SUPER GREEN - the International Academy of Design and Health

October 2008 | WORLD HEALTH DESIGNARCHITECTURE | CULTURE | TECHNOLOGY OCTOBER 2008SUPERGREENCreating healthy environmentsin Singapore through eco-designVolume 1 Issue 3ALSO:Market reports: China and Eastern EuropeInquiry: Making the case for single roomsScientific review: Urban design in the PhilippinesTechnology report: San Diego’s hospital of the future

ContributorsBernd RechelSuccessful capital projectsrequire much more thanjust good architecturalsolutions and healthy design,comments the EuropeanObservatory’s Bernd RechelPhil NedinArup’s new global headof healthcare calls forinvestment in research andindustry support to helpdevelop the evidence basefor better health buildingsIan ForbesGHD Architecture’s IanForbes presents a designtool created to helpoptimise the birthingexperience for bothmothers and midwivesMary Anne AkersMorgan State University’sMary Anne Akers presentsa study of the impact ofthe informal architectureenvironment on streetvendors in the PhilippinesPhil AstleyMARU’s Phil Astley praisesa new book on biophilicdesign for its challengeto design complacency inaddressing connections to anew living architectureARCHITECTURE | CULTURE | TECHNOLOGYLast chance saloonAs the world reels from the fi nancial storm that has blown throughglobal banking institutions, it would be easy to forget what reallymatters in the real economy.Health capital is central to the socioeconomic progress of nationsin the east and the west, and in the developed and developing world.It is also integrally linked to the sustainability of our environment,where innovative approaches to green design are key to addressingclimate change, in what could be our ‘last chance saloon’.Research demonstrates that a connection with nature is centralto our health and wellbeing. In this issue, we feature Ken Yeang’ssignature ‘Super Green’ design for a £55m mixed-use researchand science building in Singapore on the cover and in our newPlacemaker photo feature (see pp 10-11).More international examples of benchmark ‘green’ designs areexplored in the new book Biophilic Design, reviewed by Phil Astleyon p76. Are we ready as designers, clients and developers to speak anew language of value and performance that properly accounts forthe morphological and biodiverse cost benefi ts of eco-environments?It’s perhaps no surprise that Arup is leading the way in ecoinfrastructuredesign and we wait in anticipation to see whetherits eco-exemplar for the fi rst zero-waste city at Dongtan in Chinabecomes a reality (pp22-27).Our special features on China and Eastern Europe demonstrate,however, that despite rapidly growing demand for health, only a fewwestern architectural fi rms have managed to meet the cultural andeconomic challenges of designing in these regions.In our scientifi c review, the impact of urban design on health andwellbeing is explored by Dr Mary Anne Akers in a study of streetvendors in the Philippines (pp59-63), awakening us tothe health conditions that result from the marginal,temporary and fl uid existence of outside workers – aglobal phenomenon that is certainly not exclusive to thedeveloping world.Gunnar ÖhlénStrategies for whole-lifecosting of healthcare estatewill reap long-term rewards,writes Gunnar Öhlén ofthe European Society forEmergency MedicineMarc SansomEditorial directorWORLD HEALTH DESIGN | October 2008 03

ContentsEditorial DirectorMarc Sansom MBAT: +44 (0) 1277 634 176E: marc@designandhealth.com22PresidentPer Gunnar Svensson PhDDirector GeneralAlan Dilani PhDT: +46 70 453 90 70E: dilani@designandhealth.comEditorial Advisory Board:Joint ChairmenProf Romano Del Nord, ItalyDr John Zeisel PhD USProf Jacqueline Vischer, PhD CanadaProf Philip Mead, PhD USDr Patricia Tzortzopoulos Fazenda, PhD UKProf Clare Cooper Marcus, USProf Young Sook Lee, PhD KoreaDr Ruzica Bozovic-Stamenovic, PhD SingaporeProf Noemi Bitterman, IsraelMike Nightingale, UKAlice Liang, CanadaPeter Scher, UKMartha Rothman, USDiana Anderson, CanadaJeanette Paul, UKDr Martti Teikari, PhD FinlandProf Reza Emdad, PhD SwedenDr Linda Jones, PhD New ZealandDr Eve Edelstein, PhD, USPublished by:The International Academy for Design and HealthResearch Centre Design & HealthPO Box 7196103 88 StockholmSwedenT: +46 70 453 90 70F: +46 8 745 00 02E: academy@designandhealth.comwww.designandhealth.comInternational Academy for Design and Health UK8 Weir Wynd, BillericayEssex CM12 9QG UKT: +44 (0) 1277 634 176F: +44 (0) 1277 634 041E: WHD@designandhealth.comDesign and production:Graphic Evidence LtdWood Farm, Moreton RoadOngar, Essex CM5 0EY UKT: +44 (0) 1277 890 900E: info@graphic-evidence.co.ukwww.graphic-evidence.co.ukVolume 1: Number 3ISSN 1654-9654Subscriptions:To receive regular copies of World Health Designplease telephone +44 (0) 1277 634 176to place your order, or emailWHD@designandhealth.com (include postal addressand telephone number). Yearly subscription rates:1 year £70; 2 years £115; Single Issue £25World Health Design is published four times a year bythe International Academy for Design and Health UK.No part of WHD may be reproduced or stored ina retrieval or transmitted in any form, electronic,mechanical or photocopying without prior writtenpermission of the Editorial Director.BRIEFING060709OPINION0313LEADER Marc Sansom commentson eco-design in the last chance saloonLEARNING THE LESSON BerndRechel says successful capital projectsneed more than good architectural solutions16CULTURAL CHALLENGES:Phil Nedin and John Cooper discussthe international challenges of employingcredible research to inform facility design20DOES ONE SIZE FIT ALL?As single patient rooms becomethe industry standard in the US, four expertsdebate its value for patient care71WORLD EXPERTS IN SINGAPOREDesign & Health 6th World CongressBEST PUBLIC BUILDINGRoyal Alexandra Children’s HospitalACTION FOR DESIGN QUALITYFour international healthcareorganisations have developed an action plan toimprove the quality of healthcare facility designINVEST TO SAVE Gunnar Öhlénsays a whole life costing approach tocapital investment in healthcare estate willreap long-term rewardsPROJECTS10SUPER GREEN Eco design is at thecentre of a Singapore’s new mixed-useresearch centre designed by T R Hamzah & YeangMARKET REPORTS22CHINA RISING As the onceCommunist nation embraces capitalism,what is the future for innovative healthcare design?28EASTERN PROMISE With healthcareinfrastructure in need of modernisation,private investors are looking to fi ll the gap3404 October 2008 | WORLD HEALTH DESIGN

55TECHNOLOGY REPORTS34CONCERT OF CARE Eve Edelstein visits PalomarPomerado Health to fi nd out about the US healthcareprovider’s design for the hospital of the future41FABRICS & FURNITURE New products bring colourand form into healthcare facilitiesSCIENTIFIC REVIEW45AWAKENINGS Evidence-based research helps us toopen our eyes to the health impact of the everyday builtenvironment, say Dr John Zeisel and Prof Romano del Nord47BIRTHING UNIT DESIGN A team from Sydney’sUniversity of Technology have developed a set of principlesthat can be used to optimise the design of healthy birthing units55DESIGNING HEALTHY COMMUNITIES A studyof the informal architecture in which Filipino streetvendors work and how it impacts on their health61PERCEPTION AND WELLBEING Two NewZealand studies explore how the built environment– internal and external – can impact on mood28ARTS & CULTURE6741BIOPHILIC DESIGN Phil Astley reviews a new bookthat examines the impact of buildings, both in terms ofenvironmental performance and their effect on health and wellbeing68RESTORATION OF THE LIVING IDEAL VeronicaSimpson visits a major exhibition in Liverpool, celebratingthe enduring legacy of iconic architect Le Corbusier68WORLD HEALTH DESIGN | October 2008 05

Briefi ngWorld experts come to SingaporeDelegate registrations are already pouring in as Singapore prepares for the Design & Health 6th WorldCongress and Exhibition, scheduled to be held at The Ritz-Carlton Millenia in Singapore, 24-28 June 2009Following a record number of scientifi c and professional submissions for next year’s Design& Health world congress – the foremost global event promoting interdisciplinary research andpractice – interest is building fast. Delegates are signing up to hear world-renowned speakers fromevery part of the globe.Sessions will include presentations by physicians, psychologists, designers, architects, planners, artists,nursing professionals and economists, bringing together a rich blend of interdisciplinary perspectives.Topics will include the latest research fi ndings in the fi eld including: design quality standards; evidencebaseddesign / research-based design; mental health; restorative justice; senior care; and children’s andyoung people’s healthcare.In addition, trends and infl uences on design and health will be considered in sessions coveringdifferent global locations, including: the Middle East, China, India, South East Asia, Europe and the US.Founder of the International Academy for Design and Health, Professor Alan Dilani said: “At a timeof great uncertainty following the global fi nancial crisis, it is important to remember that a country’shealth capital is the new indicator of economic wealth, and that infrastructure investment decisionsmust continue to be evidence-based and founded on credible research.“Our network, who by attending in Singapore next year, will benefi t from the opportunities toshare, create and disseminate knowledge at an international level, will be the same people and organisations who will thrive in the future, as wedevelop new paradigms that place design and health at the centre of the world’s socioeconomic development.”Design & Health 6th World Congress and ExhibitionUniting the disciplines of architecture, design, psychology, the health sciences and economics24-28 June, 2008 The Ritz Carlton, Singaporewww.designandhealth.comCraig Dixon, directorof consulting, TribalConsultingMichail Kagioglou,co-director, HaCIRIC,Salford UniversityHealthcare Infrastructure event bringsinternational perspectiveInfl uential speakers of international renown will lead a heavyweight line-up at HealthcareInfrastructure 2008 in December – a new event aimed at evaluating future health capitalinvestments in the community.As healthcare around the world comes to terms with ever rising demand andincreasing costs, this new conference, organised by Building Better Healthcare inassociation with the International Academy for Design & Health, aims to address thekey drivers shaping future capital investments in our healthcare infrastructure.International speakers will join a programme that also includes UK speakers fromthe Commission for Architecture and the Built Environment, the King’s Fund andCommunity Health Partnerships. In a unique programme, current government policywill be reviewed alongside real-life examples of best practice and reports on the latest research fi ndings in the sector, ensuring an interdisciplinaryevent that will attract policy makers, health managers, estates and facilities managers, clinicians, health planners, architects, designers, developersand university-based researchers. The new conference will address how a more fl exible healthcare infrastructure with a community focus is betterplaced to meet the changing needs of patients, and embrace rapid advances in medical and information technologies.Healthcare Infrastructure 2008: Building Better Healthcare in the Community2 December, 2008; The Savoy Place, Londonwww.binleys.com06 October 2008 | WORLD HEALTH DESIGN

UK: The ‘Alex’ wins againLast year’s winner of the Design & HealthBest International Project award, the RoyalAlexandra Children’s Hospital in Brighton,has scooped the UK Prime Minister’s BetterPublic Building Award. Designed by BDP, theproject was delivered by PFI consortiumKajima Partnership.US: Safety fi rstA new organisation called Patient SafetyDesign Consultants, LLC – Architecturefor Safer Healthcare has been launched toadvise medical professionals and design fi rmsabout the relationship between the physicalenvironment and its impact on the safedelivery of care. For more information, visitpatientsafetydesign.orgAustralia: Call for papersThe Australian College of Health ServiceExecutives and the University of New SouthWales’ Centre for Health Assets Australasiaare calling for abstracts for papers and postersfor the ACHSE 2009 National Congress,which will take place from 4-7 August, 2009on the Gold Coast. The deadline for abstractsfor papers and posters is 28 November andshould address the theme of ‘Building ourHealthcare System around People and theirNeeds’. More information is available at:www.achse.org.au/frameset.htmCanada: Loneliness makes you coldA team of scientists from the University ofToronto have found that social isolation canmake people feel cold. Dr Chen-Bo Zhong,who led the research, which is published inPsychological Science, said: “This may be whypeople use temperature-related metaphorsto describe social inclusion and exclusion.”Ireland: Anshen + Allen project winAnshen + Allen is part of the NorthernIreland Health Group consortium, which hasbeen appointed preferred bidder for the newacute hospital in Enniskillen, Co Fermanagh.The £267m scheme will be located amongwooded hills, meadows and lakes, andrepresents a genuine integration of buildingand landscape in an environmentally andsocially sustainable design.UK: HOK to design research labHOK is to design the UK Centre for MedicalResearch and Innovation (UKCMRI), whichwill be built on 3.6 acres of land, close toSt Pancras Eurostar terminal and the BritishLibrary. Set to open in 2014, it will house 1,500scientists. The lab will replace the NationalInstitute of Medical Research (NIMR).US: Vaginal birth mums sensitiveA new study has found that mothers whodelivered vaginally compared to caesareansection delivery were more responsive to thecry of their own baby, identifi ed through MRIbrain scans two to four weeks after delivery.The results of the study were published inThe Journal of Child Psychology and Psychiatry.Bahrain: Community masterplanA masterplan for a new Water Garden City inBahrain has been revealed by designers HOK.The huge 2,200,000m 2 scheme will include thedevelopment of residential accommodation,hotels, schools and commercial, leisureand retail space for a community of up to40,000 people.UAE: New city in DubaiJapanese architectural fi rm Nikken Sekkei hasbeen appointed to design Jumeira Gardens,a new 350-billion dirham ($95.3-billion) cityin the emirate of Dubai in the United ArabEmirates (UAE). The contract was awardedto the fi rm by the government-owneddeveloper, Meraas Development.Canada: PPP win for StantecStantec has been named part of the InfusionHealth consortia contracted to deliver aC$432.5m expansion project, undertaken asa public-private partnership with the InteriorHealth Authority of British Columbia. Stantecwill provide architectural, mechanical, electrical,structural, civil and Leadership in Energy andEnvironmental Design (LEED) consultingservices for both the Kelowna GeneralHospital and Vernon Jubilee Hospital.US: Green credentials for designThe Parrish Healthcare Center at Port StJohn, Florida, US has received LEED Silvercertifi cation from the United States GreenBuilding Council. Designed by RTKL, thefacility’s architecture takes advantage of itsnatural surroundings and incorporates avariety of green building principles.New research publicationArup has published its fi rst Research Reviewto promote the fi rm’s research capabilities touniversities, academics, funding organisationsand clients. The publication demonstrates thequality and credibility of the fi rm’s researchcapability through case studies highlightingthe benefi ts of collaborative working andArup’s continuing impact on key researchdevelopments internationally. For moreinformation, contact: Marta Fernandez atmarta.fernandez@arup.comUS: Natural allianceHOK and the Biomimicry Guild have forged a‘fi rst-of-its-kind’ alliance linking the natural andbuilt environment. The relationship will seethe integration of nature’s innovations in theplanning and design of buildings, communitiesand cities worldwide. Established by biologistsJanine Benyus and Dr Dayna Baumeister in1998, Biomimicry is a science that studiesnature’s best ideas and imitates these designsand processes to solve human problems.Canada: Carillion team shortlistedMontgomery Sisam is a member of theCarillion Canada team which includes HOKArchitects, Vanbots Construction, Carillion/Vanbots Services Bridgepoint, and CIT GroupSecurities (Canada) and has been shortlistedto design, build, fi nance and maintain thenew Bridgepoint Hospital in Toronto. Thewinning project team will be selected in early2009 with construction of the new facilityscheduled to begin shortly after.UK: Three up for global awardThe Intermountain Medical Centre in theUS, designed by Anshen + Allen, NBBJ’sWashington Medical Center in the US andthe Midland Regional Hospital in Tullamore,Ireland, designed by Murray Ó Laoire andBrian O’Connell Associates, have all beenshortlisted for the Best International Projectat the UK’s Building Better Healthcare Awards,supported by the International Academy forDesign & Health.South Africa: Nightingale new offi ceNightingale Architects (SA) has openedfor business in Cape Town. A part-ownedsubsidiary of Nightingale Associates,Nightingale Architects (SA) is 26% ownedby historically disadvantaged individuals andhas been independently verifi ed as a Level 3broad-based black economic empowerment(BBBEE) service provider.UK: Building better health e-zineBuilding Better Healthcare, in collaborationwith the International Academy for Design andHealth, has launched an electronic magazinefocusing on the planning, design, fi nancing,procurement, construction and managementof the UK healthcare estate. To download thefi rst issue, visit: www.bbhealthcare.co.ukWORLD HEALTH DESIGN | October 2008 07

iefingExperts call for actionon design qualityFour leading international healthcare organisations havejoined forces in the development of an initiative that aimsto improve standards in the design quality of healthcarefacilities around the worldProfessor Alan Dilani,director-general,International Academy forDesign and HealthIn a meeting held last month in Geneva, the World Health Organization(WHO), the International Hospital Federation (IHF), the Union of InternationalArchitects and the International Academy for Design and Health decided onan action plan for establishing a global forum for the exchange of knowledgeon the development of standards in healthcare facility design.The action plan will include the creation of an international referencegroup to inform, though the dissemination of examples of best practice andexemplary design from around the world, the development of national andinternational guidelines for healthcare design.The reference group, which will be interdisciplinary, will aim to:• maintain and enrich the integrated planning software developed bythe WHO and to promote its use in different countries• develop indicators to measure the impact of the healthcareinfrastructure on the health and wellbeing of patients, staff and visitors• engage a global study on capital investment in relation to healthoutcomes, with a focus on developing an understanding of the decisionmaking process leading to capital investment• update the guidelines for healthcare facility planning worldwide.Hosted by IHF general director Dr Eric Roodenbeke, the meeting wasattended by Dr Andrei Issakov, WHO health technology and facilities planningco-ordinator at the World Health Organization, Hans Eggen, director theUnion of International Architects’ Public Health Group, and Professor PerGunnar Svensson and Professor Alan Dilani of the International Academy forDesign and Health.Calling for an international effort to support improvements in the designquality of healthcare facilities, Dilani said: “Healthcare facilities are highlyDr Eric de Roodenbeke,director-general,International HospitalFederationProfessor Per GunnarSvensson, president,International Academy forDesign and Healthcomplex and subject to continuous changes in use and function, refl ecting an ever-changing political, social, economic and technological context forhealthcare provision.“The healthcare environment also has a great impact on the standard of service provision and the healing process, which is supported bysignifi cant research fi ndings that demonstrate a clear relationship between the quality of healthcare design and health outcomes.“Whilst the specifi c needs of different countries should always determine the design outcome, political and fi nancial pressures may often takepriority. These pressures can be overcome through the wide dissemination of knowledge and international expertise in order to fi ll the knowledgegap and help to raise the standard of healthcare facilities all over the globe.”The fi rst meeting of the reference group is scheduled for the early part of 2009 in Geneva. Up to 30 key stakeholders will be invited toparticipate in the initiative, which will be launched by the WHO during a workshop event in 2009. WHD will publish regular news updates on theinitiative and its outcomes.To contribute to the initiative, the Design & Health network and other interested organisations should contact Dr Alan Dilani at dilani@designandhealth.com or Dr Eric Dr Roodenbeke at ederoodenbeke@ihf-fih.orgWORLD HEALTH DESIGN | October 2008 09

PlacemakerSuper greenSuper green design will be the signature of a new £55m mixed-use researchand science building in Singapore. The project, designed by Llewelyn DaviesYeang’s sister company in Kuala Lumpur, T R Hamzah & Yeang, and theSoilbuild Group, will form part of the iconic Fusionopolis cluster, a focalpoint of Singapore’s science, engineering and media industries.The Fusionopolis Phase 2B building will be the latest addition to the 200-hectare, one-north site in central Singapore, next to its acclaimedscience parks and close to the National University. The site lies within a masterplan designed by Zaha Hadid Architects. Soilbuild was awardedthe contract in April 2008, following a competition held by the Jurong Town Corporation (JTC). The proposed facility will have a site area of7,734 square metres and a plot ratio of 6.5, as well as the potential to develop up to a maximum gross fl oor area of 50,271 square metres. Thedevelopment cost is estimated to cost about S$148m and will take 22 months to complete.The design aims to achieve the Singapore Government Building and Construction Authority’s highest rating for green buildings – the GreenMark Platinum award. The building is designed to be distinctive with a green aesthetic, featuring a veranda-way surrounding the building at groundlevel, said to be reminiscent of the traditional Chinese shophouse semi-covered walkway. Spiralling around the building’s exterior is Ken Yeang’ssignature ‘ecoinfrastructure’, a 1.4km-long recessed continuous landscaped feature that wraps itself around the building’s façade.The ecoinfrastructure will complement the building’s gardened rooftops and an ‘eco-cell’ at the basement that enhances the biodiversity of thesite. The building has a novel solar shaft that is an inclined oversized light-pipe which brings daylight into the inner parts of the building.Besides the enhanced biodiversity landscaped features, other proposed green features include rainwater harvesting, roof gardens to reducesolar heat gain, solid waste separation and recycling.10 October 2008 | WORLD HEALTH DESIGN

WORLD HEALTH DESIGN | October 2008 11

StandpointEach year, many billions of euros are spent on capital investment projects in the health sectoracross Europe, and this amount is likely to increase in the coming years, as many countriesface a backlog of maintenance and refurbishment.Nowhere is the need greater than in Central and Eastern Europe, where levels of capitalinvestment have been particularly low over the last 30-40 years.When funds become available to address the long-standing lack of capital investment – forexample through structural funds for new EU member states or the oil boom that countries likeRussia or Kazakhstan are experiencing – there is a real danger that resources are not spent in themost effective and sustainable way. Before rushing into building new facilities, there are some keylessons to be learnt from capital investment in Europe.What should precede any capital projects, is a comprehensive analysis of health needs and howthese needs should be translated into services and appropriate facilities. Long gone are the dayswhen hospital beds were seen as an indicatorof a good healthcare system, such as under theSoviet Union, which placed great emphasis on alarge number of hospital beds and physicians.Health facilities should not be perceivedmainly in terms of buildings, beds or specialties,but rather from the perspective of the patientswho are treated in them and the processesdelivered by the health professionals who spendtheir working lives in them.This approach entails going beyond the singlehealth facility and taking account of the wholetrajectory of care. Far too often, capacity planningin the health sector fails to move beyond hospitalsand does not take account of the overall healthneeds of the population and the spectrum ofhealth services required to meet those needs.Health facilities also often continue to be used beyond their functional lifespan and refl ect outdated patterns of care – such as thelarge number of tuberculosis hospitals throughout the former Soviet Union that are at odds with modern approaches to tuberculosistreatment. Flexibility must encompass all aspects of health facilities, including their scale and scope, architectural design, supportinginfrastructure, services to be provided, relationships with the rest of the health system, revenue fi nancing, and sources of capitalinvestment. Paradoxically, in a few countries, policy is moving in the opposite direction – the Private Finance Initiative in the UK involvescontracts, which are specifi ed in great detail for the lifetime of a project, usually around 30 years, with very little scope for change.Effective capital investment requires intelligent fi nancing mechanisms, both for services and capital. In terms of services, resourceallocation should reward outcomes rather than capacityThe cost, risksand value of capitalhave largely beenignored acrossEuropeLearningthe lessonSuccessful capital projects in Europe require much morethan good architectural solutions, healing design andenvironmental sustainability, claims Bernd Recheland provide a smooth patient journey across differentlevels of care. With regard to capital, the cost, risks andvalue of capital have largely been ignored across Europe,with investment and revenue costs belonging to differentstreams, removing any incentive for hospital managers tomanage assets effi ciently. This traditional split is graduallyeroding in many European countries, as hospitals areincreasingly becoming responsible for their capital assets.It is abundantly clear that successful capital projectsrequire much more than good architectural solutions, healing design and environmental sustainability. Theywill need to be based on an assessment of health needs, comprehensive capacity planning, a whole systemsperspective, systematised care pathways, anticipated fl exibility and intelligent fi nancing solutions. None of thecountries in Europe has perfect solutions for all these issues and those involved in planning major capital projectsare well advised to try and ensure the long-term effectiveness and sustainability of anticipated health facilities.Bernd Rechel is a lecturer at the London School of Hygiene & Tropical Medicine and a researcher at theEuropean Observatory on Health Systems and Policies. He will be presenting a paper on ‘Hospitals of theFuture: Improving the Effectiveness of Health Capital Investment’ at Healthcare Infrastructure 2008: BuildingBetter Healthcare in the Community on 2 December at the Savoy Place in London. For more information onthis event, which is endorsed by the International Academy for Design & Health, see p6.WORLD HEALTH DESIGN | October 2008 13

Uniting the disciplines of architecture, design,psychology, health sciences and economicsInternational Academyfor Design & Healthwww.designandhealth.comLiak Teng LiatSingaporeProf Alan DilaniSwedenProf Per GunnarSvensson, SwedenProf Romano DelNord, ItalySteven SobakSingaporeDr John ZeiselUSLord Nigel CrispUKIan ForbesAustraliaProf JacquelineVischer, USRuzica StamenovicSingaporeSarita ChangAustraliaMike NightingaleUKMichael MoxamCanadaTye FarrowCanadaChris LiddleUKBill RostenbergUSKen SchwarzUKKen LedouxUSAChang-Ho MoonKoreaKate BishopAustraliaPeter ScherUKTerry MontgomeryCanadaProf James BarlowUKMarc SansomUKRitz-Carlton Millenia, SingaporeFor online registration and an early bird discount rate, please visit www.designandhealth.comOr for a delegate booking form, contact Prof Alan Dilani: academy@designandhealth.com

Creating global healthand wellbeing throughenvironmental designInternational Hospital FederationBook before15 April 2009for anEarly BirddiscountDesign & Health6th World Congress & ExhibitionRitz-Carlton Millenia, SingaporeAn international forum for continuousdialogue between researchers and practitioners24-28 June, 2009Singapore Medical AssociationSingapore Institute of Architects• International health development• Global thought leadership• Research-based design• Awards, advocacy and standards• Exhibition and technical showcase• Developing tomorrow’s leadersFor sponsorship and exhibition opportunities, or to apply for corporate membershipContact Marc Sansom: T +44 (0) 1277 634176 E marc@designandhealth.com

DialogueCultural challengesPhil Nedin and John Cooper go head to head on the role that research and evidence-baseddesign can play in improving the quality and performance of the global health estateUsed by architects, interior designers, engineers, and estates and facilities managers in the planning, design and constructionof healthcare buildings, evidence based design (EBD) is one of the more popular tools available within a rich and complextapestry of research methodologies.Project teams, working with informed clients, applying an EBD methodology, create a design solution following an assessment ofthe best available information from the research literature, post project evaluations and from evidence collated from the client’s ownoperations.A successful EBD solution, tested and measured regularly, should then demonstrate improvements in clinical outcomes, economicperformance and patient, staff and visitor satisfaction.The founding principles of EBD are in the main without dispute. Where controversy reigns appears to be where the methodologyhas been cannibalised or misused for commercial gain in order to convince decision-makers to rightly or wrongly commit to a capitalinvestment.Fad or fashionSpeaking in a live debate, hosted by the International Academy for Design & Health at the UK’s annual Healthcare Estates conferenceearlier his month, Anshen + Allen director, John Cooper and Arup’s global head of healthcare, Phil Nedin both recognised EBD as aninternational issue, but one which should be considered within local cultural contexts.Tackling attacks on EBD as a ‘design’ fad or a fashion, Cooper said: “Is EBD yesterday’s buzz-word? Has it been displaced by ‘leanthinking’? Is EBD a thing of the past? Let’s not simply throw the evidence out because it’s been misused.”He recalled design briefs in the late 90s that demanded new healthcare facilities to possess 21st century qualities, querying: “Isn’t itamazing that here we are in 2008, and we’re still calling for 21st century hospitals?”Cooper’s suggestion is that the UK has missed a trick and an opportunity to build an evidence base that will support and informfuture design solutions, questioning whether anything has been learned about the impact of design on nosocomial infection, reducingpatient falls or increasing staff retention. He says: “In the UK, between £17-23 billion has been spent on the healthcare estate in the lastten years, but precious little has been learned.”Comparable methodologiesEBD fi rst came to the fore in the US as the design equivalentto evidence-based medicine, which Nedin points out is atthe heart of healthcare provision. “No therapy, drug orprocedure is offered unless the necessary research andrepeatable clinical trials have been successfully conducted.”Recognising, however, the complexity of making a faircomparison of the value of applying similar scientifi cmethodologies to clinical and non-clinical subjects, Nedin,whilst supporting the principle of research, identifi essome important caveats. “Take the idea of the therapeuticenvironment, which architects, designers and psychologistsare endorsing. It is largely intuitive that good acoustics,environmental control, natural ventilation, lighting, colour andart can bring patient benefi ts, but there are also increasingnumbers of studies to support its case too.“However, patients are spending less and less time inhospital environments – an average of 3.5 days rather than16 October 2008 | WORLD HEALTH DESIGN

11 days in the 1970s. Diagnostics is moreregularly performed as an outpatientactivity rather than as an electiveprocedure. The payback on the therapeuticenvironment is now longer per individualpatient,” explains Nedin.Complex relationshipsThe second caveat, he suggests, isconcerned with the credibility of theevidence, and the ability to repeat aresearch study, given the complexity of therelationship between clinical outcomesand environmental space.In the modern world of medicine,where the patient rather than the diseaseis increasingly the focus of care, Nedinsays: “On what basis do we select patientsfor research? Each patient has their ownunique clinical condition/s, and mental andphysical characteristics, different levels of stress, and a specifi c drug regime.“They will also hold different perceptions of the different models and levels of care they are subject to, and of theenvironmental space around them, not to forget different levels of social support from families and friends.”Cooper suggests however that it is possible to measure the variables and develop an evidence-base, citing the work of theCentre for Health Design in the US, and particularly the Pebble Project, of which the new Pembury Hospital in Tonbridge Wells,UK, designed by Cooper, is a member. “There are over 600 studies in the US which will withstand peer review and demonstratethe impact of good design on clinical outcomes.“It’s about taking a new building and making it a pre-requisite to measure the variables,” explains Cooper.By being a part of the Pebble Project, the Pembury Hospital is subject to an EBD approach that takes a small set of variables,such as nosocomial infection, the reduction of patient falls and the misapplication of drugs, and compares the outcomes in thenew facility with those of the old facility. “We can then see whether the evidence that supported the design solution has beenrightly or wrongly applied,” says Cooper.As a member of the Pebble fraternity, Cooper says he receives 30-40 e-mails every week saying, ‘Do you know anythingabout this?’, ‘What’s happening here?’ or ‘We’ve learnt this’. He says: “A member of the estates staff we worked with in theUS spent six months working out which carpet offered the least resistance to pushing a trolley along. The work is invaluablebecause you can use it.Cultural driversCooper also recognises however that local cultural contexts must be takeninto account when assessing the evidence. “If you go to Europe and talkabout infection control, or if you go to the US, you’ll fi nd a lot of what weconsider to be best practice is entirely cultural. It’s not absolute and that isa diffi cult issue when you’re building an evidence-base.”In the US, he explains, “they use carpets in places we would never dreamof, supported by a culture of steam cleaning once a week. We all operatewithin very different clinical as well as operational cultures internationallywhich adds another layer of complexity.”Phil Nedin adds that examples such as the use of carpets versus vinylfl ooring also demonstrate how different interpretations of the evidencemay depend on the research objectives. “There is an assumption that thesafest fl oor covering is a vinyl fl oor. But if you’re dry sweeping a vinyl fl ooror a visitor leaves the building dragging their coat behind them, all mannerof dust and matter carrying a microbiological load can be stirred up.“So suddenly, we’re beginning to think that carpets are pretty good“As a practisingarchitect, I’veonly once everbeen given clearmeasurableobjectives”WORLD HEALTH DESIGN | October 2008 17

Dialoguebecause they act as a blotting paper – when the particlessettle, they settle for good. But you must have a means ofcleaning the carpet properly.”Cooper adds, however, that research can also be usedto challenge cultural paradigms. “There is apparently noevidence whatsoever to support the use of laminar fl owcurtains in orthopaedic theatres, and in the US they don’tuse them.“Any why are the British more combustible than anyother nation? HTM81 is far more onerous than any otherfi re code in the US, Europe, Australia or any other area inwhich I’ve worked. This is an extraordinary restriction aswe move towards 100% single rooms.“Much of what we design is shaped entirely by therigours of fi re code. Research is needed to validatedifferent hospital arrangements that do not increase therisk of mishap or injury due to fi re.”Phil Nedin2008 Director, Healthcare BusinessLeader - Arup2008 NHS Design Review Panel member2006 – 2008 President of Institute of HealthcareEngineering and Estate Management(Now Immediate Past President)Danger of complacencyDespite his warnings about the use of evidence, Nedinsays the danger is not getting proper research done thatwill help to develop the evidence-base. “Real problemsemerge when something is intuitive and you try to writeguidance around it without the research to support it.”Recalling a recent conference presentation he gave inthe US, Nedin said: “I put up a slide of a map of the USdivided into 30 different areas to demonstrate the changingclimate from north to south, and east to west.“In some of these regions, you can naturally ventilatefor 80-90% of the year, in other areas you may not haveconsidered appropriate, natural ventilation is possible for50% of the time. In other areas, where the humidity is high,there may be ways of addressing that problem. Both thearchitects and the engineers said they would love to dothat, but that the code ensured that the fi rst decision wasalways to seal the hospital.”Warning against complacency, Nedin said that whenJohn Cooper RIBA ARBpressed on how the code had been developed to support sealing of the hospital, the designers said that when asked to attendthe guidance meetings, they had sent a junior staff member, whilst the manufacturers of the air handling units had sent theirmanaging director.Nedin said: “It was a business opportunity. If the air handling people could seal the building they would sell lots of kit. There’s alesson here, that we must not be complacent or we’ll soon have laminar air fl ow units and hepa fi lters everywhere!”Make it mandatoryCooper suggests that the only way to overcome similar knowledge gaps and ensure a continuous and comparable cycle ofresearch is to make it mandatory that every pre-business case sets out its clinical policies and explicitly establishes clinical goalsand objectives. “Rather than talking about world class facilities, let’s defi ne it. As a practising architect, I’ve only once ever beengiven clear measurable objectives.“The clinical objectives should be in every brief, so that we can apply the evidence to achieve them. Let’s also make it mandatorythat there is a universal or comprehensive methodology for post-occupancy evaluation. Every facility over an agreed value shouldbe evaluated on an annual basis in its fi rst fi ve years of operation, and then we will generate the evidence we need.”In a fi nal warning, however, Nedin says: “We have to be careful because even evidence can be ignored. Look at smoking. Wepackage cigarettes that say, ‘give us your money, and we’ll kill you’ and people still buy them. But without good research to infl uencethe guides, we’ll get guides that tell us the wrong thing, so we must never be complacent.”Marc Sansom is editorial director of the International Academy for Design & Health2002 – Present Director, Anshen + AllenPresent CABE Enabler1981 – 2002 Founding Director, Avanti Architects1972 BA (Hons), Diploma in Architecture,University of CambridgeWORLD HEALTH DESIGN | October 2008 19

InquiryDoes one size fi t all?Increasingly recognised as an industry standard in the US, in other areas of the worldthe jury is still out on the 100% single patient room model of care. Our four expertsconsider when, where and for whom single patient rooms are appropriateIn the Canadian system, existing hospital wards contain an assortment of patient roomtypes, including private, shared and the four-person ward room. But As the US movestowards a private room healthcare model for new construction, does ‘one size’ fi tall? Before this design guideline becomes the industry standard, we must consider theissue from both a medical and a designperspective. Are private rooms benefi cialfor all patient populations? Will this designconcept alter important psychologicaland social aspects which accompany theprocess of illness and healing? How will this change the experienceof hospitalisation?Along with private patient rooms, some US facilities nowincorporate private pre- and post-operative rooms, in contrast tothe larger open spaces which separate patients with curtains. In thisnew scenario an individual undergoing a procedure might neversee, or be in, the same room as another patient. This characteristicof prospective inpatient facilities may enhance the sense of fearand disruption that accompanies the hospitalisation experience.In addition, family zonesMore researchis needed toexplore theimpact onvarious patientpopulationsare now provided in eachpatient room, but there maynot always be visitors thereto provide companionship.For some patient groups,most notably palliativecare, geriatrics, and certainpaediatric groups, sharedspaces can provide socialsupports for patients andfamilies which are benefi cial in the healing process, decreasing thesense of alienation often felt in the wake of medical illness. A costeffectivedesign solution may be one where smaller private roomsare provided with more area devoted to a variety of social spaces.This need not be limited to designated lounges found at thecorridor’s end, but benches and alcoves could be provided in thehallway space outside each room to promote interaction, whileallowing an easy retreat when isolation or privacy is desired.Before we accept the private room model for all medicalwards, more research is needed to explore the impact on variouspatient populations. Through the design of fl exible spaces toaccommodate individual preferences, patients and families canmaintain an element of choice for room type. Ultimately ‘one size’may not fi t all.Diana Anderson MD, 2008-2009 Tradewell Fellow,WHR Architects, USABy now, we’ve all heard the argumentsfor and against single-bed wards. Evenas this debate wages on, however,much of the world is moving – and willcontinue to move – toward this patientroom model, not only in the US andWestern Europe but in Eastern Europeand the Middle East as well.The arguments, particularlysurrounding the heightened risk of infection, continue to stackup in favour of it. Not only that, but as healthcare worldwidebecomes an increasingly commercial venture, patients andmarkets are demanding it.On the other hand, single-bed wards are not alwayseconomically feasible. In many countries, the objective is simplyto bring the quality, effi ciency and accessibility of care up toan international standard. Even in places where the healthcaresystem is fully developed, social health services are often betterserved with more economical solutions that provide a mix ofsingle and multi-bed rooms.Cultural issues also play a role. In many developing countries,there are confl icting requirements driven by the substantialseparation between the very wealthy and the poor; theneed for affordable healthcare; and the desire for fl exibility toaccommodate a large family entourage. For any designer workingglobally, an understandingof context and culture iscrucial to determiningthe ideal mix.Ideally, single-bedwards will grow tobecome the industrystandard in the interestof delivering the besthealthcare worldwide. Inthe meantime, it is our responsibility as healthcare designers tobridge the gap between the two types of rooms, reducing thedrawbacks and exploiting the benefi ts.Alan Morgan, director, RTKL Associates, UKSingle-bedwards arenot alwayseconomicallyfeasible20 October 2008 | WORLD HEALTH DESIGN

The debate about single hospital rooms continues topreoccupy the UK’s NHS as it strives towards a modelfor 21st century healthcare. Whilst some initiatives forchange might be compared to rearranging the deckchairson the Titanic, others – improving infection control,enhancing patient dignity and privacy – are all crucial.I believe that single patient rooms have major benefi ts.However, not everyone is convinced. The elderly, inparticular, tell us at public consultation meetings that theyfear soulless corridors and the prospect of dying alone and unnoticed by hospitalstaff. Healthcare architects play a key role in persuading potential patients thattheir fears about single rooms are unfounded.The Ulrich model and the US experience offer hope for a model of care which will provide all the benefi ts of patient-focused care– shorter recovery times, better infection control, more effi cient bed management, effi cient bedside use of some hospital facilities(physiotherapy, pharmacy, pre-operative assessment) – thereby producing an overall improvement in the patient experience. The capitalcost of providing single rooms will, of course, increase as hospitals become larger. As a society, we must decide on the relative meritsof increased costs since the rewards are considerable. In the future, if we do achieve a higher ratio of single rooms to wards, we maywonder what the fuss was about.Some things, with the benefi t of hindsight, are obviously worth doing. Then the image of the ‘Carry on Doctor’ style hospital will bea historic one.Chris Pye, partner, Watkins Gray International, UKThe US experienceoffers hope for apatient-focusedmodel of careThe Australian health system is one of the best in the developed world in terms of healthoutcome indicators, and at a cost of approximately 9% of GDP (similar to the UK) offershigh quality, equitable and accessible healthcare to the Australian people regardless of age,employment, health status or income. It does this at a fraction of the cost of the US systemwhich costs approximately 15% of GDP – a system that also scores a great deal worse onmany of the same health outcome indicators where Australia excels.Although the debate for and against 100% single rooms for inpatient facilities may bewon in the US, it continues without defi nitiveAre 100% singlerooms thebest way tospend valuableAustralian healthdollars?conclusion in Australia. Recent Australian researchsuggests that although there are many benefi tsassociated with 100% single rooms, there are also signifi cant additionalcapital and recurrent costs. The question must then be asked whether100% single rooms is the best way to spend valuable, yet ultimately limited,Australian health dollars or is it possible to accept a lower percentage ofsingle rooms (say 50-60%) and spend the money that is saved on otherimportant health initiatives?With an increasingly ageing population, greater demands for costlytechnology, diversifi cation of care from the acute sector into the homeand community, plus an increasingly limited medical and nursing workforce,it is obvious that we simply cannot have it all!The debate is ongoing and the ‘evidence’ continues to be gathered,reviewed and assessed to support a decision regarding the proportionof single rooms appropriate for the Australian health system. Ultimately,we must spend health dollars wisely to achieve the best possible healthoutcomes for our population. Our facility-related decisions, such as theproportion of single rooms, must accord with this reality.Jane Carthey, director of the Centre for Health Assets Australasia(CHAA), Faculty of the Built Environment, University of New SouthWales, AustraliaWORLD HEALTH DESIGN | October 2008 21

Market Report: ChinaChina risingThere are more than 320,000 hospitalsand clinics in China, most of them eitherundergoing – or needing – refurbishment.What opportunities are being created forenlightened and progressive new healthcarebuildings? Veronica Simpson reportsIt would be impossible to calculate the billions that have beenspent transforming China’s cities in the last fi ve years, as that great,once communist nation embraces consumerism, capitalism andmodernity. But while western eyes widen in amazement as shinysteel and glass skyscrapers and 12-lane highways are constructed ina matter of months by the vast Chinese workforce, there has beengrowing concern that, in the rush to dazzle the world’s TV camerasassembled for this year’s Olympics, little or no attention has beenpaid to infrastructure. The health and wellbeing of the communitycertainly seems secondary to the lust for new, statement offi ceblocks and stadia. International architecture practices are generallysteering clear of involvement in healthcare projects – even ifthey’re active in other sectors in China – because of a perceived diffi culty in achieving quality outcomes, or realistic fees.Brad Barker, managing director for RTKL’s healthcare practice worldwide, says: “Quality healthcare is beginning to emerge as a priority,but not at the pace of commercial development. In addition, most commercial development is driven by entrepreneurial ventures, whilehealthcare is a function of the government and, therefore, lacks the competitive element that drives a commercial project.”He admits the practice has had its fi ngers burnt by a common tendency to bring in international consultancies for design inspiration andthen leave them high and dry. “I must admit our two experiences have not been positive. In both cases we were never paid in full for ourplanning/design services and as a result, we are not spending much time on this market.”Despite having offi ces in the region, Steffi an Bradley, Atkins and NBBJ have, for now, also steered clear of any healthcare projects, as hasLlewelyn Davies Yeang (LDY). But it’s not as though China doesn’t have enough of its own architects to take care of business. As LDY principalKen Yeang points out, whether they operate within the remnants of the vast municipal architecture institutes or as part of the burgeoningprivate practice scene, China has many excellent architects, most of them trained at the best UK and US architecture schools.However, Memphis, Tennessee-based practice TRO Jung|Brannen has made inroads here. Its relationship with the region goes backsome 15 years, when a young Chinese graduate intern, Kai Wang, fi rst suggested sharing the practice’s healthcare knowledge withChina’s medical fraternity at various seminars. Wang is now running its offi ce in Beijing. TRO Jung|Brannen’s fi rst project was the600-bed, 60,000 square metre Shanghai East Hospital, which had to be constructed in three phases, on the same site as the existinghospital, to keep the building operational throughout.Completed in 2000, the 500 bed Tianjin Children’s Hospital is one of a number of innovativehospital designs in China by TRO Jung|BrannenEast meets westKeen to incorporate the best of Western practiceswith those of the East, TRO Jung|Brannen had toaccommodate many cultural differences. PrincipalDavid Rhodes says: “In China the hospital is the centreof all healthcare. People come there for everything– treatments, checkups, visits to all outpatient clinics.So we had to accommodate large volumes of people.We put in big windows, and were able to bring alot of daylight into where the diagnostic clinics andoutpatient clinics were.“In China there is a strong preference for all patientrooms facing south. So how do you come up witha scheme that accommodates that, but doesn’t walkthe nurses to death? We actually created two nursingunits, on each fl oor, side by side. The rooms stretch outalong a semi-circular wing. The north side has all the22 October 2008 | WORLD HEALTH DESIGN

Dongtan City: An eco-exemplarClient: Shanghai Industrial Investment CorporationMasterplanning and sustainability guidelines: ArupSize: 86 square kilometresCompletion date: Linking bridge will be completed by 2009support facilities – staff quarters, lockers – and that keepsthem away from all of the patient facilities.”Since then, most of TRO Jung|Brannen’s projects haveadapted this model, with southeast-facing patient rooms,natural, in-room ventilation and air conditioning onlywhen absolutely necessary. There is strict separation ofclean and soiled materials – even separate lifts.As we know, China has a long and proven medicalhistory of its own, and most patients these days receiveboth traditional Chinese and western medicine. “Allthe hospitals we have been in have acupuncture andtraditional chinese medicine, with its own pharmacy thatinvolves the cooking of herbs, with very strong smells. Weseparate that from the western pharmacy and exhaustthem like a kitchen.Dongtan City: An eco exemplarDongtan is planned as a development of three villages that jointogether to form a city centre. It is designed to run entirely onrenewable energy for its buildings, its infrastructure and its transportneeds and will recover, recycle and reuse 90% of all waste in thecity, with the eventual aim of becoming a zero-waste city.Arup’s masterplan includes a combination of traditionaland innovative building technologies which will reduce energyrequirements by around 66%, saving an estimated 350,000 tonnesof CO 2per year. It is designed so that all housing will be withinseven minutes walk of public transport and with easy access tosocial infrastructure such as hospitals, schools and work.Dongtan will produce suffi cient electricity and heat for itsown use, entirely from renewable sources, including wind farms,biogas (extracted from the treatment of municipal solid wasteand sewage), and photovoltaic cells and micro wind turbines sitedwithin buildings. There will be practically no emissions from vehicles– vehicles will be battery or fuel-cell powered. A combination ofcycle-paths, pedestrian routes and varied modes of public transport,including buses and water taxis, will be provided to circulate citizensaround the city.“In China there is more sensitivity to the (need for) daylight, more emphasis on what the patients see when they look out of the room,rather than opting for the most effi cient design. We have waiting rooms with atriums, and patient recovery rooms must have outsidewindows.” Only radiology, surgery and laboratories are windowless.Room size is still an issue. Says Rhodes: “We’ve been convincing them to follow US minimum guidelines, which is much larger thanthey are used to. It’s been a bit of a compromise. They’ll often add in extra beds. Most of the jobs we’ve done have had four-bed wards.Most of them have been semi-private. In one case we designed for four beds in each room, and they put in six.“It’s evolving. You have this emerging middle class in China that is looking for higher standards. Even though the public system is whatthey are using, they are willing to pay for a bit of privacy.”But it has to be said, these new, improved hospitals are still in the minority, and only the big municipalities have the budgets tocommission them.WORLD HEALTH DESIGN | October 2008 23

Market Report: ChinaShenzhen Bin HaiSusan Francis of the UK’s Commission for Architecture and the BuiltEnvironment (CABE) visited Beijing, Shanghai and the surroundingCost: 7,000 RMB/mcountryside on a recent trip organised, during the Olympics, by the Royal2Client: Shenzhen Healthcare BureauInstitute of British Architecture (RIBA). Her impression was that of a countryArchitect of Record: Shenzhen General Architecturalin the process of “an obliteration of a culture and a bringing in of the new”. OfDesign and Research Institutegreat concern to her, from a health perspective, was the fact that rural areasDesign Architect: TRO Jung|Brannen– which still constitute the vast bulk of China’s landscape – are seemingly leftStructural Engineer: Shenzhen General Architecturalin the dark ages, while the cities advance at warp speed.Design and Research InstituteRhodes agrees: “District and county hospitals are in a real dilemma. TheyLandscape Architect: To be determinedare barely buildings. There are naked light bulbs hanging from the ceilings,and no heat or air. For the country to leap from that to what we are doingis really inconceivable.”Which all adds up to a model of work and lifestyles that are far from green. But China is taking note of green concerns. Arup,heavily involved in the engineering and design of many Chinese cityscapes, has drawn up the blueprint for the futuristic, and asyet unbuilt, eco city of Dongtan, which will be constructed on the southeastern tip of Chongming Island, Shanghai.Head of global healthcare Phil Nedin says: “The trouble with this area is high humidity. That doesn’t help us when we’reseeking low carbon solutions. But we are looking to incorporate openable windows, natural ventilation wherever possible.Healthcare design is very prescriptive, but we are trying to be as open-minded as possible. We are looking at the idea of alabyrinth (cooling and ventilation system) in the basement area, exposed concrete and high ceilings.”However, the scheme has yet to attract suffi cient backing to begin construction, and it’s notable that Arup has not exposeditself to the healthcare sector in China, yet. But things move fast in China.A year ago, Steffi an Bradley Associates CEO Kurt Rockstroh was turning down healthcare work in the region, partly because“the majority of these projects are very parochial in their approach. They are trying to bang out a lot of hospitals to cater forlarge numbers of people. But it is opening up. There are a few well thought-out projects that are designing for the future andbetter models of care, and as people see how much better that is, they will begin to demand it.”Veronica Simpson is an architectural journalist and writer24 October 2008 | WORLD HEALTH DESIGN

Shenzhen HospitalShenzhen Hospital, at 2,000 beds and 3,000m 2 , is the largesthealthcare project TRO Jung|Brannen has ever designed.On a greenfi eld site, it has a 30m height restriction, “so it’sspread out the length of almost two soccer fi elds,” saysprincipal David Rhodes. “We have organised the project intoclusters of services, cardiac and inpatient, outpatient clinic,diagnostics and separate treatment.” The buildings are allconnected at the basement and fi rst-fl oor level, with bridgesat three levels above, connecting the outpatient clinics andinpatient towers to the central diagnostic and treatmentblock. The three buildings on the north side of the site havesecond fl oor bridges for staff access to the hospital. Thereare shared facilities for food, pharmacy, laboratory and othercentral services. The ‘hook’-shaped wing at the southeastcorner of the site is a 300-bed VIP facility with many of itsown diagnostic and treatment facilities and support functionsincluding extensive wellness and rehab spaces.Given the low rise, and dispersed nature of the buildings,there are multiple opportunities for lush planting, and botanic gardens are planned between the hospital and the adjacent coastline.All parking is underground, minimising road traffi c and, unusually, all the patient rooms have open balconies facing the south and thesea. This is something TRO Jung|Brannen wouldn’t be allowed in the US, for health and safety reasons, but will undoubtedly make for adelightful patient experience. The central ‘mall’ between the outpatient and diagnostic/treatment block is covered and partially enclosedto take advantage of the moderate climate. The enclosed part can be air-conditioned but not heated, and the covered area allows forventilation without air conditioning. Green roofs will be provided over the D/T block and used as outdoor gardens for the inpatientunits. The outpatient building utilises interior courtyards to allow for natural light and ventilation.WORLD HEALTH DESIGN | October 2008 25

Market Report: ChinaHangzhou District HospitalIn the lakeside city of Hangzhou , TRO Jung|Brannen has created plans for a new district hospital for the Hangzhou municipalgovernment, with 1,200 beds with 152,000m 2 . Won as part of a design competition, the mayor specifi cally wanted to see thisfacility as a signifi cant piece of architecture. It’s on a clean site with water features.The materials in the rectangular block are primarily stone, similar to that found on many buildings in Hangzhou, frontedby a bow-shaped glass structure. All outpatient clinics and most of the diagnostic and treatment functions are located in therectangular block, separated from the bow-shaped structure by a central atrium/mall. All waiting rooms open onto the mall.Bridges above the fi rst fl oor are used to transport inpatients across to the D/T facilities without going across the fi rst fl oorof the mall.A two-level basement connects the entire structure and provides strict separation of clean from soiled traffi c. A separatebuilding houses the administrative, education,and research activities including staff dining andkitchen. There is a green roof over the D/Tblock, and underground parking to maximisegreen areas and water on site.Hangzhou Bin JiangCost: 4,200 RMB/m 2Client: Hangzhou Healthcare BureauArchitect of record: Hangzhou ArchitecturalDesign and Research InstituteDesign Architect: TRO Jung|Brannen DesignStructural Engineer: Hangzhou ArchitecturalDesign and Research InstituteLandscape Architect: To be determinedWORLD HEALTH DESIGN | October 2008 27

Market Report: Eastern EuropeIt has been 17 years since the collapse of the Soviet Union, but it is only now that the rebuilding of the healthcare sector in thecountries of the former USSR and Eastern Europe is really beginning to get under way. Years of neglect have left buildings in a poorcondition, impacting on patient care. And as they look for ways to modernise, architects and construction specialists from around theworld are looking at how they can get involved.During the Soviet era, health was not a priority and investment was low. At the same time, there were large numbers of smallhospitals. The primary care sector was relatively undeveloped, hospitals were often disease-focused and there were parallel healthsystems for specifi c sectors, such as the army, the police or transport, each with their own set of hospitals and medical care.In the USSR, funding was focused on bed numbers rather than the care provided. This, says Bernd Rechel from the LondonSchool of Health and Tropical Medicine, led to unnecessary hospitalisation and an ineffi cient use of resources. In its 2004 report onhealthcare in the Ukraine 1 , the EuropeanObservatory on Health Systems andEasternPolicies said: “Despite the limited resourcesavailable for the healthcare system, planningcontinued to be oriented towards the goalof ever-increasing capacity, measured bythe number of hospital beds and of healthpromiseThe modernisation of healthcare facilities and reform ofthe healthcare sector is gaining pace in Russia and EasternEurope. Kathleen Armstrong looks at recent developmentsand the challenges and opportunities they providepersonnel. As a result, Ukraine, as manyother former Soviet republics, had one ofthe world’s highest numbers of hospitalbeds and physicians per capita. Inevitably,increased quantity was at the expenseof quality, and in many cases encouragedharmful practices such as lengthyhospitalisations for minor disorders.”Under-investment in facilities meant thatsome hospitals in rural areas didn’t evenhave basic amenities, such as running wateror sewerage 2 .After the fall of the Soviet Union, mostof the countries in the former USSR andin Eastern Europe fell into a period ofeconomic decline and, as a result, healthcaresuffered further. In Russia, the “worseningeconomic situation in the 1980s and 1990sled to a slow deterioration in services, asequipment became antiquated or needed to be replaced, drug stocksdwindled and the fabric of buildings decayed” 2 .A mixed storyCountries in the region are now stepping up investment in the sector.Funding is most secure in Russia and Kazakhstan who are reaping thebenefi ts of the oil boom and, therefore, have more funding availableMedicover Hospital, WarsawCost: approx £13million (at 2006 prices)Client: MedicoverLead Consultant: ArupArchitect: Nightingale Associates and Atelier 7Health Planners: TribalStructural Engineer: ArupServices and Environmental Engineer: ArupQuantity Surveyor and Planning Supervisor: ArupLandscape Architect: Atelier 728 October 2008 | WORLD HEALTH DESIGN

to invest in new facilities. However, for other countries in the region budgets aremore insecure and progress has been slower.Funding to support infrastructure development has come from a range ofsources, including the European Union, the World Bank, the Islamic DevelopmentBank and the World Health Organization. However there are many other areas ofinfrastructure in each of the countries that desperately need attention and are alsolaying claim to the funds, so resources are limited. So, many countries in EasternEurope and the former Soviet Union are now looking to the private sector as away to fi ll the gap.In Romania, the government announced plans in May 2007 for the constructionof 20 country emergency hospitals and eight regional hospitals 3 . Procurementprocedures for the facilities were originally planned to be fi nished a year ago butSwissmed Hospital, GdanskCost: 70.000.000,00PLNClient: Swissmed Centrum ZdrowiaLead consultant: ARCHstyl Maria PodwojewskaGeneral Contractor: POLNORDArchitect: Watkins Gray International LLPConstruction Management: Jacek SwigostLandscape Architect:ESTA Jolanta Bogucka-Delezuchthey have only recently been completed. Once construction begins, the government says they will be completed in 18 months.In Bulgaria, there were only 18 hospitals in the country in 2000. By 2007, there were 71 new hospitals and another 80 are expected tohave opened by the end of 2008 4 . The government has a policy of public-private partnerships and at the beginning of this year approvedthe full privatisation of hospitals.Georgia has also privatised its healthcare sector and all butfour of the 254 state-owned hospitals have now been taken overmainly by healthcare and real estate companies, on the provisothat they will be refurbished and will not be converted to anyother use for a period of seven years. According to a report inPharma & Healthcare Europe 5 , fewer than 30% of the country’s16,455 hospital beds are currently in use and the governmentis aiming to eventually reduce the number of hospitals in thecountry to 100, restructuring healthcare to a system with lessspecialised and more general hospital care.The WGI-designed Swissmed hospital in Warsaw, currently under constructionPrivate inroads into PolandIn Poland the switch to private healthcare is also well under way.Construction of the fi rst private hospital since EU accessionbegan in June 2007 with €30m investment from medical servicescompany Medicover. Colin Hockley, managing director ofNightingale Associates which designed the facility, said the hospitalWORLD HEALTH DESIGN | October 2008 29

Market Report: Eastern Europeis targeted at “the inhabitants of Warsaw andother insured customers”. Nightingale’s healthdevelopment director Kieren Morgan said thebuilding is designed to be noninstitutional, incontrast with existing state provision. Medicoverwanted the hospital to provide a welcomingatmosphere and exude clinical excellence. Thedesign also had to incorporate fl exibility to allowfor eventual expansion.Polish architectural fi rm Atelier 7 took overthe technical design of the project to ensure thatit met local regulations – it was a requirement ofthe Polish government that a local fi rm becomethe ‘legal author’ of the development.Hospital wards in Poland, Morgan said, areoften self-contained entities, each with its ownfacilities. The Medicover hospital, however, will bestructured more around international models,with a separate operating theatre departmentand diagnostics that cater to the whole hospital rather than an individual ward.The Swissmed general hospital in Gdansk is another response to the perceivedneed for private healthcare. Designed by WGI Architects, the 75-bed hospital willcater mainly for international companies who provide private health insurancefor their employees. The design includes natural light and healing gardens,incorporating many of the values of evidence-based design – a movement thathas yet to take a real hold in countries with emerging economies like Polandwhere trying to fi nd ways to fi x basic infrastructure and crumbling architectureon very limited budgets is more of a priority.The Gdansk facility was constructed before Poland’s accession to the EuropeanUnion (EU), opening in January 2004, and WGI is now designing two further hospitals for Swissmed – one, a larger modern hospital inBratslav and the other in Warsaw.WGI partner Chris Pye said the design had to include enough space in patientrooms for visits by relatives and extended family, as well as the development ofmixed-use hotel-type accommodation adjacent to the hospital that could beused by patients’ families and by passing trade.State hospitals, Pye said, are often impoverished and crumbling, badly inneed of repair. At the same time, there is a growing middle class in the countrywho are willing to pay for a higher level of care and access to better facilities.Russian regulationsIt is a similar situation in Russia, where the private sector has also begun totake hold. However, the process of complying with regulations, especially forprojects that move beyond the traditional, can mean projects are delayed,often for extended periods of time. And for non-Russian architectural fi rmsand other companies wanting to design and build facilities that go beyond thenorm, it can be a steep learning curve.Up to now, much private sector development has focused on smallprivate clinics retro-fi tted into existing buildings. But a number of commercialdevelopers are planning more ambitious projects, large hospitals that will offera full range of care.When planning fi rst began for CMI Development’sThe 16, 631sqm MedicoverHospital in Warsaw bringsUK and Polish designstandards together in amodern facilityMoscow Medical CenterProject Cost: $95mConstruction Cost: $75mClient: CMI DevelopmentArchitect: NBBJ (Columbus, Ohio offi ce)Structural Engineer: Korda NemethLandscape Architect: NBBJMoscow Medical Center, the aim was to become thefi rst ‘western-style’ hospital in the country. The standalonefacility was designed by NBBJ Architects in Columbus,Ohio who began working on the project in 2002.Architect Tim Fishking said one of the main challengesWORLD HEALTH DESIGN | October 2008 31

Market Report: Eastern Europewas to learn how the regulatory process worked, how to successfully marry international best practice with Russian regulatory requirements.English translations of the regulatory requirements – the SNIPS and norms – were diffi cult to obtain and trying to get approval from theregulatory authorities for standards that were outside the Russian norm was often diffi cult. To help facilitate the approval process, CMIDevelopments brought representatives from the regulatory agencies to the US, to visit facilities with a similar vision.The standards that were the main sticking points, Fishking said, were related to the physical architecture – such as plumbing, quality ofair, power and water. Eventually, approvals were given and construction on the project began. However, construction came to a halt whenmany of the approvals that were verbally agreed were reversed, and it remains only partially complete. Whether it will be used in the endfor healthcare or put to some other use, he is unsure as NBBJ is no longer involved in the project.Fishking said NBBJ learned a lot from the process, which it will not only apply to future projects in Russia but some of which it is also applyingto projects in the US, including standards whichFishking originally thought were old-fashionedbut learned to appreciate during the process.The process was smoother for Cadolto, whichworked directly with the Russian governmenton the construction of 14 specialist medicalcentres around the country. The company,which specialises in modular buildings, had atight deadline in which to deliver the facilitiesbut chief operating offi ce Dr Björn Werner saidthe ability to provide a quick turnaround wasone of the reasons why modular constructionwas chosen for the projects.Constructed in the Cadolto factory, when theyleave to be transported to the site, they includeall medical, laboratory and building technology,sanitary installation, tiles, fi tments, equipment, aswell as the façade of the building.Initial discussions about the project fi rst beganin 2005 and the fi rst seven fully equipped prefabricatedmodules, each of around 19,000m 2 ,had been delivered by June 2008. The remaining seven are due to beready for use sometime in 2009.The facilities will comprise traumatology centres in Krasnodar,Cheboksary, Smolensk, Barnaul and Vladivostok; cardiosurgery centresin Chabarovsk, Krasnoyarsk, Astrakhan, Penza, Kaliningrad, Perm andChelyabinsk; and neurosurgery centres in Tyumen and Novosibirsk.The modernisation of healthcare facilities and reform of healthcaredelivery throughout Russia and Eastern Europe is gaining momentum.Canada’s Zeidler Partnership is in the initial stages of discussion aboutthe design of another new private hospital in Russia and WGI, NBBJ,Nightingale and other architectural fi rms are exploring opportunitiesin Romania, Hungary and other countries of Eastern Europe.The challenges remain high, but the opportunities are great.Penza Cardiology Centre, Russian FederationThe 19,000m 2 cardiology centre in Penza in Russia’ssouthwestern region includes a three-storey main buildingand four-storey Y-shaped wing. Large expanses of glass andcolours give structure to the building’s varied exterior.Facilities in the 185-bed unit include three operatingtheatres, 40 intensive care beds and two angiographyrooms. It is one of 14 modular facilities constructedfor the Russian government by Cadolto, which havebeen developed to meet the needs of local populations,according to assessments carried out by the government.Kathleen Armstrong is a health writerReferences1. European Observatory on Health Care Systems. Healthcare Systems in Transition:Ukraine. 2004. Accessed at www.euro.who.int/Document/E84927.pdf2. European Observatory on Health Care Systems. Healthcare Systems in Transition:Central Asia. 2002. Accessed at www.euro.who.int/document/Obs/0335209262.pdf3. Guineva S. Hospitals: the next hot thing? Sofi a Echo. 5 Sept 2008. Accessed athttp://www.sofiaecho.com/article/property-focus-hospitals-the-next-hot-thing/id_31557/catid_234. Romanian Hospitals Need to Comply with EU Standards by 1214. Mediafax.ro. 9Sept 2008. Accessed at http://www.mediafax.ro/engleza/romanian-hospitals-need-tocomply-with-eu-standards-by-1214.html?6966;31556315. Completing the Switch to Private Healthcare. Pharma & Healthcare Insight. June2008. Accessed at http://www.pharmaceuticalsinsight.comWORLD HEALTH DESIGN | October 2008 33

Technology Report: Palomar Pomerado HealthConcertof careEve Edelstein visits Palomar Pomerado Health tosee how the US healthcare provider is integratingleading-edge medical and information technologyinto its design for the hospital of the futureAs hospitals grow ever larger and care servesan increasingly acute patient population, anew range of technologies is being soughtto enhance care and transmit medical informationwithin and beyond hospital walls.This movement explores systems that functionsimultaneously at internal, individual and global levels.Information technology and microelectronic systemsare being developed to transmit patients’ vitalsigns and physiological states so that triage canoccur before the patient reaches the hospital, at thesame time as enabling access to medical expertisearound the globe.As scientists develop microtechnologies thatmonitor the health status of people in the mostextreme environments, whether in space fl ight oron the battleground, we can expect to have thesetechnologies trickle down to our homes and publicplaces. In hospitals, it will enable timely and continuedlogging of patient status that can be accessed bycaregivers on site and remotely.Hospital of the futurePalomar Pomerado Health (PPH) in Southern California is looking to incorporate such technologies, building an innovative healthcare systemfor the seven communities and outlying areas it serves in northern San Diego County, the largest public health district in California.With expenditures of approximately $1.2 billion, PPH will build a hospital of the future, a 450-bed tertiary medical centre that will replaceits current hospital in downtown Escondido; double the size of its second hospital in Poway to more than 200-beds; seismically retrofi t andconvert its existing 326-bed hospital in downtown Escondido into a specialised campus featuring mixed-use retail, housing, physical rehab,urgent care, behavioural health, oncology services and administrative offi ces; and build four major satellite health centres throughout thehealth district. These plans are driven by its projection of at least a 30% increase in population with a doubling in the number of those overthe age of 65, and an unfunded state mandate that requires acute care facilities to meet earthquake standards.The stated goal of Michael Covert, president and CEO, is to “build the Fable Hospital” described by Berry et al 1 , to increase operational34 October 2008 | WORLD HEALTH DESIGN

effi ciency, reduce errors and injury, build in fl exibility, and improve thecontribution of architecture to a healing environment. “Throughout thisprocess, we needed to remind ourselves repeatedly that we are notbuilding with today’s technology in mind or even for the innovations of10 years from now,” Covert said. 2PPH’s process includes evaluations of cutting-edge technologies,including operating suite robotics, remote medical presence via rovingconsultation robots, personal RFID tracking devices, high-tech patientbeds and automated systems that monitor patient health status andmovement, LCD image and information panels in each patient room,and patient rooms that can be quickly reconfi gured to support rapidlychanging patient needs and advances in medical procedures.Shed burdensomeheritage...comefrom nowhere;change the game;innovate; and actThe innovation challengeA confl ict arises when selecting information and high-technology solutions for healthcare environments. Technological innovationsand developments occur at a pace that is more rapid than the architectural process. By the time a healthcare facility has beenplanned, approved, and built, several new generations of technologies may have been tried and tested.To meet this challenge, Orlando Portale, PPH’s chief technology and innovation offi cer, uses an approach borrowed from systemsdesign philosophy: “Shed burdensome heritage; put everything on the table; come from nowhere; fail early and small; embraceconstructive dissatisfaction; change the game; innovate; and act.”This approach considers not only products readily available today, but also looks to future systems at the ‘bleeding edge’ oftechnological innovation. This process builds a view of the future that can be used to formulate more informed and educatedguesses about changes in architectural infrastructure. Finally, the PPH strategy may include a delay of technology purchases untilthe last practical moment, so that innovations can beincorporated when the hospital opens in three years.The nature and risk of healthcare provision posesadditional challenges that arise when choosingtechnologies. The margin of error for medical technologiesmust be extremely low. An error rate of one may resultin one death or multiple injuries. However, old systemsimpose their own risks. Portale suggests that they canbe ineffi cient; at worst, deadly, including errors in surgicalorders, medication dosage or follow-up care.Testing technologiesUpdated information technologies and operationalsystems are thus being sought to reduce the vast amountsof information permanently lost because of outdated orpoorly conceived information transfer and managementsystems. Critical to the successful implementation ofany new system in a complex, high risk environmentsuch as healthcare, is the testing of technologies byinterdisciplinary planning and care teams in clinical unitsduring real-time, real-world healthcare operations or inmock-up conditions.PPH chief nursing executive, Lorie Shoemaker, recruitedstaff from across the hospital to participate in a userassessment of design concepts and to test some of thetechnologies on its units. For example, remote telepresenceis being explored in Pomerado’s intensive careunits, using internet and video conferencing via the InTouchHealth Kodak camera to review patient results from scansand images.A novel mobile robot is being tested as a means toprovide remote medical presence in several clinical areas.The terrace at the Palomar Pomerado Health’s ‘Hospital of the Future’WORLD HEALTH DESIGN | October 2008 35

International Hospital FederationCALL FOR EXHIBITORSDESIGN & HEALTH6TH WORLD CONGRESS & EXHIBITIONAn international forum for continuous dialogue between researchers and practitioners24-28 June 2009,Ritz-Carlton Millenia, SingaporeWho attends?• Architects • Health scientists • Senior health managers • Clinical and nursing professionals• Engineers and contractors • Estates and facility directors • Environmental and clinical pyschologists• Government policy makers • Health planning and design consultants • Art directors, artists and art therapists• Landscape designers • Industrial designers • Interior designers • University researchersWhy exhibit?• Build global brand awareness • Develop research programmes • Enhance market intelligence• Generate international business • Network with an interdisciplinary audience • Contribute to knowledge developmentwww.designandhealth.comInternational Academy for Design & Healthacademy@designandhealth.com+44 (0) 1277 634 176Join Design and Health as a corporate member and enjoy up to a 50% discount on your exhibition standSingapore Medical AssociationSingapore Institute of Architects

Technology Report: Palomar Pomerado HealthDubbed ‘Iris’ because it functions as another pair of eyes, the robot rolls through units and patient rooms, controlled remotely by doctorsusing a joystick and laptop. Via a high-speed internet connection, the robot allows remote consultation with colleagues, patients and visitors,as if the doctor were in the room. The robot, developed by InTouch Health, can navigate down hospital corridors, rotate 360 degrees, zooma camera in on a patient’s eyes, or view x-rays or vital sign monitors.High-technology patient bed monitoring units add to the armament of high-tech devices that support continued monitoring of patientstatus and needs, supplementing visual surveillance by nurses. The LifeBed, produced by Hoana, uses a non-invasive ‘smart’ fabric on topof the bed to record vital signs, pulse, breath rhythm, heart rate and respiration without any connection whatsoever. Hoana’s technologytransforms any hospital bed into a LifeBed. If the patient begins to deteriorate, the LifeBed immediately notifi es the hospital nursing staff.Changes in a patient’s condition identifi ed early, may result in earlyinterventions and positively impacts patient outcome. LifeBed,reports some hospitals, have reduced falls by as much as 90%. 3Cisco Systems has developed RFID bracelets that will guidepatients. Encoded on the band is the patient’s name, date ofbirth, gender and a medical record number, linked to the hospitalnetwork that connects the patient record to labs, billing and tothe pharmacy.Doctors and nurses will be equipped with a tablet-style PC withan RFID reader and a Wi-Fi connection to access the network.The system consists of an integrated RFID application, developedby Siemens Business Services (SBS), which connects the hospital’selectronic medical records, lab systems and billing system. Theexisting computerised physician order entry system allows for a seamless RFID implementation. Tablet PCs are embeddedwith SBS RFID software and used as hand-held readers for RFID wristbands provided by Precision Dynamics Corporation(PDC). PDC’s Smart Band RFID wristbands include a 13.56 MHz RFID inlay from Texas Instruments 4 .RFID systems linked to sinks are being considered as a method of alerting clinicians with the sound of an alarm as theyenter a patient room to encourage them to wash their hands before contacting the patient.Patient room designPatient rooms for the new hospital have been designed as fl exible acuity rooms, based on concepts described by Hendrichet al 5 . A mock-up has been built for user feedback, demonstrating improvements in surface fi nishes, headwall design, familyzones and accessible shower rooms that add to amenity and patient comfort. The square footage of each room has beenexpanded from 140 square feet at the present facility to approximately 350 square feet.Hendrich et al 5 reported a decrease in errors and injuries related to the reduction in patient transfers in acuity-adaptablerooms, and improved fl exibility of use. Their comparison of pre- and post-patient room conditions revealed that as patienttransportation was reduced by more than 90%, medication errors decreased by 70% and the fall index for patients in the highriskcardiac test population fell from six to two falls per 1,000 patient days. Palomar will track such outcomes, as well as metricsthat include costs, quality of care and patient satisfaction in fl exible acuity rooms compared to the previous designs. Palomaris modeling scenarios with governmentregulators and collaborating with anadvisory group to ensure that nurses andancillary staff are appropriately trained forthis new nursing model.The patient room has also been adaptedfor information systems. As physiciansmake rounds, large LCD panels in eachpatient room will provide the means toconcurrently display patient demographics,vital signs and medical information.Patients will be able to remotely controlroom temperature, order a meal, surf theinternet, conduct videoconferences withtheir doctor, and play music. Patients mayalso display images, family photographsand possibly works of art from theMuseum of Modern Art.Voice-based fall alarms will not onlyPalomar Pomerado Health’s new hospital on site and under constructionThe robot rolls throughunits and patientrooms, controlledremotely by doctorsusing a joystickWORLD HEALTH DESIGN | October 2008 37

Technology Report: Palomar Pomerado Healthalert nursing staff to fall risk but also speak to patientsusing voices recorded by loved ones, gently instructingthem to return to bed. Initial pilot studies in functioningclinics were successful, and 51 units have been rolled outin operational units. Ceiling-mounted patient lifts will beinstalled in all patient rooms, in addition to handrails leadingfrom the head of the patient’s bed to the toilet in orderto minimise preventable falls. Patient rooms are organisedinto nursing pods with both central clinician stations anddistributed nursing stations, providing continuity of careby maintaining good lines of sight between nurses andpatients. The hospital plans to track patient, staff andeconomic outcomes relative to such design changes.Community engagementIn 2004, seeking broad input from the community, a virtualPalomar hospital was launched on the internet, offeringvisitors a reproduction of the proposed development.Developed by Linden Labs, Second Life visitors can tourthe site in the form of avatars, moving through simulatedmodels of the facility and learning about proposedtechnological innovations. Second Life enables a uniqueopportunity for involvement with an audience. Unlikemost traditional web sites, this virtual world platformencourages high engagement.Other organisations have taken advantage of this3D interaction space to conduct research and solicitfeedback 6 . Palomar will use this vehicle to model howarchitectural design and technological interventions mayinfl uence workfl ow 7 .What becomes clear from both virtual and mock-upvisits is that technology and architecture must work inconcert. As the fulcrum of activity in emergency situations,healthcare spaces must remain functioning despite loss ofenergy or communication bandwaves.Although backup electrical generators are required, care provision must continue despite their failure. Therefore,architecture must provide adequate sightlines to patients and other staff, and create spaces for communication inverbal and written form as well as remotely.Accordingly, hospital design must facilitate multiple electronic transfer systems and allow for innovations tobe incorporated with minimal physical change. At the same time, hospital design must support the transfer ofinformation from person to person, encouraging information carried in the expression of urgency seen in theeyes above a surgical mask, and the transfer of knowledge and caring provided by face-to-face encounters.Dr Eve Edelstein MArch, PhD, Assoc AIA, F-AAA is senior vice-president of research and design at HMCArchitects and a visiting scholar working with the California Institute for Telecommunications and InformationTechnology (Calit 2 ) at the University of California, San Diego.Above Top: Patient roomshave been designed asfl exible acuity-adaptableenvironmentsAbove: Large LCD panelsin each patient roomwill provide patients andphysicians with the meansto concurrently displaypatient demographics,vital signs and medicalinformationReferences1. Berry LD, Parker D, Colle R, Hamilton DK, O’Neill D, Sadler B. The business case for better buildings. Frontiers in Health Services Management2004; 21(1):3-24.2. Covert M. The time is now. Health Environments Research & Design Journal. October 2007.3. Accessed at: www.hoana.com/products.aspx?id+4064. Schwartz E. Siemens to pilot RFID bracelets for health care. InfoWorld. 23 July 2004. Accessed at: www.infoworld.com/article/04/07/23/HNrfi dimplants_1.html5. Hendrich AL, Sorrells AK. Effects of Acuity-Adaptable Rooms on Flow of Patients and Delivery of Care. American Journal ofCritical Care 2004;13: 35-45.6. What is Second Life? Accessed at: http://secondlife.com/whatis7. Palomar West: Hospital of the Future. Accessed at: www.virtualpalomarwest.orgWORLD HEALTH DESIGN | October 2008 39

The Philips’ Wake-up LightTechnologyA sense of homeSeating from the new Knightsbridge Mental Health Furniture collection is helping to establish a therapeuticenvironment within a pioneering new mental health complex in Leicestershire, UK.The Herschel Prins Centre is a specialist low-secure facility run by Leicestershire Partnership NHS Trust.Furnished in line with an ethos of accessibility and homeliness, the centre ensures an ambience which encouragesboth respect and courtesy from patients and regular visits by their friends and families.Working closely with the project team, the Knightsbridge team helped to develop colour and design storieswhich engender a positive and therapeutic response. Woodwork is a light shade of natural beech and fabricscoordinate with the artwork which adorns the walls of every room. Yet all the furniture retains its suitability foruse in challenging mental health environments: within patient areas, for example, non-retractable screws have beenspecifi ed to avoid the risk of patients self-harming.Visitors to the centre are greeted by smart Melroseclub chairs and twin-seat settees in luxurious red hideupholstery, an elegance matched in the dining rooms bychairs from the Knightsbridge Elliot and Katrine collectionsin shades of cream and navy faux leather. In the family areasand faith room, a more informal atmosphere is enhancedby the curved profi le and soft covers of Bugatti easychairs and settees, whilst patients and visitors can enjoythe comfortable low-line Byron armchairs in the lounges,where practical loose covers feature a diversity of designs.Owen chairs are co-ordinated with individual themesin clinical and administration sectors, while offi ces areequipped with Harris visitor seating, complemented byNimbus armchairs in meeting rooms and in the staff room.Seating from the Knightsbridge Mental Health Furniture collectionwww.knightsbridge-furniture.co.ukWake up, it’s a beautiful morningThe Philips Wake-up Light 2008 is designed to evoke a feeling of sunrise with a steadily increasing light intensityemanating from the light itself.Smaller than previous dawn simulators, and with a more user-friendly interface and new materials, the iconiclampshade offers a contemporary aesthetic and more modern design that integrates seamlessly with its environment.Combining a reading lamp with an alarm clock, the new Wake-up Light offers a more pleasant way to wake up, bygradually illuminating as it turns on to simulate a sunrise and follow the natural rhythm of the body.This is further enhanced by the diversity ofalarm sounds to choose from to accompanythe waking experience – from sounds derivedfrom nature to a gentle, ambient wakingalarm. Once fully illuminated, the lamp recallsa sunset on the horizon as it shines over thedivider that sits between the luminescenceand the dark part of the device.www.philips.com/simplicityWORLD HEALTH DESIGN | October 2008 41

TechnologyClassic stylingClassic styling and essential practicality are claimed to be the keyfeatures of a new concept in fl ame-retardant fabrics, created by PanazHealthcare.Designed for care homes and supported living environments,‘Richmond’ comprises a harmonious balance of formal and freehandfl orals complemented by subtly coordinating trails, toning stripes and fi nechecks. ‘Richmond’ also features a series of spirited colour stories. Fuchsiasits with soft Sage, Aqua with rich Chocolate, Mulberry with Olive andCitrus with Henna in an array of distinctive palettes.For ‘Richmond’ drapes, bedcovers and accessories, a supple lineneffectbasecloth has also been created by the Panaz developmentteam, combining the appeal of a natural handle with durability and highperformance, fi re-retardant characteristics.www.panaz.comThe ‘Richmond’ collection of fabrics by Panaz HealthcareNatural rhythmsInspired by the healing benefi ts of nature, coupled with simple symmetry and modern abstracts, Secret Garden, the latest creationfrom Mosaic by Skopos, is a relaxing and rejuvenating collection ideally suited to enhance a variety of healthcare interiors. SecretGarden has been created from a desire to work with nature’s own rhythm and the known benefi ts nature can have on anindividual’s recovery rate. Such holistic benefi ts may include relaxation, stress reduction, decreased mental fatigue, restored mentalclarity and an increased sense of wellbeing.As a versatile and contemporary collection, consisting of seven sereneand tranquil designs across an invigorating and uplifting colour pallet,Secret Garden is designed to work either as complementary pairs or asindividual pieces to help create a sense of wellbeing and calm. Notabledesign points include expressive organic forms, fl uid waves and chambersof colour, all of which can be seen to refl ect elements included withinmodern complementary medicine.All Secret Garden designs are printed on 100% polyester and areinherently fl ame-retardant, in addition to being fully washable to 71˚Cfor thermal disinfection. Secret Garden is suitable for a variety ofapplications including: cubicle curtains, window curtains, counterpanes,and bedspreads.www.skoposdesignltd.comSecret Garden, from Mosaic by Skopos DesignWORLD HEALTH DESIGN | October 2008 43

Design & Health Scientifi c ReviewAwakeningsDr John Zeisel is chair of theinternational advisory boardof the International Academyfor Design & Health andpresident of HearthstoneAlzheimer CareProf Romano Del Nordis chair of the scientifi ccommittee of the InternationalAcademy for Design & Healthand deputy rector of theUniversity of FlorenceIn our daily lives we are often so busy and preoccupiedthat we don’t see obvious every day things in front of oureyes. We pass a particular store and don’t notice the shopwindow has been changed, and we sit in our favourite chairwithout noticing that it has been cleaned for the fi rst timein years. These things pass unnoticed – until someone pointsthem out!That’s what evidenced-basedresearch in the built environmentcan do for us, as is the case withthis issue’s articles. Shopping in acrowded street market, womenhaving babies, and looking out awindow at an ocean view are some of the every day events in which thebuilt environment can impact on our health and wellbeing.Akers and Akers’ careful multi-method study of the health implicationsof selling vegetables and other household goods on crowded sidewalksin Baguio City, Philippines makes us take a second glance at all those whowork outdoors in crowded cities. It is now de rigueur in New York City tohave a gyro sandwich and fruit shake on the corner for lunch. In Bangkok,food and knock-off clothing vendors line every downtown sidewalk.This study also demonstrates how important it is to analyse environmentscarefully when drawing conclusions – the width of the sidewalk and theslope of the street in this example – and to employ the most appropriatemethod for each dimension.Forbes, Homer, Foureur and Leap carry out a similarly careful study ofplaces for birthing. If birthing at home is so much more comfortable andnatural, they posit, we ought to design hospital environments for birthing thathave the same supportive characteristics. Their design recommendationsinclude such subtle elements as the fl ow rate of bath water so that thewater can be heated up quickly for comfort, and location of the bath againsta wall so that mothers feel less “on display”.Jones and Manighetti, in part of their research, examine the every dayaction of looking out of an offi ce window – something we do many times aday. But are we aware of what we are looking at, how one view differs fromanother, and how that view affects our wellbeing? I seldom am!Their fi nal hypothesis focuses on what it is that makes views of natureso engaging and health promoting. What they conclude is that it may wellbe the colours – is it “nature” that makes us feel better or the colours blueand green?All in all, evidence-based design research does more than just giveus design guidelines; it helps us wake up to our surroundings. For thisI am thankful.47-53Birthing unit design:Researching new principlesIan Forbes MSc, (HealthServices Planning and Administration), Grad Dip BusAdmin, BArch, FRAIA; Caroline Homer, RM RN MN, PhD;Maralyn Foureur, RM, RN, BA, Grad Dip Clin Epidem &Biostats, PhD; Nicky Leap, DMid MSc RM55-59Urban design:The health impact of street vendorenvironmentsMary Anne Alabanza Akers, PhD; Timothy A Akers, PhD63-67Environmental psychology:The impact of colour and light on wellbeingLinda Jones PhD; Barbara Manighetti PhDWORLD HEALTH DESIGN | October 2008 45

Design & Health Scientific ReviewBirthing Unit DesignBirthing Unit Design:Researching New PrinciplesThe Birthing Unit Design Guideline developed at the Sydney’s University of Technology createsa design tool that will help to optimise the birthing experience for both mothers and midwivesIan Forbes MSc (Health Services Planning andAdministration), Grad Dip Bus Admin, B.Arch,FRAIA; Caroline Homer RM RN MN, PhD;Maralyn Foureur RM, RN, BA, Grad Dip ClinEpidem & Biostats, PhD; Nicky Leap DMidMSc RMAs part of an effort to moderniseexisting birthing facilities, manymaternity units throughout Australiaare currently being rebuilt or refurbished.However, in the state of New South Wales(NSW), a critical appraisal of the recentlyupdated Department of Health Guidelinesfor Maternity Services revealed that theyhad failed to take into account a numberof new developments in the area of ‘caring/healing’ architecture 1,2 .These new insights, and the set of holisticdesign principles that stem from them,need to be considered in order to be ableto optimise healing environments in caresettings, especially in maternity.MethodologyTo look at the impact of birthing unit design,our research team conducted an extensiveexamination of the existing literature, andgathered further insights from surveys ofbirthing women, and in-depth interviews withmidwives in clinical practice and architects inhealth facility practice. Using this information,the investigating team then prepared a set ofprinciples for the creation of optimal birthspaces that are less stressful for womenand more conducive to normal birth. Theseprinciples were enumerated and describedin detail in a Birthing Unit Design Guideline.From this guideline an audit tool, called theBirthing Unit Design Spatial Evaluation Tool(BuDSET), was developed.The next step in the methodology isto conduct a validation process, using theBuDSET instrument, at six selected sites foreach of six birth units within the South EastCalming colours, in this birthing pool room designed by Keppie Design, help to set the moodSydney and Illawarra Area Health Service(SESIAHS) of New South Wales.SESIAHS provides birthing services ina range of primary to tertiary maternityunits in rural and urban settings. These units,therefore, provided the team with a rangeof sites, including newer, older, smaller andlarger units, to enable comparison of contextand setting and also to determine a baselineof compliance with the BuD principles.Birthing contextOver the past 50 years, the design ofbirthing units in developed countries hasfocused on providing places for womento give birth in hospital environments,fully equipped with technology in order toensure that births are safe. However, bothdoctors and midwives have raised concernsthat medicalised hospital environments mayhave, in fact, contributed to the increasingrate of interventions – and in particular,caesarean sections – and the additional risksthat these interventions bring 2,3 .The campaign to promote ‘normal birth’conducted in 2005 by the UK’s Royal Collegeof Midwives refl ects how the tide is turningagainst the continued acceptance of technicalintervention 4 . Concerns were raised about theconsequences on the health of the mother– the potential for infections, deep venousclots, longer recovery, reduced physical andemotional health – as well as the impacton children born to mothers who hadhad previous caesarean deliveries, includingstillbirths, congenital malformation, centralnervous system injury and other risk factors 3,5 .But even if interventions are being usedto help ensure good outcomes, hospitalsneed to realise that most women do notneed to give birth in physical spaces that arethe equivalent of an intensive care unit.Learning from home birthsIn 2004 there were only 589 homebirthsreported in Australia, representing 0.2% ofthe 257,205 births that took place that year.There were 5,079 births in midwife-managedbirth centres 6 . Despite the small numbers– which may not take some unreportedbirths into account – it has been throughthe home birthing movement that changeCredit: Alan McAteer PhotographWORLD HEALTH DESIGN | October 2008 47

Design & Health Scientific Reviewhas come. Particularly in the UK, Europe andAustralia, an understanding of what womenchoose to do when unencumbered by amedicalised environment has become moreevident 7 .Comparing the behaviour of labouringwomen in hospital with those who give birthat home reveals that homebirth midwiveshave developed a profound understanding ofthe important elements in non-medicalisedbirthing 8,9 . At the turn of the 20th century,during the move away from birthing athome, three critical elements were lost 9 :• the opportunity to undergo labour in afamiliar environment• the close and trusting personalrelationship between the woman andmidwife and the continuous support thatwas provided by this person• the belief in childbirth as a naturalphysiological event.The ‘environment’ is more than physicalspace or location – it also takes up anemotional space in the hearts and mindsof women who are undergoing labour andgiving birth. This environment has a powerfulinfl uence on both the woman and themidwife. Women who are asking for homelikeenvironments and continuity of carewith a designated midwife, as well as morechoice and involvement in decision-making,are unconsciously looking for the elementsthat have been lost from the home birthingenvironment 9,10 .Studies of women giving birth at homeshow that women respond in dynamic anddisinhibited ways in response to the feelingof the baby pressing on their cervix ormoving through the pelvis. Women werequiet and noisy, clothed or naked, restless orstill, paced the room, rocked back and forth,sat in chairs, lay on the bed, squatted in thetoilet, stood under the shower, lay in the bath,leaned over the mantelpiece, window sill orpartner and chose many different locationswithin their homes in which to give birth 10 .This was not the experience foundin hospital births. In hospital, midwivesand birthing women found themselvesconstrained not only by the lack of privacyand the lack of accessible bathroom and ensuitefacilities, but also by the only piece offurniture in the room: the high, narrow, metalbed with plastic under-sheet and ever-readystirrups. The bed, taking up the majorityof space and seeming to suggest the birthA calm environment at Aryshire Maternity Unit at Crosshouse Hospital, designed by Keppie Designshould only be on the bed, has become amajor theme in the changes needed tocorrect the architecture of birthing spaces.Is birthing design important?Italian architect Bianca Lepori 10 , aninternational specialist in birthing unitdesign, has raised concerns through herpublications and conference appearancesabout poor total environments for birthingin hospitals. Especially having an impact is herrecognition that poor physical environmentsare a major contributor to the creation of apathological rather than a physiological placefor birthing.Lepori constrasts the positive spirit of thehome birth to hospital environments, which,she believes, cause women to unconsciouslyaccept the technologically expedient pathwaylaid down by the hospital birthing process.In doing this, women have disconnectedthemselves from the natural pathway ofbeing present and actively participating inthe birth.Lepori says that, although technology isessential for safe birth, we have forgotten the‘soul’ of the places we build – and we needto bring the battle between the technicaland the emotional into balance. She usesthe idea of the integration between the leftand right hemispheres of the brain comingtogether in ‘Mindbodyspirit Architecture’,creating an optimally correct place forbirthing to occur.Only recently has the general publicstarted to become aware that the spaceswe build, and the environments enclosed bythese spaces, have a signifi cant impact onour health. Populist books by authors likeChristopher Day (Places of the Soul, 2004 11 )and Alain de Botton (The Architecture ofHappiness, 2006 12 ) have extended this ideato wider audiences.But the building itself is not the onlyelement in the whole human environment.By concentrating on the building itself andnot on the kind of place it creates, we havefailed to grasp the psychosocial impact ofour buildings.De Botton 12 argues: “The signifi cance ofarchitecture is premised on the notion thatwe are, for better or worse, different peoplein different places – and on the convictionthat it is architecture’s task to render vivid tous who we might ideally be.”In other words, the places in whichwe undertake specifi c tasks will affectus in profound ways and we need tounderstand who we are and in what waysthe environment created by our buildingsis supportive of what we wish to do. Thecorollary to this is that in understandingCredit: AIan McAteer Photograph48 October 2008 | WORLD HEALTH DESIGN

Birthing Unit Designlevels when needed, and quietness wereimportant to help birthing.Unhelpful elements were: the hospitalatmosphere, small spaces that did notenable movement and walking around, anuncomfortable bed that was not adjustable,open doors, being heard, toilets outside theroom, and rooms that were either too hotor cold with no temperature control.Clearly the consistency across the NCTsurvey, and its correlation with other research,provides a high level of confi dence that theresults can be applied more generally.The ability to lie back, kneel or move into other positions in the birthing pool all assist during labour and birthpeople’s behaviour when they occupyspaces, we begin to understand how todesign them better.Christopher Day 11 notes: “All activitiesdemand different states of being. If we are inthe wrong state for the job, we feel stressed.Our environment can provide the soulmood appropriate to the situation.”Stress reduction is a critical element insupportive or salutogenic (health-giving)space design. And the relationship betweenstress and the physical environment hasbeen well established in studies over thepast 10 to 15 years 13 .Getting women’s viewsA signifi cant piece of research conductedby the National Childbirth Trust (NCT) inthe UK in March 2003 14 provides convincingevidence that not only do women believe theplace in which they give birth is importantfor a successful birth, but they are also clearabout what they need in that space.The NCT surveyed 2,000 women whohad given birth between the years 2000 and2003. The results showed that:• Ninety percent of women felt that thephysical surroundings can affect how easy ordiffi cult it is to give birth• Many women did not have access tofacilities felt to be essential during labour• Most women felt a clean room withensuite, comfortable furniture for themselvesand their companion and the ability to movearound were highly important• Women wanted control of heat, lightand, especially, who came into the room• Women did not want to change roomsto give birth or to use a birth pool• Women giving birth in a hospital wereless likely to have helpful facilities availablethan those who gave birth at home or inmidwife-led birthing centres• Women with good facilities were morelikely to have a natural birth, while womenwho had an emergency caesarean were lesslikely to have had access to good facilities.Privacy was an essential element that camethrough in many ways, including the abilitynot to be overheard, to control those whoentered into the room and to not be able tohear other women labouring or birthing.Most women felt the hospital bed wasnot important as an adjustable device fordifferent positions in labour or in birth –many suggested it be moved out of the way.The items that were considered importantincluded: a birthing pool (although thosewith no experience of this were ambivalent),beanbags, fl oor mats, pillows and comfortablefurniture. The ability to have control of lights,so they could be adjusted to low brightnessHumans and their environmentIn order to create the kinds of spaceswomen need for birthing in hospitals, wemust understand what women do whenallowed to birth naturally and to judgethe quality of that space in achieving itssalutogenic objectives.Research into the quality of architecturalspace and usage has proven diffi cult whenexamining ‘scientifi c’ evidence 15 . Essentially,this is because studies carried out in normallyoccupied spaces are hard to control forconfounding variables. As Day 11 notes: “Whatis often dismissed as human subjectivity isthe unconscious ability to synthesise manyfactors: however because it’s unconscious,many personal preferences get muddled in.”When we come to designing better livingand working environments it is with theunconscious response to space that we areconcerned. As Day 11 says: “Even if nobodylooks at them, everybody responds tobackground visual impressions. We see thisvisual ‘mood’, can talk about it afterwards,remember it for years – but when asked todraw any of it, have hardly any idea how itactually looked!”Particularly in health facility planning, weare anxious to ensure that the unconsciouseffects of built space provide positivehuman physiological responses – principally,stress reduction. Good spaces generatepositive feelings or mood through theparasympathetic nervous system. Byunderstanding what causes the negativeeffects of stress and anxiety, we are able toreduce the impact on people who are usingour spaces.A format for design guidelinesChristopher Alexander 16 , through his seminalwork on design quality, showed that if weWORLD HEALTH DESIGN | October 2008 49

27 June 2009The Ritz Carlton Millenia SingaporeRewarding global excellencein research and practicewww.designandhealth.com

Birthing Unit Designexamine the whole space, and not just theelements of it, we can achieve a qualitativeresponse that is considered pleasing,stimulating and ‘good’.Birthing Unit Design GuidelinesIn order to present the fi ndings of thisresearch we have chosen to use the PatternLanguage format developed by Alexander.He provided a formula that identifi ed a designproblem (an observable problem requiringa solution), the underlying assumption aboutthis problem (a testable hypothesis) and thesolution (the suggested way of solving theproblem). The formula produces a series of‘patterns’ that can be linked into a designsolution – these are recognised as universalobjectives for the design.The project team have developed a seriesof patterns as a guide to determining thebenchmark for an ideal birthing unit. Thesepatterns form the basis of the BuDSET audittool. In the following section, we have usedAlexander’s format to illustrate and describethe tendencies people have for use of spacesand it is that which drives the quality of thespaces needed in the birthing unit design.The essential starting point for thisBirthing Unit Design Guideline is givingbirth at home. Evidence shows that, forwomen who are healthy and anticipatehaving a normal birth, giving birth at homeis ideal 17 . However, we acknowledge that inmany developed countries, the proportionof women who give birth at home is small.Therefore, the birthing unit outlined inthis document provides principles for thedesign of a health facility birth unit based onhomebirth principles, listed in a sequencethat refl ects the progressive fl ow that awoman takes through the birth unit.Access to the communityLabour and birth should happen as close tohome as possible. Proximity to friends andsupport are essential for a healthy healingbirthing experience and being a long wayfrom home makes this diffi cult. Proximityto home can also be a spiritual thing. Thefamiliarity of the birth space can refl ectsuffi cient elements of home to reducealienation and anxiety.Outside access to the birthing unitThe entrance to the maternity unit must beeasily identifi ed. There should be a dedicatedArtwork helps to set the tone, providing a welcoming atmosphere for birthing mothersentry area in a general hospital facility toreduce anxiety and give confi dence for asafe arrival. Entry through the emergencydepartment is inappropriate.Welcoming arrivalConsideration must be given to how we fi ndand then approach the birthing unit onceinside the health building. Long corridors canbe frightening and cause anxiety for fi rst-timearrivals, especially those who are not surehow far it might be or if there is help nearby.This fear is exacerbated at night when thelights are low and no one is around.Easy wayfi ndingDouble doors and airlocks that are notautomatic can be diffi cult to manoeuvreand put roadblocks in the way of hurryingor anxious people. Airlock spaces, whilenecessary for security, can make labouringwomen claustrophobic and increase anxiety.The preference is for an easy route from theoutside door to a birthing unit entrance thathas glass doors where staff and support canbe readily seen.Birthing unit as homeA birthing unit should be like a home. Itshould be possible to become familiarwith the unit very quickly. Small is beautiful,therefore larger birthing units should bedeveloped in groups or clusters that havean individual feel. Access to an outside areais important, both for enabling a view tothe outdoors as well as providing potentialaccess to nature.The arrival hallThe public arrival area should be a transitionspace. We need to be able to transferemotionally from being an ‘outside person’to an ‘inside person’. A space that enablesthis transition to take place is emotionallyimportant. Staff should be accessible forsupport and direction, and the space shouldbe as nonhospital-like as possible.The family roomFrom the transition space, one should entera welcoming shared space. This is where thefamily or support people, when not in thebirth room can wait comfortably, occupiedor asleep on a lounge. Women can shareexperiences and give each other support.The mother’s roomThe mother’s personal space for birthingshould be immediately accessible from thepublic area. It should not be possible to getlost down corridors on the way. Corridorsshould be familiar and welcoming, hotellikewhere room entries are highlighted inrecessed openings, focused ceiling lightsidentify rooms and, if possible, externalwindows in the corridor enable orientationto the outside and the way ahead.PrivacyThe birthing woman should control theWORLD HEALTH DESIGN | October 2008 51

Design & Health Scientific Reviewroom. An alcove at the entry can providea place to wash hands and a cupboardfor supplies before entry to the unit. Thewoman can see who is entering and hascontrol over her space. The room shouldhave an atmosphere of cleanliness and orderand contain feminine symbols of beauty,wholeness and harmony.Home comfortsMany women complain that rooms aredesigned around clinical procedures andthe simple things, which make the spacefamiliar and accessible, are missed 14 . Thereshould, therefore, be a cupboard to provideadequate space for the woman’s belongings.This should be designed for easy access, andfor quick unpacking and repacking as womenare not there for long.Birthing pools and large bathsIn the NCT study 14 , the second mostimportant feature of the labour roomidentifi ed by the women as helping tofacilitate their birth was access to a poolor large bath. Of those who felt this wasan important element, two-fi fths had nothad access to a pool during their last labour.Midwives who use birthing pools say womenprefer the bath not to be in the centre of aspace but drawn over to one side of theroom. The ability to lie in the water, hold onto a supporter, kneel, move about or sit up,all assist during labour and birth.There should therefore be a tub bath inone corner of the room, preferably designedso that only one side of the bath faces theroom and is not able to be approached fromall sides – thereby not placing the occupanton display. The approach side of the bathshould allow a support person or midwifeto sit and assist or to remain for some timewithout discomfort. There also needs to bea wide edge on the wall side of the bath sothe women can sit out of the bath or thepartner can lean in (as shown above).The bath must be deep enough for awoman to be on her hands and knees withher bottom submerged. Most commercialbaths are not deep enough and mean thata woman must recline (lie on her back) tolabour or give birth. A supine position hasbeen shown to be counterproductive to thephysiology of giving birth.The bath must have a showerhead witha pulsing feature and the fi xed rail for theThe birthing pool should be suffi ciently deep and provide comfortable access for birthing partners and midwivesshower head must be nogged into the wallif plasterboard, so the woman by pulling upcan use it for support. Keeping the bathwater hot is an issue and considerationmust be given to allowing higher levels oftemperature or faster fl ow rates than thenormal to quickly add hot water to the bath.Spa baths are not recommended due tocleaning and infection control issues.Convenient ensuite/bathroomIn addition to the bath, which becomesmore of a feature of the birth room, thereshould be a bathroom with toilet, hand basinand shower for normal ablution functions.The studies supported by the NCT surveyindicate that ready access to an ensuite toiletenables women to remain relaxed and canopen up their bodies without fear of soilingfl oor mats or the bed.Material support for birthingWomen will use other features in the roomat different times during labour and birth.Such items include a mantle piece for thewoman to lean on. Women often feel morecomfortable leaning on something whilestanding. The mantle piece should preferablybe of wood so that the texture and theappearance are domestic and have a naturalfeeling. Where possible, there should betiered soft-covered benches along a wall sothat the woman can lie or sit on them. Thesespaces are also important for the midwife orpartner to rest on as well.The woman can sit on the fl oor and leanagainst the benches, or use them to stabiliseherself while squatting. They need to becovered in soft material that can be easilycleaned. Material such as fl oor mattresses,bean bags, balls, pulling ropes and othersupports for labour and birth should beavailable but kept out of the room andbrought in as required.Lighting sets the moodLighting is critically important. In the fi rstinstance, natural light should be available andused. Natural light supports the biorhythmsof the body and knowing whether it is day ornight is an important orientation. Light affectsmood and stimulates people physiologicallyas well as psychologically.Colour builds the spiritCareful selection of colours is importantto support mood, by either stimulatingwith brighter colours or providing restfulpsychological responses with warm tonesthat are more subdued in colour. Smallamounts of strong colour will providestimulating vignettes but generally roomsmust have less white and cream in exchangefor stronger pastel colours.52 October 2008 | WORLD HEALTH DESIGN

Birthing Unit DesignTechnical supportThe need for medical gases and suctionare fundamental to delivery, even thoughthe focus of this guide is on low-riskuncomplicated births. Oxygen, suction andnitrous oxide should be stored behindcupboards and a service panel exposedby pulling open doors or dropping a tabledown. While women want the assurance ofthis technology, they don’t want to see it.Managing the bedThe bed in the birthing suite is importantand currently bed types vary dramaticallybetween units. Some have typical inpatientbeds incorporating electronic or manualadjustments while others have fi xed homestyledouble beds. An examination ofbeds leads to the following performancespecifi cation. The bed must not be the focusof the room. Too often the room has beensized with a bed in mind and little else. Thismeans that mobility and a capacity to remainupright becomes limited. Recently, largedouble beds have been used in birthingsuites and, while the intention is fi ne, thishas meant even less room is available foranything other than a bed. It is preferablethat the bed is pushed out of the way, forexample behind the door, and the balanceof the room left for multiple activities to suitthe woman during labour and birth.Most women do not use the bed whenalternatives are offered. This is especially trueif suffi cient space is available and womenare supported to remain off the bed. Somewomen will kneel or stand in front of thebed, some will squat using the side of thebed to hold onto, and many will give birth ontheir hands and knees on the fl oor leaningagainst the bed.The bed needs to be low. It needs tomove. It needs to be possible to lean againstthe bed when there is no other means todo so. If the woman has to use the bed,a birthing bar across the end of the bedcan be used to lean against. The bed is acritical element in setting the expressionand impression of the birthing room. If thebed ‘screams’ of technical clinical proceduresthen the whole birth experience will refl ectthis style of labour and birth.Controlling soundSoundproofi ng is required so that the roomis quiet on the inside and women feel theycan make noise during labour without beingoverheard. Soundproofi ng the room alsomeans that women in the waiting room arenot distracted or worried by the noise ofwomen in labour.Ancilliary spacesOther rooms in the unit should include thesupply room, a blanket warmer, clean linensupply and dirty linen hold, and a disposalroom. The equipment store should be ofa reasonable size. It needs to be locatedclose to the birth room to reduce clutterand to allow fl exibility in the use of differentbirthing support materials.Biophilia: connecting to natureAn important element of health facilitydesign is the connection with nature – toenable patients, family and the public tomove easily out into gardens and courtyards.This is recognised as an important stressreducingelement. Considerable research bybioscientists in the past 30 years suggeststhat humans gain enormous psychological,physiological and certain health responsesby engaging with living things.ConclusionThe development of the patterns whichled to the audit tool and the consequentreview of built facilities will help providedocumented evidence for use in the design ofbetter birthing units. The literature supportsthe notion that physical environmentsprovide both positive and negative effectson birthing outcomes. Women prefer quitespecifi c types of places in which to give birth.If we can ensure the essential elements ofthese designs are provided in every case, wewill have reduced anxiety, increased supportand might expect to see reductions in the‘fear cascade’ that creates the demand forinterventions that could have negativeconsequences for both mothers and babies.AuthorsIan Forbes is adjunct professor and directorof the Research Unit Group for HealthArchitecture and Planning at the Universityof Technology in Sydney, New South Wales.He is also a principal health planner andarchitect at GHD Architecture.Maralyn Foureur, Nicky Leap and CarolineHomer are professors of midwifery in theFaculty of Nursing, Midwifery and Healthat the University of Technology. CarolineHomer is also director of the Centre forMidwifery, Child and Family Health in theFaculty of Nursing, Midwifery and Health atthe University of Technology.References1. Buckley SJ. Gentle Birth, Gentle Mothering: the wisdomand science of gentle choices in pregnancy, birth andparenting. Brisbane: One Moon Press; 2005.2. Page L, McCandlish R. The New Midwifery;science and sensitivity in practice. 2nd edition. London:Elsevier; 2005.3. Dolan T. The Lure of Cesarean Sections. For TheRecord 2005; 17(18):34.4. Royal College of Midwives. Campaign for NormalBirth; 2007. Available http://www.rcmnormalbirth.net5. Maternity Center Association. What every pregnantwoman needs to know about caesarean section. New York:Maternity Centre Association; July 2004.6. Laws PJ, Grayson N, Sullivan E A. Australia’s Mothersand Babies 2004. Perinatal statistics series no. 18.AIHW cat. no. PER 34. Sydney: AIHW Perinatal StatisticsUnit; 2006.7. Walsh D, Downe SM. Outcomes of free-standing,midwife-led birth centres: A structured review. Birth2004; 31(3):222-229.8. Fahy K, Foureur M, Hastie C. Birth Territory andMidwifery Guardianship: Creating Birth Space. Oxford:Elsevier; 2008.9. Foureur M, Hunter M. The Place of Birth. in PairmanS, Pincombe J, Thorogood C, and Tracy S, Midwifery:preparation for practice. Elsevier, London; 2006.10. Lepori B, Foureur M, Hastie C.Mindbodyspirit architecture: Creating Birth Spacein Fahy, K; Foureur, M; Hastie, C. Birth Territory andMidwifery Guardianship: Creating Birth Space. Oxford:Elsevier; 2008.11. Day C. Places of the Soul: architecture andenvironmental design as a healing art, second edition.London: Elsevier; 2004.12. De Botton A. The Architecture of HappinessMelbourne: Penguin Group; 2006.13. Dilani A, A New Paradigm of Design andHealth. in Design & Health III: Health PromotionThrough Environmental Design edited by A. Dilani. (pp15-25) Stockholm: International Academy for Design &Health; 2004.14. Newburn M, Singh D. Creating a Better BirthEnvironment. London: National Childbirth Trust; 2003.15. Rubin H, Amanda J, Owens, J, Golden G. AnInvestigation To Determine Whether the Built EnvironmentAffects Patient’s Medical Outcomes Concord: The Centerfor Health Design; 1998.16. Alexander C, Ishikawa S, Silverstein M. A PatternLanguage: towns, buildings, construction. New York: OxfordUniversity Press; 1977.17. Olsen O, Jewell MD. Home birth versus hospitalbirth (Cochrane Review) (Issue 3 ed.). Oxford: UpdateSoftware; 2001.WORLD HEALTH DESIGN | October 2008 53

Design & Health Scientific ReviewUrban DesignDesigning Healthy Communities:The health impact of streetvendor environmentsThis study, spanning seven years, reveals how the informal architecture of the environments, in whichstreet vendors ply their wares in countries like the Philippines, impacts on their healthMary Anne Alabanza Akers, PhD, Timothy AAkers, PhDThe built environment plays a powerfulrole in the health of a population.Its infl uence has been documentedin numerous studies, ranging from urbansprawl and its impact on obesity, diabetesand poor nutrition to highway developmentand the increase in pedestrian injury, and theimpact of nature deprivation on low mentalhealth and well-being. However, many of theexisting studies have not used comprehensiveresearch designs and methods; they lackmultiple study points in time; and they havenot interviewed respondents in situ.This study contributes a perspective ofdesign and health that goes beyond designinghealthcare facilities for patients who arealready diagnosed with health problems.It unveils a different world of people whowork in busy, often chaotic, and noisy urbanstreets. Their environments are temporary,marginal, uncertain and fl uid.Such informal architecture is found in urbanplaces all over the world 1 . In this context, itinvolves viewing the built environment withina framework that includes street people’scultural lifestyles, socio-economic values andspatial behaviour.Baguio City street vendorsThis study comprises a longitudinal andtransdisciplinary study of street vendors inBaguio City in the Philippines. It is a fastgrowingregional centre for higher education,medical services, business opportunities andtourism. Situated in the rugged upland regionof the Cordillera Mountains, the city wasplanned for 50,000 people but now holdsabout 250,000 residents. Lack of offi cial jobsand the economic downturn of many globalcities have driven residents to legitimatelyearn a living on urban streets.Typical female street vendors in Baguio City, out in the open, exposed to traffi c pollution, weather and diseaseStreet vendors create spaces withinexisting buildings, sidewalks and streetsto establish their ‘territories’ and sell theirproducts. The result is a tapestry of informalarchitecture set on the existing builtenvironmentinfrastructure. The questionis: “How does the architecture impact onstreet vendors’ health?”Literature on the health of street vendorshas focused largely on studies related topublic safety and food-borne diseases. Otherresearch projects have examined vendorhealth in terms of pollutant contamination intheir bodies and reproductive conditions 2,3,4 .These studies generally imply that vendors’presence in the streets for long periods oftime poses an occupational health hazard.However, to date, no study has delvedinto the physical environment – thearchitecture and land-form features – andits contribution to the health conditions ofvendors. Furthermore, design guidelines tomitigate their health circumstances have notbeen addressed. This paper hopes to lessenthis gap in the literature.The study involved multiple researchmethods from 1999 to 2006. Table 1(see p59) describes the various researchphases of the project. The methods rangedfrom personal surveys and physical placeassessments to health screening procedures.This eclectic use of research techniqueshas contributed to a comprehensiveunderstanding of vendors and the impact ofthe street environments on their health.Throughout the seven-year durationof the research project, two surveys wereconducted – one in 1999 and the otherin 2003 – with samples of 219 and 187respondents, respectively. Many of theseindividuals were repeat respondents.Generally, the characteristics of the vendorsare the following:• At least 80% are women in theirearly 40s• They have an average of four children.• At least 50% have a high schooleducation• The majority of respondents have stayedin the same vending locations between sevenWORLD HEALTH DESIGN | October Summer 2008 00 55

Design & Health Scientific ReviewStreet vendor concentration nodes scattered throughout the central business districtAn important part of the environmental design plan isto ‘pedestrianise’ several streets in the CBDand 11 years. Vendors choose to engage inthis type of street occupation• They work long hours – 10 hours a day,Monday to Sunday – and earn only aboutUS$20 a week.The research siteBaguio City’s central business district issituated in a deep valley with four arterialstreets leading to it. In the early 1900s thelocation was selected by the Americancolonialists as a resting and healing place fortheir troops. Documents written by militaryphysicians have chronicled the positiveimpact of this upland city on soldiers’ healthbecause of its high elevation and cool air.From a quiet convalescent place, Baguio Citytransformed throughout the centuries into abusy economic engine for the region.At the initial phase of this longitudinalstudy, the vendor spaces were measured,together with sidewalk widths and otherphysical attributes. The space metrics showthat 44% of vendors are located in relativelyfl at areas and 56% are sited on steepinclines 5 . Topography is an important factorin the entrapment of air pollution, which inturn affects health conditions.Another signifi cant feature of the centralbusiness district is the high traffi c volume thathas exceeded its streets’ carrying capacity.Major colleges and universities, governmentoffi ces, as well as the city market, aremagnets that draw people and diesel-runvehicles to its centre. Idling vehicles in theland basin and those running uphill on steepinclines contribute to the mix of polluted airand noise.Also important to this study of place andhealth is Baguio’s local climate. Elevatedat 5,000 feet above sea level, the cityexperiences temperatures ranging from10ºC during the cold months of December,January and February to around 30ºCduring the warm months of March, Apriland May. Cold temperatures often create aninversion effect that traps polluted air duringthe early mornings. Warm weather, on theother hand, often brings an onset of gastrointestinaldiseases because of food-bornebacteria found in non-refrigerated foodsthat vendors either sell or pack from home.It is also known for its prolonged monsoonseason in which rainy weather is evidentfrom June to early September. During thisseason, a rise in the incidence of fl u andother respiratory problems is common.Vendor sites & urban architectureThe local spaces that hold vendors’microbusinesses are varied, interesting andindicative of socio-economic factors. Forexample, the vendors who have establishedtheir territories for many years are locatedin spaces that are mostly fl at and have highpedestrian traffi c. Relative newcomers areleft with secondary spaces in minor streetswith moderate foot traffi c. Vendors selecttheir spaces based on the type of productssold, friendships and ethnic affi liation. Fruitvendors tend to settle in places adjacentto eateries while those selling hard goodslike t-shirts, DVDs and household productsare found close to banks and retail outlets.However, most, if not all, vendors use a partof the physical environment as a basis fortheir location decisions.The urban architecture found in centralBaguio City is characterised by diversebuilding types, uses and forms. Four- tofi ve-storied modern designed buildingsframe the main street. Other buildings aremodest, with only three stories withordinary architecture.Building architecture impacts on thequality of vendor sites. For example, only25% of vendors are located under buildingoverhangs that span the entire sidewalk.In fact, about 32% of vendors are in sitesthat are not under any overhang. They areexposed to climactic elements like themonsoon rains and cold mountain air.Integral to urban architecture is thepresence of sidewalks fronting the buildings.As the owners have responsibility forconstructing and maintaining sidewalks, the00 56 Summer October 2008 | WORLD HEALTH DESIGN

Urban Designinfrastructure is included in the overall designof the property. This results in varying heights,widths and quality of sidewalks throughoutthe central business district. Sidewalk widthsvary from seven to 16 feet 6 . Sidewalkdensity, as measured by pedestrian countsand sidewalk widths, has an effect on healthconditions. Higher sidewalk densities createenvironments that encourage the spreadof communicable diseases like infl uenza,bronchitis and pneumonia, especially duringthe monsoon season.Street vendors soften and personalisethe existing architecture by creating workspaces made of simple materials to displaytheir products and work ‘comfortably’ forten hours a day. Cartons and cardboardboxes make up fruit stands and tarpsare used to display special items. Othervendors use building walls as stands forposters and magazines. The colourful arrayof products contributes to the fi ner texturesof urban places.Air qualityIn 2004 the research team monitored andassessed the air quality in 30 populatedvendor sites and a fi xed site on the thirdfl oor of a building. Generally, the data showedelevated levels of pollution in many areasin the central business district. The data atthe fi xed site also indicated that particulatematter concentrations were higher than theNational Ambient Air Quality Standardsused in the United States.Environmental factors such as buildingheight, distance to a stoplight, street widths,number of street lanes and topography, aswell as vehicular and pedestrian volume,were added to a group of other variablesin a regression analysis model but werenot found to be statistically signifi cant. Thefactors that contributed signifi cantly tostreet level pollution were traffi c volumeand wind direction 7 .The built environment and healthIn his treatise On Airs, Waters, and Places,Hippocrates strongly links disease withplace, particularly, a community’s locationand local climate 8 . This observation, thoughdeveloped centuries ago, has come full circleas scientists today accept the connectionbetween the physical environment andhealth. We have based this study of streetvendors on Hippocrates’ fi ndings but thediscussion has been extended to includethe impact of the built environment and airquality on health. The variables considered inthe analyses were:Physical environment factors: slope;vehicular volume; vehicular movement(idling, moving uphill); pedestrian volume.Architecture and built environmentindicators: building height; building overhang;curb height; distance to a drainage hole;distance to a garbage disposal; and qualityof the sidewalk.Air quality: morning and afternoonmonitoring of: particulate matter 2.5;particulate matter 10; and carbonmonoxide.Health variables: number of healthproblems experienced in 2003; type ofhealth problems.ResultsUsing bivariate correlation tests, the resultsshowed the following patterns:Slope and health conditions: Acorrelation between slope and type ofhealth condition was found to be signifi cant(r=0.344, p

Urban DesignTable 1 Research protocol for the street vendor studysome of vendors’ health problems.Compared to Magsaysay Avenue andAssumption Road, Harrison Road isconsidered the ‘healthiest’ site of all. Unlikeother sites with similar traffi c volumes, thisstreet has the best air quality conditions. Amajor explanation for such good air qualityis that the two sites on Harrison Street areadjacent to the main public park in BaguioCity. Burnham Park is about an acre of greenthat stretches along Harrison Street. Itstrees and good wind circulation mitigate theimpact of vehicle exhaust on vendors’ healthconditions. Those located on this street didnot report as many ailments as the others.Design and planning implicationsThese results clearly demonstrate therelationship between health and the builtenvironment. In the case of Baguio City, adrastic transportation plan to decrease thevolume of traffi c in the central businessdistrict will improve the health of notonly street vendors but also the generalpopulation that live, work, recreate and goto school in the area.A conventional solution would be toconstruct a bypass around the urban core– but that approach is far from beingsustainable. To preserve the character of thecity’s centre, highways should not be builtbecause these structures will only increasethe dark and cold tunnel effect of urbanspaces beneath them.Rather, a framework that encouragessatellite service centres around the city willdecrease the number of vehicles enteringthe urban core.Banks, professional offi ces, medical offi cesand other businesses can relocate todisperse services around the city.An important part of the environmentaldesign plan is to ‘pedestrianise’ severalstreets in the CBD. This move will decongestYear Research focus Research methodology1999 Social networks, microeconomicnature of street enterprisesBuilt environment assessment2000 Relationships between streetvendors and adjacent formalbusinesses2003 Health and environmentalassessmentthe sidewalks and encourage the use ofurban spaces for more community-oriented(social, leisure, cultural, and arts) activitiesand active living, while increasing theireconomic vitality.Several cities in India and Indonesia haveclosed major streets to accommodatepedestrians 9 . Evaluations of these planningstrategies have yielded positive results.Businesses have increased their sales, airquality improves, users are more encouragedto stay in these places, crime decreases andurban spaces are enlivened.Lastly, to improve the health of streetvendors and urban residents living, workingor visiting in the CBD, a greening movementshould be embarked upon. Restoringexisting parks to better health and plantingvegetation around the CBD will improve airquality and decrease the effects of the urbanheat during the hot, summer months.Next stepsThis longitudinal study of street vendorsis an example of a transdisciplinary work.Survey of 219 vendorsPhysical inventory of vendor sitesVisual documentation and informalinterviewsSurvey of 187 vendorsPhysical inventory of vendor sites2004 Air quality Air quality monitoring on 30 vendorsites and one central fi xed site2006 Health screening and visualdocumentationMedical screening for 15 vendors (e.g.physicals, blood tests, oximeter readingsat vendor sites)In-depth health survey for 10 vendorsVisual documentation of 30 vendor sitesThe extensive quantitative and qualitativedata that was collected provided adescription of places and people whichhelped us understand the relationshipbetween the built environment, architectureand the health of, in this case, street vendorsin the Philippines..However, to validate the implications ofthe study results, a tangible intervention, suchas implementing a transportation schemeto decrease traffi c in the central businessdistrict, is necessary. Medical screening tests,pre- and post-intervention, can be extendedto include the entire sample of vendors.These next steps would indeed put closureto the entire project.AuthorsMary Anne Alabanza Akers, PhD, Dean,School of Architecture and Planning, MorganState University, Baltimore, Maryland, USTimothy A Akers, PhD, assistant dean forresearch, School of Community Healthand Public Policy, Morgan State University,Baltimore, Maryland, USReferences1. United Nations. Human settlement country profi le.Washington DC: United Nations Department ofEconomic and Social Affairs, Division for SustainableDevelopment; 2004. Retrieved August 31, 2007 fromwww.un.org/esa/agenda21/natlinfo/countr/philipi/humansettlements2004.pdf2. Furman A and Mehmet L. Semi-occupationalexposure to lead: a case study of child and adolescentstreet vendors in Istanbul. Environmental Research 2002;83(1): 41-45.3. Pick WM, Ross MH and Dada Y. The reproductiveand occupational health of women street vendors inJohannesburg, South Africa. Social Science & Medicine2001; 54(2): 193-204.4. Ruchirawat M, Navasumrit P, Settachan D,Tuntaviroon J, Buthbumrung N, Sharma S.. Measurementof genotoxic air pollutant exposures in street vendorsand school children in and near Bangkok. Toxicology andApplied Pharmacology 2005; 206(2):207-214..5. Akers MAA, Sowell R and Akers TA. A conceptualmodel for planning and designing healthy urbanlandscapes in the Third World: a study of street vendorsin the Philippines. Landscape Review 2004; 9(1):45–9.6. Akers MAA, Akers TA. Urbanization, land useand health in Baguio City, Philippines. In G. Guest (Ed.),Globalization, health, and the environment: An integratedperspective. Lanham, MD: Altamira Press; 2005.7. Cassidy BE, Akers MAA, Akers TA, Hall DB, RyanPB, Bayer CW, Naeher LP. Particulate matter andcarbon monoxide multiple regression models usingenvironmental characteristics in a high diesel-use area ofBaguio City, Philippines. Science of the Total Environment2007; 381 (1-3): 47-58.8. Hippocrates. On airs, waters, and places. 400 BCE.(F. Adams, Trans.) Retrieved September 30, 2006 fromhttp://classics.mit.edu/Hippocrates/airwatpl.1.1.html9. Institute for Transportation and DevelopmentPolicy. Pedestrianizing Asian cities. Sustainable Transport2003; 22-25. Retrieved November 10, 2006 from www.itdp.org/documents/st_magazine/ITDP-st_magazine-15.pdfWORLD HEALTH DESIGN | October Summer 2008 00 59

Design & Health Scientific ReviewEnvironmental psychologyPerception and wellbeing:The Impact of Colour and LightTwo New Zealand studies explore how the built environment can impact on mood – one, theinternal features of a dentist’s offi ce, the other views from an offi ce buildingDr Linda Jones & Dr Barbara ManighettiPeople who are not normally botheredby anxiety may feel stress and anxietyin specifi c environments, where theyexperience both a sensory insult and a lossof power to change or control the conditions.Some environmental stressors, such as noise,extremes of temperature or malodour, arewell documented 1,2,3 . But negative emotionalresponses can also be learned – in hospitalsor dentists’ rooms, for example.Environmental psychology can also beapplied to the workplace. Studies haveestablished relationships between thephysical environment and both workattitudes 4,5 , and wellbeing 6,7 . Elements suchas window size, sunlight or view, have beenshown to affect levels of arousal and stressrecovery 8,9 and even intention to quit 6 .The benefi ts of ‘natural’ elements are welldocumented 10,11 .Stigsdotter 12 explored stress and access togarden environments in Sweden, reportinggreater workplace comfort where gardenaccess was available, and asking whethera garden view could also have a causalinfl uence on workplace wellbeing.This paper reports on two New Zealandstudies, each contributing to the growing bodyof knowledge on environmental perceptionand well-being, then discusses colour and/orlight as explanatory mechanisms.students’ feelings and the assumptions theymade about the professor’s character.In Jones’ study, a dentist’s waiting roomwas presented using overhead projectorslides – also to university students, butin groups. This made it possible to add aqualitative stage, where the groups discussedthe experiment. The 102 students rated the16 environments covering all combinationsof the four independent variables – art,plants, seating arrangement and level oftidiness. The dependent variables rated howwelcome and inviting it felt, and attributionsabout the dentist.Ratings for the dentist’s waiting roomshowed a near parallel pattern to theprofessor’s offi ce across all variables, exceptthe dentist’s waiting room was always morenegatively rated than the professor’s offi ce.Table 1 shows the relative ratings, by meanscore only, of each of the environments.Tidy waiting rooms with plants had thefour highest scores. The presence of plantsprovided more positive ratings for feelingwelcome and feeling comfortable. Onlyin some combinations did art made apositive difference. Seating variations werenot signifi cant. While tidiness had very highscores, this was not signifi cant either. Thesignifi cance level was set at p< 0.05 (twotailed)with 14 df in all cases.In discussion, it was thought that thepreferred seating would be one conduciveto conversation between waiting patients.However, while most participants agreed thatthis would be the preferred arrangement innon-threatening environments, it was notthe same for the dentist’s waiting room– some preferred withdrawing from socialcontact when stressed and did not likeseating where they felt they must interact.Others, however, said they would welcomesocial contact as both a distraction andsupport when stressed.There were also competing discoursesabout tidiness. The cultural value placed ontidiness was explored and its implications forthe quality of dentistry: if a dentist could notkeep the waiting room tidy, could patientsexpect quality dental work? An untidywaiting room in a solo practice might suggestthe dentist was busy and so was perceivedpositively. But in a large practice, the studentsfelt untidiness indicated lower standards andless concern for patients’ welfare.Plants were spontaneously and specifi callyStudy 1: ‘Greens’The study of a dentist’s waiting room hasbeen cited as a ‘methods’ paper, usingenvironmental perception to illustrate howthe choice of methodology can elicit differentlevels of understanding of a phenomena 13 . Itwas a partial replication of a study whereCampbell 14 showed students a one-off35mm-slide presentation of a professor’soffi ce and asked the students to rate theirfeelings about the environment and theprofessor. Campbell found that the presenceof plants had a strong positive infl uence onDentist’s waiting room: while plants made people feel welcome, tidiness and art were not as signifi cantWORLD HEALTH DESIGN | October 2008 61

Alan DilaniDesign & HealthLord Nigel CrispProf James BarlowHACIRICPer Gunnar SvenssonDesign & HealthJohn CooperAnshen + AllenProf Jacqeline VischerUniversity of MontrealArchitecture | Culture | TECHNOLOGYGlobal perspectives, local designsMaking thought leadership countSubscribe today toWorld Health DesignAnd saveSubscribe today and you will receive:£30off the cover price• Incisive comment and analysis• Thought leadership interviews• Latest scientific research• Architectural project reviews• International market reports• Global technology updates• Arts and culture reviewsDiana AndersonWHR ArchitectsIrini AntoniadouEORNAPhil NedinARUPFaye Le DouxEllerbe BeckettSusan FrancisCABEMike NightingaleNightingale AssociatesTo subscribe, call: +44 (0)1277 634176 or email: whd@designandhealth.com

Environmental psychologyIV art IV plants IV seating IV tidinessMean of combinedwelcome/comfort ratingMean rating of how busydentist wasArt Plants Open Messy 3.73 6.06Art Plants Open Tidy 4.88 4.35Art Plants Closed Messy 3.82 5.99Art Plants Closed Tidy 5.50 4.27Art No Plants Open Messy 4.26 5.81Art No Plants Open Tidy 4.78 4.09Art No Plants Closed Messy 4.10 5.85Art No Plants Closed Tidy 4.41 3.81No Art Plants Open Messy 4.28 5.92No Art Plants Open Tidy 5.97 4.31No Art Plants Closed Messy 3.34 6.33No Art Plants Closed Tidy 5.37 4.08No Art No Plants Open Messy 2.30 6.14No Art No Plants Open Tidy 4.07 3.88No Art No Plants Closed Messy 3.38 6.30No Art No Plants Closed Tidy 3.81 4.21Table 1Overall mean DV ratings (9 = high, 1= low). Highest rated environments are shadeddiscussed, but more to suggest that ‘greenery’is an important element in a wider varietyof environments than the dentist’s waitingroom. However, gender differences mayconfound this fi nding. In a review of gendereffects in environmental research, Zelezny,Chua and Aldrich 15 found that women heldstronger attitudes to environmental issuesthan men. In the Jones study 13 , the ratio ofwomen to men was seven to three.Study 2: ‘Blues’The relationship between the environmentand physiological aspects of wellbeingis important for understanding thehealth implications of different types ofemployment 16,17 . Physical health may beadversely affected by stress 18 , including ‘dailyhassles’ 19 and more severe trauma 20 . Studieshave linked wellbeing with windows 7 , , lightingand natural illumination 21 , and naturalviews 11,22,23 . Mood (affect) has been suggestedas the mediating factor linking environmentand wellbeing, with pleasant environmentseither evoking a positive affect or loweringthe negative affect and buffering the impactof stress. Restorative environments havebeen shown to lower blood-pressure 10,24and cardiac inter-beat interval 25 .The aim of this study was to examine theinfl uence of view on employee mood andself-rated health at a single workplace, basedon the work of Ulrich 8,9,23 and Hartig et al. 10.The hypothesis was based on the probablelink between offi ce view and wellbeing, withmood as a likely mediating factor. A goodview was predicted to be associated withhigher positive affect and/or lower negativeaffect scores – and with better perceivedhealth. Confounds from age, organisationalseniority and sex were anticipated.MethodEighty anonymous participants wererecruited through a questionnaire deliveredto staff mailboxes at the National Institute ofWater and Atmospheric Research (NIWA),in Wellington, New Zealand. There were noinducements. The NIWA building is orientedroughly north-south. Offi ces either facedeast, with a natural view, or west, facing anurban development. The 200+ employeeswere mainly scientists, and formed a relativelyhomogeneous population in work tasks,socio-economic status and intelligence.The questionnaire instructed participantsto consider their responses “while at work”.It included the Positive and Negative AffectSchedule (PANAS) 26 for mood states, andthree visual analogue scales (VAS). The fi rstrated job satisfaction, the second was forperceived health, and the third assessedhow the participant rated the health of anaverage person of a similar age. Demographicquestions covered the employment variablesat the NIWA.Finally, participants were asked to ratetheir east- or west-facing offi ce view on afour-point scale (poor to excellent), andto indicate time spent in their offi ce on anaverage working day. In addition, they wereasked for the date and time they completedthe survey, in order to control for possibleconfounding or moderating effects such asweather or day of the week.WORLD HEALTH DESIGN | October 2008 63

Design & Health Scientific ReviewResultsThe data was grouped separately for theoccupants of offi ces with a natural view(east) and those with the urban view (west).Self-rated health results were adjusted sothat reported scores refl ected the extent towhich the participants believed their healthwas better or worse than expected for theirage. Data were analysed using SPSS.There was no difference in positive affectscores no matter what the view but therewas a small difference in negative affect,showing that people with the urban viewwere ‘grumpier’ on average than those witha natural view.For self-rated health, the natural view wassignifi cantly correlated with better healththan the urban view (t = 2.47, df (78), p =0.02), even though those with the urbanview rated their health as above averagefor their age. There was a signifi cant, lowto moderate positive correlation betweenself-rated health and negative affect (R =0.3308, p

Environmental psychologyParticipants with the urban view were ‘grumpier’ on average than those with the sea viewof possible confounding and/or moderatingvariables. For example, how does thegeographical or cultural context of a viewimpact on wellbeing? Would people fromlandlocked nations and maritime nationshave the same correlation between moodand sea view?While the NIWA offi ces had similar hoursof sunlight, new research in circadian rhythmssuggests the time of day maximum sunlightis experienced is important. Synchronicitybetween personal circadian and externaldiurnal rhythms promoted by exposure toearly morning sunlight may be the reasonthose with east-facing offi ces had betterperceived health. This could be explored in afuture study by measuring perceived fatigueversus offi ce orientation or brightness andtiming natural illumination.When Mayo and colleagues 31 discoveredthat manipulating factory lighting ledto improvements in production, theirgroundbreaking message was that doinganything for employees may improveproductivity because people respond toattention. However, 70 years on, what mighthave been lost with the establishment ofthe ‘Hawthorne effect’ 32 is that lighting doeshave psychophysical effects. Workers mayhave been responding to attention ANDlight after all.ConclusionStudy 1 concluded that greenery made sucha positive impact that not only might dentalpatients feel more comfortable in a plantcontainingwaiting room, but we suggestthat the dentist-patient interaction mightbe improved by this simple modifi cation.Importantly, exploring the environmentalcontext of anxiety shifted from individualcoping to acknowledging the wider infl uenceson behavioural reactions and hence theimportance of design on wellbeing.Study 2 concluded that there was apositive relationship between natural viewsand offi ce occupants’ wellbeing. Colours inthe view, especially blues and greens, andlight are suggested as the critical variables.Together the fi ndings raise questionsabout possible unconscious needs for certaincolours, particularly blue and green. Lewis 33,Kozak 34 , and Norfolk 35 go further to suggestthat evolution ties us inextricably to natureand fundamental narratives in Westernculture may reinforce the connections,making access to nature a prerequisite towellness. The urban descriptor ‘concretejungle’ is associated with misery. Itencompasses both what there is (concrete)and what is missing (jungle). We trust thatcollaboration between social science andinnovative design may lead to solutions.AuthorsDr Linda Jones, School of Psychology, MasseyUniversity, WellingtonDr Manighetti, Department of Psychology,Victoria University, WellingtonAcknowledgmentsBM thanks the management and staff of theNational Institute of Water and AtmosphericResearch for facilitating the study and SteveHumphries and Antony Gomez for advice.LJ thanks Dr P Moodie for the use of KaroriMedical Centre for the photography used instudy 1, and photographers Markham MailLRPS and Colin Jones18. Watson D, Pennebaker J. Health complaints,stress and distress: exploring the central role of negativeaffectivity. Psychological Review 1989; 96:234-254.19. Kanner A, Coyne J, Schaeffer C, Lazarus R.Comparison of two modes of stress measurement:Daily hassles and uplifts vs. major life events. Journal ofBehavioral Medicine 1981; 4:1-39.20. Ironson G, Wynings C, Schneiderman N, Baum A,Rodriguez M, Greenwood D, et al. Posttraumatic stresssymptoms, intrusive thoughts, loss, and immune functionafter Hurricane Andrew. Psychosomatic Medicine 1997;59:128-141.21. Knez I, Enmarker I. Effects of offi ce lighting onmood and cognitive performance and a gender effect inwork-related judgment. Environment and Behavior 1998;30:553-568.22. Sheets V, Manzer C. Affect, cognition and urbanvegetation: some effects of adding trees along city streets.Environment and Behavior 1991; 23:285-304.23. Urlich R. View through a window may infl uencerecovery from surgery. Science 1984; 222(4647):420-421.24. Hartig T. Guest Editor’s introduction: restorativeenvironments. Journal of Environmental Psychology 2003;23:103-107.25. Laumann K. Garling T, Stormark KM. Selectiveattention and heart rate responses to natural and urbanenvironments. Journal of Environmental Psychology 2003;23:125-134.26. Watson D, Clark LA, Tellegen A. Developmentand validation of brief measures of positive and negativeaffect: the PANAS scales. Journal of Personality and SocialPsychology 1988; 54:1063-1070.27. Stone N. Windows and environmental cues onperformance and mood. Environment and Behavior 1998;30:306-322.28. Kaplan S. A model of person-environmentcompatibility. Environment and Behavior 1983;15:311-33229. Kaplan S. Aesthetics, affect, and cognition:environmental preferences from an evolutionaryperspective. Environment and Behavior 1987; 19:3-32.30. Van den Berg A, Koole S, van der Wulp N.Environmental preference and restoration: (How) arethey related? Journal of Environmental Psychology 2003;23:135-146.31. Mayo E. The human problems of an industrialcivilization. New York: MacMillan; 1933.32. Parsons HM. What happened at Hawthorne?Science 1974; 183:93.33. Lewis C. Green nature, human nature. The meaningof plants in our lives. Chicago: University of IllinoisPress; 1996.34. Kozak D. Prescriptions in a pot. Prevention 2001;53(7)50-51.35. Norfolk D. The therapeutic garden. London: BantamPress; 2000.WORLD HEALTH DESIGN | October 2008 65

Arts and CultureBiophilic Design:The Theory, Science and Practice of Bringing Buildings to LifeKellert S R, Heerwagen J H, Mador M LWiley Blackwell, 2008 Price: £39.99 / €50This well conceived and edited book is published at a time that requires a fundamental generationalrethink about the impact of buildings, both in terms of their environmental performance and theirimpact on human health and wellbeing.Paradigms are shifting, with a greater focus on the value of health and environmental capital as opposedto fi nancial wealth, calling into question current design and investment decisions, at both a micro andmacro level.Long-term or short-term investment: you decide, or the markets will decide for you. Without the easyintrinsic ‘off-plan’ growth of the last decade, clients and developers will be looking for a new language of value and performance, and differentforms of cost accounting that properly appraise the morphological and bio-diverse benefi ts of buildings that plan to reduce the running costs,maintenance and rehabilitation of our existing buildings.Biophilic design is not a mainstream phrase associated with the response and intuitive affi liation of human systems with nature. And somearchitects of certain generations (including this reviewer) raised on Erskine, Aalto, Asmussen, Cullinan, Christopher Alexander and othericonic European theorists and urban practitioners, all referenced here, might fi nd themselves scratching their geodesic domes.They would recognise the case being made for fundamental design qualities where nature is included in the built environment, not theseparateness of evidence and theory meshed together by technology – raising their eyes out of a ‘room with a view’ to rest on where theargument had been buried in the garden.This is the essence of the book. It is making the case for consideration, with extensive case studies, research papers with illustrations andan exposition that takes the subject way beyond abstract consideration. It is saying whatever environment you are planning, think of theseprinciples and sensibilities and if you need justifi cation for a more responsive design here it is.So leave this book on your client’s and your funder’s desk, or lift key sections out of the chaptersto green your business case. None of these chapter authors will mind. And if you have beenfeeling left out and old-fashioned in the past few years with the triumphant pall of procurementover planning, dust down your old post-occupancy evaluations that asked the cancer patient whatwas important – the immediate outside space, the bird at the table, the door for children to playoutside when visiting. When we are ill, we need the immediacy of a supporting safe environment.Tensions with technology – yes, let the argument commence, if they can hear you in Third Lifebehind the headphones. Get this publication a Facebook site now and plan the coolest party intown. Chapters address our neurological response to the stressors and inhibitors that are placedon our environments.It begins to inform how we become part of a building’s life cycle experience, reconnectingus to a new living architecture that can respond to intense change but without degrading coreinfrastructural elements. It is about how we might manage the end of things that previously madeour cities work and are familiar to our parents and to us.The application of the lower technologies into some of the most sophisticated buildings ofour time are illustrated: the Swiss Re Tower, SkyCeilings in surgology, green roofs over familiar citybanks, new places refl ecting aspects of scale, protective and variable. And there are places andspaces that we might look to beyond this now.We should explore how the Finnish utilise mobile phone technologies for better access tohealthcare professionals from the home. Every township has a mobile phone mast, so let us makethe case for health networks free at the point of access.Mental health therapies harnessed in a series of gardens in Stockholm, hurricane resilienceplanning and urban agriculture in Havana. As these levels of intervention illustrate, there is muchgood new practice out there by inspirational individuals. And so much design complacency toattack, as this fi ne publication encourages.Phil Astley is a senior lecturer at the Medical Architecture Research Unit (MARU),London South Bank University and course director of MSc Planning Buildings for Healthwww.lsbu.ac.uk/maruWORLD HEALTH DESIGN | October 2008 67

Arts & CultureLe Corbusier – The Art of ArchitectureThe Crypt, Liverpool Metropolitan Cathedral, until 18 Jan 2009www.architecture.com/le CorbusierWhile the carcasses of countless sink estates – often shoddily assembledimitations of this mass-housing blueprint – still haunt our urban landscapes,the negative impact of this image, only one of Le Corbusier’s big ideas, canobscure us to the brilliance of the others.But what this exhibition – his fi rst major retrospective since the late 1980s – setsout to do is restore our understanding of the man as an artist, an idealist and a thinker;a ‘man of letters’ as he chose to describe himself in his passport. After all, he authorednearly as many books as he did buildings.Beneath the vaulted brick ceiling of thecrypt in Liverpool’s Metropolitan Cathedral,a rich assortment of plans, paintings, homemovies, sculptures, drawings, furniture andeven scribbled tear sheets from some of hislegendary lectures are assembled to help ussee how his inspirations, ideals and buildingsevolved over his lifetime.There are beautifully preserved modelsof his most famous projects – the villas, thechurches and even a wooden model of hisvisionary capital city at Chandigarh – as wellas virtual, digital recreations of pavilions andbuildings he designed but never got to build.Restoration ofthe Living IdealSo many sins have been committed in the name of LeCorbusier, it is hard to separate the man from his reputation.Veronica Simpson visits a major exhibition exploring theenduring legacy of the iconic architect, writer and artistEvolution of spiritWe see how this ambitious and energeticman moved from the youthful zeal of his daysas a ‘purist’, eschewing the frills, folksiness andfl ourishes of previous architectural eras forclean lines, open space and bold, white exteriors shaped by the logic of the building’s interior plan; how his travels throughAfrica and Latin America inspired a more sensual and organic response; and how, despite his declared agnosticism, he wasable to create some of the 20th century’s most striking and beautiful spaces for religion and spiritual worship.Though it was architecture that made his name, he was a prolifi c painter, very much in the style of Picasso. He allegedlyspent every morning at his easel, saving the business of architecture for the afternoon. And when he wasn’t painting, travellingor creating buildings, he immersed himself in the ideas of the day, producing and disseminating his particular brand of designevangelism through many books and magazines. “My own duty and my aim,” he wrote in his youth, “is to try and raise peopleout of their misery...to provide them with happiness, with a contented existence, with harmony. My own goal is to establish orre-establish harmony between people and their environment.”Above: Portraitof Le CorbusierBelow left: ThePavillon PhilipsBelow right:Notre Dame duHaut68 October 2008 | WORLD HEALTH DESIGN

Left: A Le Corbusier muralRight: Chaise Longue Thonat-FreresBelow: Pavillon SuisseTo look at his buildings – like the Villa Savoye, the domestic ‘machine’ at itsmost elegant – is to see these ideas writ large. But, like all geniuses, he wasfl awed, his inspired rhetoric and idealism sometimes carrying him far beyondwhat might seem desirable to most mortals. The thought of having to live in the2km-long wall of high-rise dwellings he designed to run the length of the bay ofAlgiers, is truly horrifi c.And even our exhibition guide declared the citizens of Paris ‘lucky’ not to havehad his vision for a new Parisian metropolis – 1925’s Le Plan Voisin – infl ictedon them, the city’s rococo excesses stripped away in favour of a uniform vista oftower blocks and barracks-style multi-storey dwellings....his inspiredrhetoric andidealism sometimescarrying him farbeyond what mightseem desirable tomost mortalsReforming zealBut it’s worth being reminded that Le Corbusier’s fi rst completed mass housingproject, L’Unité d’habitation, was conceived as a utopian city in the sky. Theapartments were all intended to be luxurious dwellings, with fi tted kitchens,double-height lounges and private garden terraces, the community served and strengthened by generous integral gathering spaces andfacilities – a roof terrace adorned with playgrounds, creche, gymnasium; and an internal street stuffed with shops and eateries.I left the exhibition convinced that the power of his buildings lay in that heady combination of technical virtuosity, reforming zeal, and theevident poetry in his soul, nurtured and maintained through his dedication to art, travel, sculpture, and the life of the mind.In lesser hands, his ideas were quickly corrupted, seized on by individuals more seduced by the economy and speed withwhich massive housing units could be constructed. The failure of these buildings as dwellings, when cheaply built, badly sited andfi lled with the urban poor, cannot be laid at his door.As The RIBA Trust photographic footnote at the endof the exhibition reminds us, in the right hands, his ideascould inspire brilliant buildings – London’s Barbican andthe Southbank complex to name but two. It’s a timelyreminder, however, as new cities that celebrate the egosof the world’s leading architects are constructed all overthe Eastern part of the globe, that architecture is only oneelement in the mix.Intelligent social engineering and a robust, supportiveinfrastructure are what creates truly healthy environmentsand cities.Veronica Simpson is an architectural journalistThe Le Corbusier exhibition has been produced by the Vitra DesignMuseum, in co-operation with the RIBA Trust and the NetherlandsArchitecture InstituteWORLD HEALTH DESIGN | October 2008 69

Health recordInvest to saveGunnar Öhlén says a whole life costing approach to capital investmentin the global healthcare estate will reap long-term rewardsThe world is full of appropriately planned and well-intended healthcare buildings. But, all too often, as a result of fi nancial compromisesagreed towards the end of the planning process, the fi nal outcome results in a suboptimal building that fails both patients andthe healthcare staff that work there. As head of a large emergency department, less than 10% of my annual budget and that ofthe hospital relates directly to the built environment. Yet, every day, it’s possible to observe how the qualities of our healthcare buildingsnegatively impact on the wellbeing of our patients and staff.In recent years, one of the greatest infl uences on any decisions I have been involved with in relation to new projects and refurbishments,has been an article by Berry et al 1 . Berry discusses the impact and need for additional investments to be made in the hospital environment.In particular, he calls for larger private patients rooms, acuity-adaptable rooms, larger windows and larger patient bathrooms with doubledooraccess, hand-hygiene facilities, decentralised nursing substations, additional HEPA fi lters, family/social spaces on each patient fl oor, ahealth information resource centre, mediation rooms, a staff gym, art for public spaces and patient rooms, and healing gardens.He explains not only the clinical value of these key features, but also theeconomic benefi ts they can bring to the hospital’s bottom line, by reducingpatient transfers, falls, nosocomial infections and the costs associated withdrug delivery.Creating a better working environment also has an infl uence on staffsick leave and turnover. Research at the Karolinska University Hospital byHagerman et al shows that noise-reduction measures have infl uenced thephysiological parameters of cardiac ICU patients as well as staff 2 .All too often, however, fi nancial restraints create suboptimal healthcarebuildings, resulting in an increased operating cost, which ultimatelyrepresents 90% of the overall department and hospital budget. Berry etal suggest another road. By increasing the initial building investment by5% above the baseline to improve the quality of care for patients and theworking environment for staff, operational building costs can be reduceddramatically, providing a payback time on extra initial investment of only6-10 months.In short, there exists a clear choice for those fi nancing our healthcarebuildings. Invest at the outset of a project to decrease the annual running cost of the facility by 5%and, depending on the value of the initial investment, after a number of years you will have savedthe cost of the entire building. Fail to make that investment and, after the same period, you willhave spent the whole building cost again. This is the evidence base upon which capital investmentdecisions in healthcare buildings should be made, but are we doing enough to make this knowledgeavailable and accessible to the bodies that fi nance our healthcare buildings?To play devil’s advocate, it might be argued that the capital investment simply isn’t available tobuild that optimal ten-storey building needed. My answer would be to build nine optimal stories thatin turn will generate the capital for another new optimal building. The alternative is being saddled for40 years with a suboptimal, potentially dangerous ‘white elephant’ building for our patients.Let’s climb the barricades. Let’s raise our voices. Together we can refuse to build healthcarefacilities that are not based on a credible platform of evidence. As Winston Churchill said: “We shapeour buildings and, afterwards, our buildings shape us.”References1. Berry LL. Coile RC Jr, Parker D, Reiling J. Facility Design Focused on Patient Safety/Reply. Frontiers in Health ServiceManagement 2004 (Fall); 21(1):3-24.2. Hagerman I, Rasmanis G, Blomkvist V, Ulrich R, Eriksen CA; Theorell T. Infl uence of intensive coronary care acoustics on thequality of care and physiological state of patients. International Journal of Cardiology 2005; 98:267-270.Gunnar Öhlén MD PhD is headof the emergency department(ED) of the Karolinska UniversityHospital and president of theEuropean Society for EmergencyMedicine (EuSEM). This articleis a personal view and does notnecessarily refl ect the positionof EuSEM70 October 2008 | WORLD HEALTH DESIGN