking into Bioclimatic Technologies

Underground Ventilation Duct- During the day of dry season, temperature is range between 17°C to 35°C. Ventilated air is circulated through 5 large underground thermal stabilizing ducts by wind and wind extractors at a constant temperature of 25°C. Heat is distributed through the duct within the garden, maintaining the temperature of the soil several degrees below average thermal weight of the region.

Double Coolant Cover- The ceiling of the hospital consists of a double coolant layer which allows circulation of air. The upper layer absorbs heat and induces the circulation; the lower layer stays cool, avoiding infrared radiation from the upper layer.

Sliding Roofs- The rooms in the hospitalization area have manual operating sliding roofs. These sliding roofs is operated by bicycle mechanism which allows to withdraw 60% of its cover during both the day and night. Utilizing the sliding roofs helps sterilize the room using radiation and also control exposure of sun to the patient.

Wind Turbine –

References

1. http://reps.chelseagreen.com/files/pdf/gaviotas_pr_LowRes.pdf
2. Gaviotas: A Village to Reinvent the World, 2nd Edition
3. http://www.nationalpost.com/sense+sustainability+utopia+made+real+colombia/1302554/story.html

Nature and Healing

Emotional, physiological, social and cognitive benefits are generated in contact with nature as demonstrated by researches in an assortment of fields over the course of recent years. All the benefits which include improvement of emotional functioning, attention capacity and feelings of self-worth, reduces mental and physical stress that effects people on the individual level. Social benefits are also evident from studies of recreational activities and gardening. Being in a natural setting strengthens group ties and promotes prosocial behaviours. However, the understanding of nature healing is not all equally beneficial. Tall large trees, water features and a variety of shrubs and flowers serves better healing purposes than spaces with only grass.

Humans evolved in the a natural rather than artificial or human-constructed world. Biophilia developed as a genetic tendency because of our species’ long dependence on functionally adapting to the natural environment. Given the evidence of the health and well-being benefits that accrue from contact with nature, it is somewhat surprising that healthcare institutions have slowly incorporating nature into building and site design. Gardens, sunlight, and landscape views have positive effects on both patient and financial outcomes.

To enhance connection to nature, healthcare buildings have incorporate more views of nature and sunlight in healthcare setting. Sunlight in patient rooms is also associated with a reduction in pain, stress, and depression and gives out positive moods.

Case study – Paimio Sanatorium

The sanatorium is an establishment for the medical treatment of people who are convalescing or have a chronic illness. The Paimio sanatorium is a former tuberculosis sanatorium in Paimio, Southwest Finland, designed by a Finnish architect Alvar Aalto. Prior completion in 1932, the building served exclusively as a tuberculosis sanatorium till 1960s, and then converted into a general hospital. The building was soon nominated to become a UNESCO World Heritage Site due to its importance.

Alvar Aalto’s starting point for the design of the sanatorium was to make the building itself a benefactor to the healing process, which he referred the building as a ‘medical instrument’. Alvar Aalto utilized what was naturally available which was sunlight due to lack of medical advancement. Sunlight balconies was design on each floor of the building to improve lives of the tuberculosis patients in Paimio Sanatorium. Weak patients were able to pulled out of their bed to rest in an environment to be exposed to sunshine and clean air. Furthermore, the sun balconies are also a platform for patient to take pleasure in the generous views to the woodlands surrounding the place.

Effectively incorporating these biophilic design elements in constructed buildings and landscapes to varying degrees and in various combinations can enhance human health and well-being. Biophilic design elements can guide healthcare designers and hospital developers in addressing the inherent human affinity for nature.

Purified Air, Clean Air?

Good Air, good Health

There have been many developments in the science and practical application of improved indoor air quality. Most recently, these developments have been in the area of source control for which the industry has developed effective guidelines and best practices. Efforts began in the 1980s with the indoor air quality guidelines of the World Health Organisation (WHO). Using these guidelines appropriately, we can inform building owners and operators about the quality of the air in their facilities. Indoor air samples taken in a building pre- and post – occupancy and during its functional life as part of an ongoing commissioning program, can be analysed for chemical concentrations. The goal is to design, construct, and operate healthcare facilities so that the indoor concentrations of chemicals of concern (carcinogens, reproductive toxicants, and chemicals with chronic or long-term health effects) are low enough to minimize their harmful effects and not impact the occupant health negatively.

Four Design Principles for Healthy Indoor Air Quality

1. Source control: minimize the indoor chemical concentrations by reducing or eliminating pollutant sources. For healthcare facilities, this involves two separate strategies:

• The building: Select and install building materials and finishes that minimize or eliminate indoor pollutant sources
• The building’s contents: substitute low-emitting furnishings, medical products, materials, and cleaning agents for the previously used, more toxic materials. Examples of this are the use of PVC-free furniture and window shades and the use of nonlatex gloves.

2. Ventilation control: Provide adequate ventilation to dissipate and purge indoor air pollutants.
3. Building and IAQ commissioning: This is a process used during design and construction to verify that a building is constructed as designed and operates as intended. Recommissioning should occur regularly to ensure that the building continues to perform as intended.
4. Operations and maintenance: Perform regular inspection, maintenance, and cleaning of the building and its contents.

Case Study

University of California-San Francisco Osher Center for Integrative Medicine

Numerous building products, including floor materials, wall panels and ceiling tiles in the Osher Centre for Intergrative Medicine have been reformulated chemically of building material to reduce chemical emissions based on these specifications. Many institution trade groups have begun developing or have already developed the same level of compliance certification.

Breathing Easier

Over the last twenty-five years, much attention has been paid to improving indoor air quality as a result of the practical application of scientific research with a new consciousness about occupant health, architects and engineers are producing new building designs, system, and specifications. The manufacturing industry is responding with both reformulated and brand new green products. Giving material specifiers more confidence in selecting healthy materials, and construction industry is responding by incorporating green construction methods.

• Scientific test proves and qualitative feedback from occupants of these enhanced IAQ buildings confirms that improved indoor air quality improves every breath staff, visitors, and especially patients take and how they feel.

A larger healthcare infrastructure will mean more energy, more materials, more development. Without the transformation of the building sector in healthcare, continued system expansion will increase the ecological resource burdens within communities. The transformation of the materials marketplace in the service of indoor air quality will be challenging. Without the limitation from organisation limiting on the budget and purchasing power of healthcare industry, greener cleaning products, and improved indoor air quality can have a major impact on moving toward cleaner building.