The Half Measures of Public Health Architecture

The Half Measures of Public Health Architecture

The Half Measures of Public Health Architecture

To build better cities, architects must not only take on projects related to our health; they must confront the contradictions of their plutocratic funding model.


The sudden onset of the Covid-19 pandemic inverted long-held assumptions. Jobs previously seen as disposable were now regarded as “essential.” Well-heeled professionals walked out on lucrative careers to focus on their lives beyond the market. Conservative politicians who had long taken fee-for-service health care as an article of faith acquiesced to free universal testing and treatment. And the belief that we are all connected changed from a dreamy left-wing mantra to a hard-headed principle of realpolitik.

In the world of architecture, Covid transformed the way designers thought about their work. A profession that had once set out to build a better world had, over the past four decades, become dominated by “starchitects” offering their services to the one percent. Those still committed to the field’s social mission mostly ended up corralled in the ivory tower, doomed to be “paper architects” whose sensitive, socially minded structures were often brilliantly conceived but existed only as unbuilt sketches and renderings. Even before the pandemic, there was a desire to recapture architecture’s sense of public purpose, the idea that the field should be about more than just creating beautiful spaces for the lucky few who could afford them. But with the coming of Covid, this return to first principles took on a new momentum, with the profession rediscovering its long-dormant social mission. As the Pritzker Prize–winning Chilean architect Alejandro Aravena observed last year, the plague taught us that whatever we do to the least among us, we do to ourselves. If the poorest don’t have access to clean air and water, everyone will get sick. “Living through the pandemic,” Aravena said, “we’ve realized that as a society we no longer do things ‘for them.’ ‘Them’ has been replaced by ‘us.’”

Much of this newfound enthusiasm for socially minded architecture is captured in a new exhibit, “Design and Healing: Creative Responses to Epidemics,” that is currently on view at the Cooper Hewitt, the Smithsonian Institution’s design museum in Manhattan. In the exhibition, cocurated by the museum staff and MASS Design Group, the pandemic is presented as an all-hands moment when everyone in the design professions asked what they could do to help. The small-scale responses highlighted in the show range from efficiently packaged rapid test kits and instant thermometers to exposure-tracking cell phone apps and outdoor restaurant pods. But the field also took the moment to return to its roots and remember how much of modern urban planning initially grew up in response to the threat of communicable disease. It is architects who decide how people meet—safely or unsafely—in urban space. In the face of a new pandemic, hospital architecture—long an ugly stepchild of the profession—suddenly seemed the most essential typology of all. Fittingly, a look at hospital architecture’s past, present, and future constitutes the core of the Cooper Hewitt exhibit.

Few architecture firms were better positioned for this rediscovered public purpose than MASS Design Group. Founded by students at Harvard’s Graduate School of Design during an earlier moment of sobriety—the 2008 economic crisis—MASS has long organized itself as a nonprofit collective dedicated to renewing architecture’s public spirit. Eschewing the standard myth-making convention of naming their firm after themselves, founders Michael Murphy and Alan Ricks made their sense of social purpose explicit in their firm’s name: “MASS” is an acronym for “model of architecture serving society” as well as a nod to their orientation toward the masses rather than the elite.

The group’s best-known project to date has been the justly celebrated National Memorial for Peace and Justice in Montgomery, Ala., which commemorates the lives lost to racial terror lynchings. But while far less famous, most of MASS’s major projects have been hospitals in developing countries, typically built in conjunction with nonprofit organizations such as Paul Farmer’s group, Partners in Health. MASS has completed projects in Rwanda, Liberia, and Haiti and is at work on a new one in Bangladesh. Many of these designs are featured in the Cooper Hewitt show, as both illustrations of the firm’s output and the kind of socially engaged work architects might do today.

The Cooper Hewitt exhibition takes a long view of the history of hospital architecture. Strange as it seems today, in the early decades of the 20th century, health care projects were sought-after commissions for the most talented and ambitious designers. The Paimio Sanatorium for Tuberculosis Treatment, for example, was seen as a landmark project of global import when it opened in 1933. Designed by two married Scandinavian Modernists, Aino and Alvar Aalto, it was built on a woodland site between Helsinki and Turku and constructed in a softened International Style that featured curvaceous design elements constructed on a human scale. In each room of the sanatorium, intimate design details, such as a bespoke crafted reclining chair, beckoned patients with a warm wood color that contrasted with the antiseptic whitewashed walls of the facility. Hoping to channel the healing powers of nature, the Aaltos’ glass curtain wall left interior spaces flooded with natural light; the six-story structure also boasted a rooftop sundeck, giving convalescing patients ample opportunities to breathe in the fresh, pine-scented country air.

New York’s “modern” Bellevue Hospital, a monolith spanning an entire city block that opened in 1973, is also featured in the exhibit; its blueprint is displayed near the one for the Finnish sanatorium as an example of what not to do. While New York City’s regulations for residential projects mandated that even the humblest tenements include shafts for natural light and fresh air, at Bellevue, only the outermost edges of the building touched either. When Covid hit, hospitals of this type, largely devoid of natural ventilation, scrambled to create negative-pressure rooms for patients, lest the facilities’ own air circulation systems become vectors of contagion (as, in hindsight, they surely had for other airborne illnesses).

The show contrasts Bellevue with not just the Aaltos’ sanitorium but also MASS’s tuberculosis hospital in Haiti, which was built after the 2010 earthquake. The GHESKIO Tuberculosis Hospital in Port-au-Prince is a thin, two-story, snake-like structure that twists through its site to create numerous open-air courtyards. Its design is simple yet thoughtful and practical: Each room comes with an exhaust fan that constantly pulls fresh air in and sends tubercular air out. For the price of a window and a working fan, these MASS rooms function like the negative-pressure wards Western hospitals jury-rigged at great cost when the pandemic hit. Like the Paimio Sanatorium before it, the Haitian hospital offers an example of designing with nature, in contrast to Bellevue and other hospitals that, in their efforts to overcome nature, ended up squandering resources and sickening patients.

While the GHESKIO project is a clear example of public-interest architecture, there are limits to what even this kind of thoughtful, efficient, socially engaged building can accomplish—and the MASS projects unintentionally highlight these limits. In tandem with the Port-au-Prince tuberculosis center, MASS was also tapped to design a cholera hospital. The dreaded food-borne illness, which had been eliminated in Haiti nearly a century earlier, came back after the earthquake. Cognizant that failing infrastructure caused cholera, MASS designed its cholera hospital to remain separate from the Haitian capital’s troubled water system. With its own self-contained system, it could treat 250,000 gallons of wastewater per year and even harvest its own rainwater. But building an island of safety in a city in need of far more urgent repair led to a vicious cycle: Cholera would spread through the impoverished neighborhood directly across the street from the hospital; residents would get sick and be brought across the road to recover there; then they’d be discharged back into the neighborhood, where they would again be exposed to the same untreated water that had made them sick in the first place. The hospital may have offered both an architectural and medical oasis in Port-au-Prince, but, for all its design merits, it did very little to address the underlying problems.

To build better cities, architecture must think outside its own boxes. The transformative one-off project is a lingering conceit of the starchitect era. To fully leave that era behind, architects must give up on this ego-boosting myth. As Covid made clear, the health of a society’s people depends on the health of that society. Places where people had adequate living space to quarantine sick family members fared better than places where they didn’t; societies with high levels of social trust were able to deploy successful vaccination campaigns while others failed; countries where everyone, by right, had a primary care physician did better than those—the United States among them—where access was a privilege. Having a new hospital is nice, but it cannot fix these larger problems.

MASS also faces another quandary: By tapping the tax-sheltered riches of the nonprofit-industrial complex, the collective seeks to build architecture in the public interest that is actively powered by the world’s extreme inequality. This is perhaps a model developed out of necessity, but one wonders if, by doing so, MASS is drawing energy away from efforts for more comprehensive solutions. The Aaltos in 20th-century Finland could enjoy well-funded public commissions because their country had checked its industrialists, harnessing their fortunes through taxation and taming their power through unionization. In that era, public projects were where the money was. Today, funding MASS’s projects allows those with vast fortunes to insist they are saving the world, even as they starve their societies of resources by evading their fair share of taxes.

The very setting of the Cooper Hewitt exhibit underscores this point. Like several of the institutions on Manhattan’s Museum Mile, the Cooper Hewitt was built initially as a private home—in this case, Andrew Carnegie’s Fifth Avenue mansion. For today’s museumgoers, raised on the austere white box as the default setting for experiencing art, seeing MASS Design Group’s contemporary architectural models in rooms lined with overwrought wood paneling and doorways topped with Tiffany stained-glass windows can feel jarring. But it is also a reminder that so much of what should be publicly and equally provided by the state has, in times of extreme inequality, been doled out unequally according to the whims of plutocrats. Carnegie himself was the first Gilded Age’s archetypal example of this phenomenon: a robber baron turned philanthropist who insisted he could solve the world’s most entrenched social problems through his private wealth. Until architecture wrestles with the inadequacies and contradictions of this philosophy, the solutions it offers will always be half-measures, no matter how beautiful or well-intentioned the designs might be.

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