The hospital as building type.

Hospitals are simultaneously almost machines for improving health and places for intensifying compassion and emotions. A new generation of buildings, particularly in Austria, shows how technology and humanity can be reconciled.

With a small addition the word hospital becomes hospitality. In the medieval world, a hospice was a place of shelter for pilgrims and strangers, while an infirmary was the department in a monastery reserved for elderly monks, usually with its own cloister. Hospitals began as religious institutions, often the only sources of charity, and until the nineteenth century they were dominated by their chapels. At first, beds for patients were actually in the room where worship took place, as with the famous Hospice at Beaune: later, as in the Ospedale Maggiore in Milan, the wards of the cross-shaped plan all met at the chapel. When separate ward wings were developed for patients, the chapel remained the most prominent building on the central axis, still dominating the plan of the institution. With the growth of city populations, secular organizations took over, and larger institutions were needed. Their organization tended to reflect the classification of patients as old or young, male or female, sometimes even first or second class. Similarities of organization were observable in prisons, asylums, and workhouses. At the same time, different kinds of specialized hospitals sprang up for women, children, lunatics and so on.

As medical understanding progressed, the spread of infection through air was acknowledged, if not fully understood, and isolation of patients in separate pavilions with cross-ventilation became a dominant consideration. Leaving people to the care of the Almighty gave way to a belief in science and an ever increasing level of technical intervention, while the chapel was reduced to a minor clement -- a place of comfort for the newly bereaved. By the time the Modern Movement broke, the hospital had become a bastion of scientific control, defending its occupants against the invasion and chaos of unreason and disease:

The perfect Modern building

The purity and abstraction of the Modernist architectural language quickly became synonymous with health and hygiene, and the hospital has remained the building type for which this kind of architecture seems most fully appropriate. The cool rationality of the grid spells order and control -- no mysterious darkness or dirty corners -- and the geometry of the cubic masses registers timeless perfection. Intense lighting stands for clarity of understanding, avoiding shadows of doubt. Bright impervious surfaces in plaster, white paint, vitreous enamel, glass or stainless steel are not just cleanable but seen to be clean.

The greatest boost to the Modernist programme came with the Tuberculosis Sanatorium. This killer disease of young people in dense cities caused coughing and was evidently exacerbated by polluted air, just as it was relieved by the pure air of the mountains. In the age before antibiotics, the bacillus was most effectively killed by sunlight, providing the most literal justification for the Modernist obsession with light and air. The key early model for Modernist sanatoria was Jan Duiker's Zonnestraal at Utrecht of 1926, but this was soon overtaken by Alvar Aalto's sanatorium at Paimio of 1928, the epitome of Modernist hospital design. Aalto designed the furniture as well as the building, and made great strides with the detailed design of the room and its fittings, considered primarily from the point of view of the anxious patient. The virtue of the functionalist approach has never seemed clearer: the buildings were not overscaled and even allowed a certain generosity, while the architect enjoyed considerable creative freedom.

As the welfare states took over, particularly in the postwar period, hospitals were at first expressions of a new pride in public provision and egalitarian care, but they increasingly became prey to bureaucratic standards and norms, due to both the understandable emphasis on safety and the need for public accountability. As medical science progressed, hospitals also became dominated increasingly by technical issues, an ever larger portion of their budget being spent on services and medical equipment. The dominant ideology remained fiercely scientific, the battle against the bugs being the front line. The discipline was almost military. Hospitals have also gradually become the places where most of the population are born and many die, yet it took a great deal of protest -- mainly from women in the 1970s and '80s -- to turn the maternity hospital from an emergency ward into a place fit to celebrate a rite of passage, a normal birth being no sickness but a joy. The other rite of passage, death, is still largely repressed. It is treated as an institutional failure, something that should not happen -- even when the patient is 95. We may no longer expect to meet our Maker, but, as a society, we have found no other way of facing that untidy situation. We try to forget that it is coming.

Development of modern medicine in industrial society has been a great success story: we live on average rather longer; very few infants die at birth; we are threatened by far fewer diseases; many bodily disfigurements can be alleviated. But all this must be paid for. Even if hospital visits have become shorter, drugs and instruments for diagnosis and surgery have become hugely more sophisticated and therefore expensive, and doctors cost as much to train as they ever did. We have come to see the elimination of disease almost as a human right. Surgical procedures are supposed to be successful, so when they do go wrong it must be the doctor's fault, and following the pattern of the United States, we are becoming more litigious. In the long run the expense is passed back to us all, hugely inflated by legal fees.

All these social and political issues are reflected in the condition of hospital architecture. In the 1950s and '60s the new welfare states proudly invested in huge new hospitals, centralizing all facilities on edge-of-town sites. In the era of functionally driven architecture, when the answer to every problem was to measure and calculate, the hospital became the technical building type par excellence. Servicing provision was a major priority, with statutory levels of heat and light provided artificially and of course closely controlled artificial ventilation. Flow patterns of doctors, patients and visitors could be worked out like a traffic system, the complex routes controlled with batteries of signs. Materials and surfaces were chosen to be clean and cleanable, yet also to be uniform and efficient. The hospital became a wondrous great machine, reassuring in its efficiency; yet it could also be a labyrinth in which the patient felt lost, shuffled from department to department, level to level. A few decades of growth and change - new machines, different medical practices - made it more haphazard and less efficient, the labyrinth more impenetrable. The steel rusted and the concrete spalled. The Utopian moment of building afresh had passed, and the bureaucratic norms intended to establish a plateau of good practice became a limitation. The rules of hospital design left less freedom, and it became regarded as a building type that was worthy and dull, more or less lost to architecture.

The Graz contribution

When asked to name the last architecturally significant major hospital in the UK, architects usually mention St Mary's on the Isle of Wight by Ahrends, Burton and Koralek (AR February 1991), a project started 20 years ago and complete by 1990. Despite an obligation to use the rigid nucleus ward template, ABK managed a lively organization and sense of place, while their art programme acknowledged the healing influence that the quality of surroundings has on people beset by worry, doubt and fear. In retrospect, it marks the last heroic moment of public welfare provision when there was still some sense of optimism and generosity. There have been a few notable small clinics and surgeries of high architectural quality in recent years but, in Britain, such large new hospitals as have been completed are relatively uninspired, and the current run of PFI projects hold out little hope for the immediate future. Reports indicate that all is not well with this method of procurement, (1) and it is by nature business-driven with architecture as a mere and almost unnecessary adjunct.

In a semi-privatized system, the rich set the standards to which others must aspire. No longer the calm austerity of Aalto's Paimio: the private hospital tries to pretend it is a hotel, so borrows from the kind of general pseudo-domestic vocabulary that is these days applied every where: brick and tiles without, cosy carpets, dados and wallpaper within, and a TV in every room. The heavy servicing is applied discreetly, the frightening medical gadgetry kept as invisible as possible Of course the operating rooms and intensive care facilities are as technical and machine-like as ever, but they belong to a separate world away from the private rooms.

The supposed domesticity is questionable on two fronts: on the one hand it dilutes the reality of domesticity, turning it into a banal generality, a shallow symbol of comfort that can hardly convince. On the other hand it avoids the atmosphere of purity and danger so aptly conveyed by the Modernist hospital. Often life is really at risk, and one submits oneself to procedures that in the world outside would be defined as crimes - nowhere else is it legal to stick a knife into anyone. It is therefore reassuring to know that it is done with the utmost efficiency by well-trained people in recognizable uniforms, that the battle against the bugs is being well fought. It is reassuring also to witness the several thresholds one must cross, from the documentation at reception through the uniformity of the ward to the sterile areas where consciousness is expunged and treatment takes place. In other words, the hospital does need to be a recognizably special place - still a kind of sanctuary - and not just a hotel with an operating theatre attached.

Several of the hospitals shown in this issue are from in and around Graz, the capital of Styria. In the 1980s and '90s this second city of Austria hosted an architectural movement that has been reported often in these pages (see ARs December 1988, April 1990, November 1993, October 1995). In an enlightened moment of political patronage, public buildings and social housing schemes were systematically opened up to architectural competition, which produced both innovative design and useful public debate. Unfortunately in the local election of 1991 the political balance changed and the patronage collapsed, (2) and these days most leading Graz architects are building elsewhere. But before the movement died, its methods had penetrated the hospitals authority, the Krankenhausgesellschaft (KAGES), who have acted as a highly enlightened client body. This has led to a wave of new buildings and extensions won in competitions by some of the best Graz architects that is just coming to fruition. They show that the archite cture of the hospital need not be blotted out by technical and bureaucratic demands: that indeed a balance between the technical and the humane can and must be struck. They remind us that a sick person needs the most carefully considered surroundings, that daylight and view are precious, that if large institutions are needed for safety and efficiency, they can be clearly planned and easily navigable. They show us once again that With big and repetitive buildings the provision of special architectural incidents and a differentiation of parts can break down the scale and make recognizable places.

(1.) See George Mombiot, Very British Corruption, Guardian, 22 January 2002.

(2.) For the full story see Peter Blundell Jones, Dialogues in Time: New Graz, Architecture, HdA Graz 1999, pp82-90.