What Paul Farmer taught me about ‘dignity construction’ in health care

Paul would not stand for spaces that dehumanize us; not in resource-rich or resource-poor settings. When I was part of a team he led in 2007 to design a new medical facility in a remote area of Rwanda — the Butaro Hospital where he passed away this week — he guided me with lessons that shaped the design of that hospital and informed a broader worldview all of us can apply.

Butaro District Hospital in Rwanda, designed by MASS Design Group.Iwan Baan

He advised us to look at the best and most innovative hospitals, from history and the present, for how they prioritized both flexibility and humanity. “Do not settle for the bare minimum,” he would tell me; anything less than the best we can offer is an injustice to our patients and our world. And even though our budget was small, “resource limitation creates great resourcefulness,” he told me.

The first resource limitation we faced in creating the Rwandan hospital was that large mechanical systems such as air conditioners were expensive and hard to maintain. So he and his colleagues encouraged us to look at historic hospitals that moved air naturally to fend off disease transmission.

One starting point for us was Florence Nightingale’s design for hospitals in the 1850s. To move air around the space, her designs set parameters for window size, plan layout, and wall height. This influenced standards of medical care for the next half century and helped usher in the sanitation era in hospital and city design.

An 1856 lithograph by William Simpson of barracks in Turkey that served as a hospital where Florence Nightingale worked during the Crimean War. What she learned there would inform the design of Nightingale Wards elsewhere.Wellcome Collection via Wikimedia Commons CC-BY-4.0

In Barcelona, Spain, at the end of the 19th century, Luis J. Montaner designed a hospital whose craftsmanship, with symbolic friezes executed by Catalan artisans, melded beauty with medicine’s social mission. Outside, carefully landscaped grounds contained lush medical flora and plantings. These are the kinds of details Paul also obsessed over in the gardens of medical facilities he helped design. He taught us that skimping on the quality of finishings or the landscape was not a choice we could afford to make. Beauty had a function too: to elevate the dignity of patients and give them an experience of hospitality and care.

Hospital de la Santa Creu i Sant Pau.Robert Ramos / Fundació Hospital de la Santa Creu i Sant Pau

In Finland, Aalvar Aalto’s paradigm-setting tuberculosis clinic from 1933 aimed to reduce disease through architecture. It has natural airflow and outdoor spaces for people recovering from the respiratory disease. Aalto’s project ushered in many ideas about how buildings can directly affect individuals’ health. Like Paul Farmer, Aalto considered no detail too small; he designed everything from the chairs and sinks to the lighting and beds with the experience of the patient in mind.

Paimio Sanatorium, Finland.Solarium Terrace, 1934, Gustaf Welin, Alvar Aalto Foundation

Bertrand Goldberg’s iconic 1960s Prentice Hospital, in Chicago, offered a cautionary tale. The building’s curvilinear tower was designed to reduce the distance between the nurses’ stations and the patients while providing each patient a window with a view. These concepts would influence Goldberg’s later designs of Brigham and Women’s bed towers in Boston (a hospital where Paul was an attending physician). Prentice’s floor plan was less adaptable than the Brigham’s to the constantly changing needs of medical facilities, and it was demolished in 2016 in favor of a larger and more flexible plan. Hospitals must be thought of as living things that adapt to changes in care.

Prentice Hospital.Brubaker Collection, University of Illinois-Chicago

Paul’s inspiration for rethinking medical systems began in Haiti, where his organization, Partners In Health, has worked to strengthen the health system since the mid-1980s. After the earthquake and subsequent cholera epidemic of 2010, the Haitian organization GHESKIO asked my firm to design a more holistic solution than the emergency tents that had sprung up in response to the outbreak. Could we treat patients with dignity even amid Haiti’s infrastructure shortcomings? The resulting cholera treatment center uses natural daylight and rainwater in a facility with high ceilings and large fans that move air and help promote sterilization.

The GHESKIO Cholera Treatment Center in Port-au-Prince, Haiti.Iwan Baan

Another modern example of these ideas can be seen in Maggie’s Centres in the United Kingdom. They are outpatient cancer treatment and recovery centers adjacent to but removed from the more institutional settings of their affiliated hospitals. They were the brainchild of architect Charles Jencks and his wife, Maggie, who suffered from the institutionalism of her cancer treatment. Maggie’s Centres have employed different architects to design various spaces, and Thomas Heatherwick’s new center in Leeds prioritizes unique interior settings, green roofs interweaving natural and built spaces, and light-filled sweeping common areas for patients undergoing treatment.

Maggie’s Centre in Leeds, England.Heatherwick Studio

How I wish we had a Maggie’s Centre for my own father during his journey with cancer. When Paul and his colleagues approached us in 2015 to design a cancer treatment center, one of the first in East Africa, at the Butaro hospital, we found these examples inspirational and just right. If they could exist in England, why not here?

The Butaro Cancer Center of Excellence in Rwanda.Iwan Baan

The COVID-19 pandemic has prompted a reckoning with the role of buildings in shaping our health and our ability to breathe clean air indoors — lessons that Farmer had inspired me and so many others to pilot on that distant hilltop in Rwanda. Those lessons turned out to be prescient. During the first coronavirus surge in April 2020, medical professionals at Mount Sinai Hospital in New York reacted by moving patients from modern air-sealed buildings to an older bed tower with windows designed to be opened. By necessity, the hospital’s old facilities were revealing ways of being more adaptable to the demands of an epidemic. They were breathing again.

The history of hospitals teaches us about air movement through architecture, about the public health risks of poor design, and about the dangers of overreliance on technology. Good design in these settings reminds people that they still matter.

The facilities you see in these images — some old, some new — have all sought to strike a balance between serving the whole person and being beacons of scientific and technological innovation. They’re a reminder of an idea that Paul described in the foreword to a book I co-wrote in 2019. In health care, he wrote, “a beautiful built environment might not be as essential to healing as a clean one, but there is no reason to choose beauty over cleanliness, or efficiency or innovation. And how better to incorporate respect for our patients and their families than to focus on dignity and design?”

Michael Murphy is founding principal and executive director of MASS Design Group, a not-for-profit architecture and design firm based in Boston. MASS is short for Model of Architecture Serving Society. He is coauthor of “The Architecture of Health: Hospital Design and the Construction of Dignity,” from which this essay is adapted.

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