NEW YORK — I was born more than a decade after Jonas Salk’s polio vaccine was introduced in the mid-1950s, but family memories of the dreaded disease filtered down to me. Myth and reality conflated in tales of distant relatives or friends who had caught the deadly virus, some who recovered, others who were paralyzed and yet others confined to iron lungs. I don’t know how many of these stories were true, but the fear was real, and fear is perhaps one of the most powerful drivers of how we think about our bodies and health and larger questions of public health.
Nothing about polio was more terrifying than the iron lung, a negative pressure ventilator — a sealed chamber that encapsuled the body from the neck down and used variations in air pressure to expand and contract the lungs. A photograph of one of these is on display in the small but potent exhibition “Design and Healing: Creative Responses to Epidemics,” presented by Cooper Hewitt, the Smithsonian Design Museum, and curated by MASS Design Group, a Boston-based firm that just won the American Institute of Architects 2022 top award.
In the photograph, a smiling woman holds a book above the head of an iron-lung patient, helping them read. For all the fear associated with the device — large tubes of metal often arrayed in long rows, their bulk dwarfing the heads of those encased — they had certain advantages over their contemporary replacement, the ventilator. The patient didn’t need to be intubated or anesthetized and could interact with others while using the machine.
During the covid pandemic, some medical practitioners began taking a new look at the old iron lung. In the same gallery at Cooper Hewitt, there’s a contemporary version of a negative pressure ventilator, designed in Bangladesh and made not of metal, but fiberglass, and designed to cover only the chest. It is smaller than its forebear, and much cheaper than the modern ventilator. In Bangladesh, which has only about 1,500 ventilators for 160 million people, and where imported ventilators can cost $25,000 to $50,000, this $1,000 machine could save lives, not just from covid, but also other respiratory ailments. Suddenly, iron lung 2.0 doesn’t seem so terrifying as the old polio-age models.
The exhibition focuses on moments of resiliency and invention in response to pandemics, past and present. Planning for the show began just before the covid crisis. It opened Dec. 10 as MASS Design Group’s founder, Michael P. Murphy Jr. (with Jeffrey Mansfield and the MASS Design team), published a substantial new treatise on health-care design, “The Architecture of Health: Hospital Design and the Construction of Dignity.” The exhibition shows dignity in practice, from cooperative efforts to address urgent needs created by the current pandemic, to the design of new hospitals for treating such diseases as cholera, Ebola and tuberculosis, which still ravage large parts of the world.
The book raises deeper questions about design, science and architecture. It also charts a history of hospitals from their origins within religious establishments, which provided basic hospice care and religious succor to the dying, to modern mega-hospitals, which seem to be constantly expanding as new specialties are developed and new techniques mainstreamed.
Murphy also has a larger argument: that the study of hospital design isn’t ancillary to larger architectural themes but central to the story of architecture itself. The old modernist argument between form and function is seen within hospital design with unique salience and clarity, in part because the consequences of this debate are so directly felt by people who need health care.
As scientists in the 19th century gained a greater understanding of how disease was transmitted, and greater control over alleviating it, the functional side of health care — control over air, cleanliness, space for machines, recovery, rehabilitation — became the prime driver of design. As surgery became more common, and the need for sterile environments essential, even the rich (who enjoyed the luxury of home health care) found themselves forced into hospitals for treatment. Hospitals, once centered in church complexes and later in buildings that looked like manor houses or banks, began to look more like factories. Patients scrabbled for whatever dignity they could salvage during their terrifying tour through the dark forest of tubes, needles and knives.
Murphy learned about the human side of health care as an architecture student, when his father was dying of cancer, an experience that spurred him to focus on health care and the “construction of dignity” as an essential design principle. MASS Design has created an acclaimed health-care center in Rwanda and innovative cholera and tuberculosis clinics in Haiti. But, as his book points out, the tension between the practical and often ugly medical side of things, and human dignity, will never be resolved. Hospitals force us to consider hard design questions because we want them to be functional and effective. Lots of architects get the form-function balance wrong in art museums — too much pure form, too little thought about practical matters — and the result is a museum people grumble about. Get this wrong in a hospital, and people die.
The basic trajectory of hospital design has, so far, been toward buildings that are ever bigger, more complex and more sealed off from the world. The trajectory of dignity is less linear, and more improvisatory, with a lot of circling back to old ideas. In MASS Design’s health facility in Rwanda, the designers looked back to ideas about ventilation, light and spacing codified by Florence Nightingale in the 19th century. The fiberglass “iron lung” developed in Bangladesh is another example of reclaiming the best parts of older technology.
The central architectural element of early hospitals, including the earliest purpose-built hospitals during the Renaissance, was the altar — the spiritual, focal and aural centerpiece of design. That faded as religion became more fractured, society more secular and hospitals more about healing than dying. But its absence has left a hole that must be filled not by ready-made ideology, but by each patient’s personal invention of spiritual meaning (religious, or otherwise).
Fear can’t be eliminated from the experience of hospitals, but it is too easily compounded and exacerbated by inequities in health care, the industrialization of the process and the capitalist mentality that has made what should be a human right merely a consumer service. Much of what is on view in the Cooper Hewitt exhibition is about resistance, sometimes spontaneous and often collective, to these dehumanizing forces. When covid struck, people started making their own masks, and improving them, and the mask has become a site for the display of identity. Masks designed to fit with turbans and hijabs are on display, as well as masks that convey political messages.
Asserting a fundamental right to dignity and health care is a recurring theme, from communities that were hit hard by covid to the devastating AIDS epidemic, in which the ill were not only neglected but also vilified.
Perhaps the most sobering takeaway from all of this is the realization that bad science will always be with us, but that doesn’t mean that science is bad. Sorting this out is essential to human survival. Among the worst of the bad science cited in Murphy’s book are global “miasma” maps, showing bad air circulating from poor and colonized parts of the world to Europe and beyond. Miasma theory, the idea that disease was spread by miasmas of bad air, is discredited. But bad air can still have direct health consequences, including in badly ventilated hospital wards, or neighborhoods that are inundated with smog and pollutants.
Common sense and open minds can reclaim what is useful from old, debunked ideas or otherwise obsolete machines and technology. It is striking to look at an image of people wearing masks during the 1918 flu pandemic and to think what simple technology it is, how easily made, easily worn and highly effective. Why would anyone resist wearing one? Care for others is the ultimate expression of human dignity.
Design and Healing: Creative Responses to Epidemics Through Feb. 20, 2023, at the Smithsonian’s Cooper Hewitt museum, 2 E. 91st St., New York. cooperhewitt.org.
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