I was first drawn to healthcare facility design in my fifth (and final) year studying architecture at IIT Kharagpur, West Bengal, India. In our fourth year we had just completed a project on the theory behind design thinking, and I was attracted to the complexity of operational and building systems that exist in a modern healthcare facility, leading to complex relationships between the constituent parts (different clinical, inpatient and support departments) that made up the whole.
I used to play chess and bridge fairly well, but once I got involved in this multi-dimensional game of architectural design (especially healthcare design) the attraction of these board and card games paled in comparison. For my Bachelor’s of Architecture thesis I chose to redesign the Hinduja Hospital at Mahim, Mumbai, India and enjoyed myself thoroughly. This enjoyment showed up in the grade, “Ex” for excellent.
That was a long time back and I have a lot of designs for hospitals under my belt since then. In this time I have worked for five organizations solely engaged in the design and construction of healthcare facilities. It’s been a long journey, difficult at times, now I find myself at the age of 60 mentoring other architects projects and pursuing a growing interest in green or sustainable healthcare projects.
I have always been comfortable working with a bed in the room since my college days, but never found much opportunity to do so after that. Now in the twilight of my life I have come full circle, as I am working out of my residence I can lie down now and then and let my mind wander. I get my best design “eureka” moments this way.
My best and favourite healthcare facility design has been one I did a long time back, Asian Heart Institute, Mumbai, India and it was made possible by having an exceptionally visionary client, the cardiac surgeon Dr Ramakant Panda. Below is a write-up released by AHI’s public relations department.
“Mumbai’s renowned Asian Heart Institute (AHI) has been ranked by an international organisation the “safest cardiac hospital in the world” with the lowest mortality rate, a hospital official said Friday. AHI’s vice chairman and managing director Ramakant Panda said the hospital was accorded the honour among 15 hospitals in eight countries that participated in the International Cardiac Benchmarking survey conducted by the Joint Commission International (JCI). “This included data analysis of more than 6000 cardiac surgeries between October 2009-March 2011,” Panda told IANS here.The 15 JCI accredited hospitals had to provide data captured on a daily basis on the surgeries conducted and reported, set parameters to measure the quality of care provided and cooperate with verification visits by principals, said Panda, who performed heart surgery on Prime Minister Manmohan Singh nearly three years ago.“After the detailed three-year study, AHI has ranked No.1 in terms of ‘lowest complication rates’ and ‘highest survival rates’ as per the JCI survey,” he said.”
I look forward to helping you design your dream healthcare facility in any way I can.
Design as Optimization, Not Compromise
We can make no better high-leverage investments for the future than improving the quality of designers’ “mindware” – assets that unlike physical ones, don’t depreciate but, rather, ripen with age and experience. Many architects, engineers and other designers, however, are not being well taught. J. Baldwin, long the technology editor of Whole Earth Review, was told on his first day in design school that “design is the art of compromise.” Design, he was instructed, means choosing the least unsatisfactory trade-offs between many desirable but incompatible goals. He believed that this formulation described “a political process masquerading as a design process,” and he realized it was wrong.
His inspiration came as he gazed out of the classroom window and saw a pelican catching a fish. For the past 3.8 billion years or so, nature has been running a successful design laboratory in which everything is continually improved and rigorously retested. The result, life, is what works. Whatever doesn’t work gets recalled by the Manufacturer. Every naturalist knows from observation that nature does not compromise; nature optimizes. A pelican, nearing perfection (for now) after some 90 million years of development, is not a compromise between a seagull and a crow. It is the best possible pelican.
A pelican, however, is not optimized within a vacuum. It exists in an ecosystem, and each part of that ecosystem, in turn, is optimized in evolution with the pelican. A change in the pelican or in any aspect of its ecosystem could have widespread ramifications throughout the system, because all its elements are coevolving to work optimally together. For the same reason, an engineer can’t design an optimal fan except as an integral part of its surrounding cooling system, nor an optimal cooling system without integration into its site, neighbourhood, climate, and culture. The greater the degree to which the components of a system are optimized together, the more trade-offs and compromises that seem inevitable at the individual component level becomes unnecessary. These processes create synergies and felicities for the entire system.
The Band – (I Don’t Want To) Hang Up My Rock And Roll Shoes
India’s Health Care Industry
Design and the Bhagwad Gita, Gautama Buddha, Jesus Christ and Baruch Spinoza
Architectural Design and Ethics: Tools for Survival
By Thomas Fisher: Extracts
The Bhagwad Gita
Take one of the oldest religious texts in existence, the Bhagwad Gita. It begins with the warrior, Arjuna, in a crisis, standing in his chariot and about to go into a battle that would pit allies and friends against each other, a situation not unlike what could happen in a future of diminishing resources and growing population, in which not only enemies might go to war with each other, but also families and neighbours. The god Krishna’s response to Arjuna’s despair with the seemingly paradoxical idea that Arjuna should do his duty and go into war without worry about dying or causing others to die, since the body and the material world in general are ephemeral and that nothing can kill the eternal soul in us.
To modern ears, such advice seems quite odd, since we have largely become accustomed to see the material world as permanent, seeing death as something to fear, and viewing the killing of others as an evil. How could a god, in this case Krishna, advise doing just the opposite? Krishna offers Arjuna, however, a profound ethical insight of great use to all of us as we face difficulties as metaphorical charioteers on life’s battlefields. We often think, as Arjuna did, that material reality really matters, that we can’t live without it and that its loss would leave us bereft, but in fact very little of it matters and we can live without all but the essentials needed to sustain life. Moreover, we can find happiness without it if, as Krishna urges Arjuna, we focus on doing our duty and serving others. As we enter a period in which many people will be needing help, valuing the duty of helping others will become key to our making it through our collective hardships.
The argument in the Gita also may seem odd to designers who make things in the physical environment all the time. Reading Krishna’s words to Arjuna might tempt a designer a designer to do what Samuel Johnson did when hearing of David Hume’s scepticism about cause and effect and reality in general: Johnson went over and kicked a rock to demonstrate that things do exist and that kicking a rock has the effect of causing pain. But Krishna isn’t saying that the material world doesn’t exist, only that it is ephemeral, constantly changing, and ultimately beyond our control, and that the only thing that lasts is the soul which exists in all living things. Every designer knows that what we do in the material world will not last, that things deteriorate, break, or fall apart. And while we rarely talk about it this way, designers also know that the best work has a spirit or soul that we find compelling and that causes us to care.
What the Gita suggests for the design community is that what matters is the spirit in what we do: how much the work helps people feel whole and how much it speaks to the spirit in every living thing affected by it. How does our work enhance the humanity not only of those who commission, use, or inhabit it, but also the humanity of those who fabricate, assemble, or build it, and those who will have the responsibility to care for, dispose, or reuse it after we have gone? And how does our work enhance the quality of life of other species – the habitat of plants and animals in the locations where what we use is harvested, where what we create is fabricated, or where what we design gets built?
Gautama Buddha
The Buddha offers another take on this ethical idea, putting less emphasis on serving others and more on being happy and avoiding suffering. Coming from a wealthy family, Buddha knew how much time and attention people paid to earning money and acquiring goods as the way to happiness, but he also saw how much unhappiness – ranging from envy and jealousy to fear and anger – resulted from this very process of gaining possessions. After a period in which he tried to rid himself of all possessions to the point of almost starving himself, he realized that the problem lay not with things, but in our thinking about them. The suffering he saw around him came from our attachment to things, and in our inability to find peace of mind, the lack of which leads us to seek it in the material world. Controlling the mind, eliminating desire, needing nothing, resenting nothing, relinquishing all attachments, focusing on the present moment, having compassion for others, being generous and kind to others – such is some of the wise counsel that the Buddha offers as the way to happiness.
Underlying this is the ethical idea of “the middle way’, the notion that we should seek a path of moderation between the extremes of self-indulgence and self-mortification. That idea also occurs in the ethics of Aristotle and it represents a position quite contrary to the extremism of the modern world, in which extraordinary levels of wealth and poverty, over-consumption and deprivation, exist simultaneously. Nor is it the way in which most of the design world has gone over the last century. Most designers depend upon wealthy individuals, organizations, and governments for many of their commissions, resulting in designers directly serving a very small fraction of the total population. At the same time, the design community has tended to recognize and award work that stakes out an extreme position of one kind or another. Moderation in a project rarely gets covered by the media, rarely draws people’s attention, or rarely attracts the kind of clients that designers sometimes assume is necessary to do good work.
On top of that, the Buddha’s urging that we not be attached to things or not desire possessions also seems to be contrary to what designers do, which is to make things that other people need and want. Is Buddhism antithetical to design? The answer depends upon whether we are talking about current forms of design practice or about design generally. As E. F. Schumacher observed about economics in his development of “Buddhist economics’, design practice has come to reflect the world in which we work, a world in which, as the buddha observed, many people continue to look at material possessions as the way to happiness, rather than their own state of mind. But there has always been design, and we need to discover a design equivalent to Schumacher’s economics, a “Buddhist design’ that isn’t about the design of Buddhist temples or decorative art, but is instead about imagining a form of design that leads to happiness through an embrace of humility, moderation, openness, and acceptance of limits.
Schumacher urged his fellow economists to re-establish their field on some basis other than greed and envy, which he saw as the unhealthy and unhappy motivators for so much economic activity. Designers need to do the same. While greed may want people to want a larger house, a bigger office, or a flashier car, and while envy may lead people to commission work that exceeds in some way that of a competitor, such frames of mind arise out of unhappiness and, as the Buddha mentioned, can only result in unhappiness, which is hardly in the best interest of anyone, be it the designer or those who commission or use what we do. If the purpose of design is to relieve suffering, to improve the world and people’s lot in it in some way, then continuing the cycle of suffering, as the Buddha describes it, renders what we do rather pointless, and possibly leads to the ironic result of design being less valued even as the design for it increases. Like addicts, our culture has become hooked on the quantity of things, wanting more and more of what, in psychological terms, means less and less. ‘Buddhist design’ would refocus people away from quantities of things to the quality of each thing, showing us how we actually need much less than we think we do, so that we can enjoy each thing more.
In a sense, Buddhist design may be more like the natural world we see all around us. It might be made, like a forest, almost entirely of biodegradable materials that serve their purpose and then disappear without a trace. It might consist of materials like rock, that can be endlessly reused by whoever needs it at the time. It might generate wastes, like a plant or animal, that serves as food for others or fertilizer that enhances the richness of the whole. And it might use the least amount of material possible, like a bird, to achieve the greatest efficiency and beauty. The Buddha achieved enlightenment while meditating under a Bodhi tree and we, in the design community, might find similar insight contemplating nature in this way, seeing how we might help others, and ourselves, actually achieve the happiness that people turn to our work for. This will become especially important in the future, when the only real abundance most of us will have will lie inside ourselves.
Jesus Christ
A third ethic to arise out of religion that can serve us as a useful tool is that of Jesus. It has become difficult to talk about Jesus’ ethics because of the current wave of fundamentalism and fanaticism that has emerged from all three of the major Western religions – Judaism, Islam and Christianity. At a time when the writer and former nun, Karen Armstrong has argued, some people see religious texts as scientific facts, as having to be literally true in order to be believed, even talking about Jesus as an ethicist will offend some. But so be it. As Thomas Jefferson did with his bible, cutting out the metaphysics to get to the ethics of what Jesus said in the New Testament, lets look at what the ethical core of what Jesus said has to offer us as we look ahead to a world that may increasingly look like the world that Jesus knew some 2000 years back.
What is most striking about Jesus’ ethical pronouncements is how much they address the needs of the poor. Just as Krishna would urge us to serve others and the Buddha to relinquish attachments, Jesus would have us give up our wealth and share it with the most impoverished people. This radical realignment of wealth, of people voluntarily giving up most of what they own so that everyone could have enough, does seem to get lost in the conflation of Christianity with capitalism that has become common, at least among many conservatives in countries like the USA. It is hard not to read Jesus’ pronouncement that the ‘meek shall inherit the earth’, and wonder about all the competition, aggression, and bloodshed that has characterized the behaviour of some Christians towards other religions or other denominations in their own religion. As Karen Armstrong observed in an interview, ‘religion…is about losing your ego…We need to rediscover what is in our religions, which have gotten overlaid with generations of egotistical and lazy theology. The current thinking – my God is better than your God – is highly irreligious’.
Many designers might be very sympathetic to Jesus’ compassion for the poor and maybe even his urging that we give to the poor everything we don’t actually need in order to live, but design remains a field for the relatively well off and out of reach for most people who do not have the money to pay our fees. What the ethics of Jesus forces us to confront is the question of how design practice can serve the poor, the very people who need, even more than the wealthy, what designers have to offer: that capacity to do more with less, to satisfy the greatest number of needs with the least amount of effort or resources. One way to achieve this would be to see design as a form of public health, which is similar to the way in which Jesus saw his role as ministering to the people that the government and established religion of the day had forgotten.
A public health version of design would entail dealing with the problems that the greatest number of people, especially the greatest number of poor people face in their daily lives. Cameron Sinclair, whose organization, Architecture for Humanity, has come perhaps the closest to achieving such a goal, once said that the one thing people around the world seem to need most is a way of fastening different materials together. Poor people can often get access to cast-off or low-cost building supplies, but connecting materials together in ways that keep out the elements or withstand the wind or possible earthquakes poses a real and largely unaddressed problem. The same is true for peoples need for basic services – water and electric supply, sanitary and storm sewage, security and safety elements. The poorest people lack such essentials, access to which should be a fundamental human right. That billions of people lack one or more of these basic services – access to clean water, to sanitation, to electricity, to security – is something that the design community should take on as both our responsibility and an opportunity. Public health designers, able to address the simplest and most generic challenges in extremely low-cost and low-skill ways, would have billions of people around the globe as users, with governments and non-profit agencies of all types as clients. If designers do not literally give, as Jesus suggests their second coat to the poor, we can at least give the poor our best thinking and most creative ideas.
As Jesus knew well, giving of our time and talent to those most in need will have a transformative effect on us as well as them. That transformation might lead at least some designers to take on, not just the objects and environments people need, but also the processes by which materials get made, products get produced, and supplies get shipped – all with the goal of maximizing local economies, developing local skills and minimizing environmental impacts. We could help end poverty simply by requiring that everything we use be made locally and sustainably. At the same time, the transformation might prompt us to design into our work the process by which it will be deconstructed, recycled, or repurposed, all of which can empower ordinary people and leverage their inherent creativity. The design community must find a way to serve the poor in more than just token ways. It is not just our professional and ethical responsibility to do so, but it is the great-untapped opportunity of our disciplines. For what Jesus said was prophetic: the long-term stewards of the planet, those who will inherit the earth, are the very people who are most ignored and least serves by us today. And if the rest of us continue in our excessive levels of consumption, we will all be like them soon enough.
Baruch Spinoza
A fourth ethics, not specifically religious, but with a strong metaphysical character, is that of the seventeenth century Jewish philosopher, Spinoza. He argued in his Ethics that everything – evry being, every particle, the cosmos itself – is one substance, which he called God/Nature, with physical and mental attributes, and existing in an almost infinite number of modes. Spinoza’s ethics sounds odd at first, and so abstract that only a philosopher might appreciate it, but the more you think about his ideas, the more they open up connections for us. For example, the notion of reality as a single substance brings to mind the work of modern-day physicists who see matter and energy as different modes of the same thing, existing at different speeds. Spinoza’s ethics also anticipated those who search for the so-called theory of everything, in the belief that all reality must follow the same physical laws. In calling this single substance God/Nature, Spinoza elides past the divide that exists in our own time between religion and science by claiming that God and Nature are really the same thing and that God is not some transcendent intelligent designer outside the natural world but is immanent in and inseparable from nature. No wonder Spinoza got in trouble with Jewish authorities in his own day, for his theistic views were much closer to the pantheism of the ancient Greeks than to anything in the Old Testament.
The ethical implications of Spinoza’s one substance also conflict with the dichotomous world view so prevalent today and around which we have designed our built environment. Spinoza argued that unethical behaviour begins with the assumption that individuals or groups are separate from each other and that there is some advantage to be had over others. By denying the validity of that very assumption, Spinoza’s ethics make it impossible or at least completely self-destructive to cause harm to others, for in doing so we only harm ourselves, since they are us, all part of a single, inseparable substance. Complexity theory has made a similar argument about the physical world – that everything, at least on earth, is interconnected so that the proverbial butterfly flapping its wings can contribute to causing a hurricane halfway around the world. Spinoza’s ethics applies a related concept to human actions: everything that we do comes back to affect us. We may not see it or know how or when it happens. It may not happen immediately or in the same way we acted towards others, but our being of one substance makes it impossible for us not to be negatively affected by our negative actions – or positively affected by our positive ones.
Spinoza’s one-substance idea also applies to the natural world, so that the damage we cause to nature, we cause to ourselves as well as to God, which he saw as identical with nature. If we accept Spinoza’s premise, the only conclusion we can draw from it is that we need to act in ways that help, improve, or enhance others – other people, other species, future generations – for there is no other way to help ourselves. That conception of service, of finding our happiness by fostering happiness in others, lies at the heart of all helping professions and offers a very different way of thinking about economics. Instead of an economy based on self-interest – which in Spinoza’s terms might mean self-harm – we might imagine an economy based on other-interest, on giving as much as possible to as many others as we can. This notion of a ‘gift’ economy, in which value and incentives depend on how much we give rather than how much we get, may work best at relatively small scales, among families, tribes, or communities, but that may be the scale many of us live in the future, once we run out of the inexpensive fossil fuels that have so expanded the scale of modern life. The gift economy also seems well suited to the internet age, in which people give advice with no quid pro quo, and where millions of people have access to and benefit from what others have to offer. Indeed, we might see the world wide web as a Spinozan infrastructure, one of many ways in which we come to see ourselves and act as a single interconnected mutually reinforcing entity.
Consider the Cherry Tree
Consider the cherry tree: thousands of blossoms create fruit for birds, humans, and other animals, in order that one pit might eventually fall onto the ground, take root and grow. Who would look at the ground littered with cherry blossoms and complain, “How inefficient and wasteful!” The tree makes copious blossoms and fruit without depleting its environment. Once they fall on the ground, their materials decompose and break down into nutrients that nourish microorganisms, insects, plants, animals and soil. Although the tree makes more of its “product” than it needs for its own success in an ecosystem, this abundance has evolved (through millions of years of success and failure or, in business terms, R&D), to serve rich and varied purposes. In fact, the trees fecundity nourishes just about everything around it.
What might the human-built world look like if a cherry tree had produced it?
We know what an eco-efficient building looks like. It is a big energy saver. It minimizes air infiltration by sealing places that might leak. (The windows do not open.) It lowers solar income with dark-tinted glass, diminishing the cooling load on the buildings air-conditioning system and thereby cutting the amount of fossil-fuel energy used. The power plant in turn releases a smaller amount of pollutants into the environment, and whoever foots the electricity bill spends less money. The local utility honours the building as the most energy-saving in its area and holds it up as a model for environmentally conscious design. If all buildings were designed and built in this way, it proclaims, businesses could do right by the environment and save money at the same time.
Here’s how we imagine the cherry tree would do it: during the daytime, light pours in. Views of the outdoors through large un-tinted windows are plentiful – each of the occupants has five views from wherever he or she happens to sit. Delicious, affordable food and beverages are available to employees in a café that opens onto a sun-filled courtyard. In the office space, each of them controls the flow of fresh air and the temperature of their personal breathing zones. The windows open. The cooling system maximizes natural airflows, as in a hacienda: at night the system flushes the building with cool evening air, bringing the temperature down and clearing the rooms of stale air and toxins. A layer of native grass covers the building’s roof, making it more attractive to songbirds and absorbing water runoff, while at the same time protecting the roof from thermal shock and ultraviolet degradation.
In fact, this building is just as energy-efficient as the first, but that is the side effect of a broader and more complex design goal: to create a building that celebrates a range of cultural and natural pleasures – sun, light, air, nature, even food – in order to enhance the lives of the people who work there. During construction, certain elements of the second building did cost a little more. For example, windows that open are more expensive that do not. But the night-time cooling strategy cuts down on the need for air-conditioning during the day. Abundant daylight diminishes the need for fluorescent light. Fresh air makes the indoor spaces more pleasurable, a perk for current employees and a lure to potential ones – and thus an effect with economic as well as aesthetic consequences. (Securing and supporting a talented and productive workforce is one of a CFO’s primary goal, because the carrying cost of people – recruiting, employing and retaining them – is a hundred times as great as the carrying cost of an average building.) In its every element, the building expresses the client’s and architects’ vision of a life-centred community and environment. We know, because Bill’s (William McDonough, an architect and co-author of this excerpt from the book: Cradle to Cradle: Remaking the Way We Make Things”) firm led the team that designed it.
We brought the same sensibility to designing a factory for Herman Miller, the office-furniture manufacturer. We wanted to give workers the feeling that they’d spent the day outdoors, unlike workers in the conventional factory of the Industrial Revolution, who might not see daylight until the weekend. The office and manufacturing space that we designed for Herman Miller were built for only 10 percent more money than it would have cost to erect a standard prefabricated metal factory building. We designed the factory around a tree-lined interior conceived as a brightly daylit “street” that ran the entire length of the building. There are rooftop skylights everywhere the workers are stationed, and the manufacturing space offers views of both the internal street and the outdoors, so that even as they work indoors, employees get to participate in the cycles of the day and the seasons. (Even the truck docks have windows.) The factory was designed to celebrate the local landscape and to invite indigenous species back to the site instead of scaring them away. Storm water and waste water are channelled through a series of connected wetlands that clean them, in the process lightening the load on the local river, which already suffers serious flooding because of the runoff from roofs, parking lots, and other impervious surfaces.
An analysis of the factory’s dramatic productivity gains has shown that one factor was “biophilia” – people’s love of the outdoors. Retention rates have been impressive. A number of workers who left for higher wages at a competitor’s factory returned in a few weeks. When asked why, they told the management they couldn’t work “in the dark”. They were young people who had entered the workforce only recently and had never worked in a “normal” factory before.
These buildings represent only the beginning of eco-effective design; they do not yet exemplify, in every way, the principle we espouse. But you might start to envision the difference between eco-efficiency and eco-effectiveness as the difference between an airless, fluorescent-lit grey cubicle and a sunlit area full of fresh air, natural views, and pleasant places to work, eat, and converse.
Peter Drucker has pointed out that it is a manager’s job to “do things right.” It is an executive’s job to make sure “the right things” get done. Even the most rigorous eco-efficient business paradigm does not challenge basic practices and methods: a shoe, building, factory, car, or shampoo can remain fundamentally ill-designed even as materials and processes involved in its manufacture become more “efficient.” Our concept of eco-effectiveness means working on the right things – on the right products and services and systems – instead of making the wrong things less bad. Once you are doing the right things, then doing them “right,” with the help of efficiency among other tools, makes perfect sense.
If nature adhered to the human model of efficiency, there are would be fewer cherry blossoms, and fewer nutrients. Fewer trees, less oxygen, and less clean water. Fewer songbirds. Less diversity, less creativity and delight. The idea of nature being more efficient, dematerializing, or even not “littering” (imagine zero waste or zero emissions for nature!) is preposterous. The marvellous thing about effective systems is that one wants more of them, not less.
Insanity has been defined as doing the same thing over and over and expecting a different outcome. Negligence is described as doing the same thing over and over even though you know it is dangerous, stupid or wrong. Now that we know, it’s time for a change. Negligence starts tomorrow.
Michael Braungart and William McDonough, Cradle to Cradle-Remaking the Way We Make Things