Healing Spaces.

I don't know how new books are selected in my local library  but it's fascinating what turns up  . Recently I chanced on a book about how birds navigate in their annual migrations half way around the world, and the elaborate experiments undertaken to prove and disprove various hypotheses about how they find their way.  Way out of my field and the science was largely beyond me, but I got a sense of the state of our understanding, and I like reading about the scientific method where nothing is taken for granted; so different from intuitive architecture.

I always have an eye out for books related to architecture and recently found Healing Spaces,1 a book that dissects the complicated relationship between the senses, the emotions and the immune system and how your surroundings have the power to help heal you.  This book reviews the work of neuroscientists, and psychologists whose expertise spans these areas

The idea that healing is influenced by surroundings isn't new of course, and goes back to the Greeks who built temples to Asclepius, the God of Healing, often far from the heat, noise and dust of towns where there was fresh water and views of the sea.  Patients were treated with a healthy diet, pure water, music, sleep and dreams, social interaction and prayer.  And amphitheatres and hot baths were always included in towns to hasten community wellness.

The idea that physical space can contribute to healing might have been intuited by the Greeks but it has only been able to be proved scientifically by late twentieth century advances that have established the specific connections between the brain and the immune system that are essential to maintaining health. It is hoped that eventually evidence-based information will come out of these scientific studies that will improve aspects of design that will in turn benefit healing in hospitals .  

The design of modern hospitals has evolved on a pragmatic path that started with Florence Nightingale's experiences in the Crimean War where conditions were so bad that mortality rates were as high as 60 percent.  After the war she wrote about her experiences and recorded her intuitive view that darkened rooms are harmful and sunlit rooms are healthy.  Her ideas influenced hospital design enormously and she was vindicated in 1877 by scientific proof that sunlight kills bacteria. 

And over this period it also became established that a major source of infection was the doctors themselves who often went from the autopsy table to deliver a baby without changing their coat or washing their hands or wearing gloves, and it became widely accepted that hand scrubbing with disinfectant prevented the spread of infection.  Advances by Robert Koch who discovered the bacteria that cause tuberculosis and cholera, the practices of the Scottish surgeon Joseph Lister, Pasteur's germ theory and inoculation and the work of many other scientists all revolutionised the way patients were treated and led to an impressive reduction in infection rates.

Perversely, the effort to reduce infection also led to sterile environments in hospitals, and as hospitals developed over the next hundred years greater attention was often given to shiny surfaces and housing equipment like X-ray machines than the patients.  As a result they weren't welcoming places and noise levels were often so high as to increase stress levels in patients which is hardly sensible if the goal is to heal!

Patients in hospitals are constantly exposed to stresses (like noise) that impair health, slow down healing and weaken the immune system, and the author makes the parallel that 'understanding and reducing stress in the hospital environment is to twenty-first century medical care what understanding germ theory and reducing infection were to nineteenth century care.'

Early pioneers of the modern movement in architecture in the Thirties, such as 
Alvar Aalto and Richard Neutra intuited the health benefits of well-planned architecture and the importance of sun and natural views in promoting health and healing. The sanitorium designed by Aalto in the town of Paimio in his native Finland (1929-1932) became the exemplar for modern hospital design and had a great influence on the Australian hospitals designed by Sir Arthur Stephenson (1890-1967).2

While we can all readily accept the intuition that windows and views of nature might assist healing, scientists could not take it on trust and needed to prove, not only that this really does happen, but also to understand exactly how this healing mechanism works. 

Florence Nightingale's intuition was finally proved by a researcher called Roger Ulrich who examined the hospital records of 46 patients who had undergone gall bladder surgery in a suburban Pennsylvania hospital during the period 1972-1981.  The beds of half of them were near windows that overlooked a grove of trees, the other half looked out on a brick wall.  The vital signs and other indicators of health, including dosages and types of pain medication and length of stay were recorded along with all other variables that might affect recovery, such as age, sex, whether the patients were smokers, the nature of their previous hospitalisations, the year of their surgery, even the floor their room was on, were eliminated.  They were even cared for by the same nurses, so differences in nursing care could not account for differences in speed of recovery! 

Ulrich found that patients whose beds were located beside windows with views of a small stand of trees left hospital a full day sooner than those with views of a brick wall.  Not only that, but the patients with nature views required fewer doses of moderate and strong pain medications.  The results were dramatic and statistically significant.'

It's fascinating stuff, although some of the medical hypotheses about the way these connections might actually work in the body and brain were often difficult for this non-scientist to understand.  Unfortunately, not enough of this work is yet at the stage where it could be translated into ideas and directions useful when buildings are being designed.  However design changes are constantly being proposed that improve patient safety and healing and one hospital that included many of these measures showed that the cost of these improvements were recouped by savings in operating costs in the first year. 

The recent Royal Childrens Hospital in Melbourne (by Billard Leece Partnership and Bates Smart Architects) is a colourful and playful attempt to overcome the cold clinical appearance of earlier hospitals and to allay the fears of children, all of which helps them heal quicker.  Sculptures children can climb on, an interactive wall panel they can draw on, and an aquarium in the main lobby, plus a playground and garden off the high atrium all help attain this end.

 Royal Childrens Hospital 01Aquarium between two floors of Melbourne Childrens Hospital

Royal Childrens Hospital 02
Interactive computer screen

Royal Childrens Hospital 03
Main lobby in Royal Melbourne Childrens Hospital

Design indicators in retirement residences  have also been evolved to help old people to cope with their physical environment.  For example wide hallways with contrasting views at either end of the hallway and landmarks such as a large fireplace all help residents to orient themselves, and a garden that is accessible to residents helps to reduce stress in patients. 

A 2003 study showed that residents in such well-designed places do better on all the standard measures of depression, social withdrawal and aggression than those people occupying hospital rooms in typical dreary nursing homes.

Office interiors is another field where progressive designers are trying to make work places not just more attractive but also healthier in all sorts of ways, not just improving physical conditions but also the psychological aspects of working and office life that affect health.  And of course retail developers and their designers have gone further than everyone else in appealing to all of our senses in an attempt to attract us to buy more.

Urban designers have looked to Disney World in Florida ever since it was built in order to find out how to emulate the litter free, friendly and accessible public environments that people like so much.  In a similar way the author suggests that urban designers should learn from retail malls, saying:

The sort of theatrical display, which sets a mood by means of auditory, odour, and collective memory-cues, is used over and over in retail marketing, so much so that we take it for granted. Appalling as it may seem, such examples show that it is possible to design urban places that buoy people's spirits, induce people to walk, and encourage socialisation.  If we could apply those principles to urban design instead of just theme parks and shopping malls, perhaps we could offset some of the negative emotional and physical health effects of the suburbs, and even improve health in the poorest areas of cities.

Sounds good but if our understanding of what we take from these places is too superficial, our suburbs could simply end up looking like shopping malls!  The idea is interesting but our level of scientific understanding of the factors involved is still rudimentary and more science is clearly needed.  We have to be careful to base what we do on the evolving science and not fall for the modernist fallacy that somehow good surroundings are enough to make people good; in fact of course, they are not related and some of the worst corporate crooks like Enron live in some of the most elegant buildings!  

We also have to appreciate, for example, that one of the things that makes Disney World work so successfully is autocratic management and decision-making that wouldn't be tolerated for long in our democracy. 

The new town of Celebration in Florida with its white clap boarded houses and white picket fences, is often held up as a model of how to make our suburbs more attractive. There are only a few design controls, a model one would think after our turgid council planning bureaucracy.  House designs have to be approved by the developer and you can break the rules as long as the design finds favour, but equally there is no appeal if they don't like it. I doubt it's a model that would be successful here.

Architects are quick, too quick perhaps, to adopt ideas that look as though they will make their buildings work better.  'Defensible Space'3 was published in 1972 and became an immediate best seller with architects.  This book argued that the high rates of violence and vandalism in public housing in the United States were related to the design of the buildings and suggestions were made that would, the author claimed, solve some of these social problems.

This book held out the vision that architects could become a type of applied social scientists who could design environments that would bring about desired behaviour though better design, and architects lapped it up.  Undoubtedly design can influence behaviour, but unlike the medical example quoted there are too many complex social variables involved in the design of public housing to be able to construct a proper scientific experiment. The impact of this book has declined recently, although it is still often quoted by police and other authorities to shift the blame for violence and vandalism onto housing managers and architects rather than to social conditions like poor education, drugs, crime and poverty where they belong, and for which all of us have to accept some responsibility. 

Don Gazzard LFAIA
September 2013

  1 Healing Spaces : The science of place and wellbeing'
Esther M Sternberg MD. Harvard Belknap Press 2009).

2 Stephenson, a controversial reformer whose reputation was established with St Vincent's, the Mercy and Royal Melbourne Hospitals, and the Royal Prince Alfred Hospital in Sydney. These hospitals are all monuments to the revolution in hospital design he brought about, and many of the other major hospitals built in Australia from the 1920s to the 1960s reflect his influence. The firm of Stephenson & Turner is still going strong.

3Defensible Space:  Oscar Newman (Macmillan 1972