Doctors Bury Their Mistakes
Some Notes on Hospitals
Nowhere is our pact with the technological devil more clear than in hospitals. They represent our enslavement to a technology that promises survival, on both a personal and a professional level, but only if we promise in return to give ourselves over to it and refrain from seeking its true nature. Despite the fact that these environments are saturated with gadgets, prosthetics and myriad technical devices that probe, invade and sustain our bodies, few are blander. This contradiction is the ultimate purpose of the design of hospitals: in addition to many other jobs a hospital must perform, its principal purpose is to mask and insulate the moment when we must confront our own corporeal reality.
The history of hospital design in this country is not a very glorious one. Since the beginning of the century, American hospitals followed either the French model, which was loosely based on the medieval cloisters and hotels-dieu that were the primary care givers in that country, or the English model of specialized pavilions. By the end of the 19th century, the new scale of the metropolis demanded more centralized and closely packed structures that could share common facilities. Hospitals became factories for health. Starting in the 1920s with such structures as the Columbia-Presbyterian Medical Center in New York, hospitals became integrated high-rises that spread out in patient wings from centralized service cores.
After the Second World War, these cores tended to increase out through the middle of the wings, so that hospitals became fat blocks whose centers were completely filled with windowless service spaces, operating and examination rooms, and offices. The perimeters filled up with repetitive modules of patient rooms. Thus the modern hospital is a hybrid of office building, factory and hotel. Smaller hospitals and clinics merely repeat this typology on a smaller scale and remain totally beholden to the orders of efficiency.
Office buildings as well as factories, however, were at least once meant to look like cathedrals of commerce, but hospitals in this country were never designed to resemble anything except an efficient processing center: a place that would not indicate what went on inside, and that would provide comfort by enveloping the visitor in mute innocuousness. A few of the skyscraper hospital towers of the 1930s were designed, according to their own propaganda, as “fortresses of health,” but it is difficult to find any hospital since then that has any aspect that contributes either to the urban context or to our understanding of the building itself. As figuration has been leached out by the logic of economic processes, hospitals have lost even this sense of comfort, and are now merely massive Goliaths.
Consider, for instance, our local Cedars-Sinai Medical Center. Huge black glass blocks sit on top of sloped concrete bases that confront the street with massive insularity-surpassing, if that is possible, even the neighboring Beverly Center in their complete disregard for their surroundings. The configuration of the various wings ignores existing street patterns, creating shaking internal corridors while bridging over the street grid. Parking garages–mega structure surround the central core, while various departments have spread out into the surrounding neighborhood, taking over office buildings and standing in stark contrast to the genteel scale and detailing of adjacent Beverly Hills. Walk up to the buildings and you will not be able to find either the emergency room or the visitor’s entrance without the help of large amounts of applied graphics. Stand away from these buildings, and those same graphics are the only clue as to what these buildings are.
The ironic logic of urban indifference and inner lifelessness of these buildings devoted to the attentive care of life continues towards increasing insularity: the famed Cancer Clinic at Cedars-Sinai is underground, while the Hollywood Presbyterian Hospital has just seen the addition of a third-level walkway paralleling Sunset Boulevard. It gives the street a sloped grass berm hiding more services, with nothing but a scaleless tube floating above. Inside, w0od accents attempt to recall the existence of a world made of something other than sterilized plastics. Graphics lead through low-ceilinged hallways to various processing points, each of which is a small room where fluorescent illumination overshadows any remnants of natural light. Public spaces are leftover voids carved out of these cubicles and filled with durable fabrics, softer fluorescent lights and muted colors.
Because there is no life in these places, they cannot force us to confront our own death and disease. Which of course is what we want. We want death handled, dealt with or otherwise professionally managed. We are embarrassed by our own infirmity, scared by our mortality, and nervous even in our compassion for those we love. We do not want to linger in hospitals, those isolated compounds of sickness, but want to pretend that we are really someplace else. We do not want to think about all the technology that we have to plug ourselves into to be saved, nor do we want to find an echo of our uncertainties about our own bodies – their gender, the nature of their internal processes, their limits. We want only an airport transit lounge on our flight either back to fully clothed, sublimating health or into another world of corporeal oblivion.
Architects are only one of many causes of the malignancy that afflicts the design of hospitals. Hospitals are the only growth sector in the construction industry, and city after city is becoming infested with a plague of such hulking, insensitive buildings. Although hospitals may be the largest employers in many urban cores, particularly those located in inner cities, these built agglomerations now tower over wastelands that had previously been the thriving residential neighborhoods or industrial workshops of Chicago, Detroit, New Haven, Birmingham or our own Hollywood. They breed giant parking garages, skybridges and their own generating plants. They spawn doctors’ office buildings and pathways cleared for ambulances. They are giant machines that produce, in addition to health for those that can afford it, massive revenues and major urban degradation.
Hospitals were ejected from the city centers they had always occupied when, in the 18th century, they came to be feared as places that spread disease rather than eliminated it. Today, hospitals are again part of a sickness in our body politic, not a cure. They are emblems of our complete refusal to understand our cities, like our bodies, not just as economic structures or service centers, but as physical places. The solution offered in the 18th century, a solution that many cities in Europe still adhere to, was to remove such centers to the periphery. Hospitals, however, confront the suburban fabric with as much insolence and insularity as they do the city.
Instead of further isolation, of either the suburban mall or urban garages–mega structure type, it is now necessary to seek real answers through some form of integration of the hospital with the fabric of the city and the communities they serve. In some cases, that might mean combining hospitals with social housing and retail, while in other cases it might mean disintegrating these condensed bunkers of technology into the texture of the city.
Given the surfeit of land – particularly in some of the emptied areas of our inner cities – the increased flexibility of technology, and the coming reform of the health care system that might slow the construction of massive medical centers, we may now have the opportunity to strip the architecture of hospitals of everything but its abstract fundamentals. Perhaps we can now build a utopian world of sunlight and space, a place of pure planes and lines and specialized nodes, a place with a clarity of form that would paradoxically reveal only our own bodies, like Kolbe’s statue in the Barcelona Pavilion. But were we to go further than Mies and accept the disintegration of traditional notions of both the body and the autonomous architectural object, the modernist ideal might still be realized. Ultimately, we might enable the architecture of hospitals to parallel developments in medicine, moving from speculative and invasive procedures devoted to a technological regime of health to the completely scopic realm of projections, radiations and interpretive recombination of both the city and the body.
Aaron Betsky, who teaches and writes about architecture, is the author of Violated Perfection, New York: Rizzoli 1990.