Norman Foster and the future of health

From the earliest records, cities and the buildings that comprise them have been shaped by many factors – but issues of health are one of the dominants. To explore this connection, it is helpful to identify the essence of urbanisation. Towns and cities are defined by the infrastructure of connectivity – boulevards, streets, plazas, parks and transportation – which forms the urban glue binding together the many individual buildings. That infrastructure will define the DNA, identity and soul of the place – whether it is ugly or beautiful, has a high or low carbon footprint and, above all, whether it is healthy or unhealthy for its citizens. Cities evolve and change over time. In the interests of health, what trends should we encourage or discourage? What are the lessons from the past? Starting with the infirmary of St. Gall of 820 CE, in present-day St. Gallen, patients were grouped around a communal garden; the health-giving benefits of a connection to nature have now, some 12 centuries later, been validated by scientific research. 

These ideas were lost in the deep-plan, air-conditioned and artificially lit mega-hospitals of the 20th century, which were doubtless influenced by similar tendencies in commercial buildings. The roots of a shift to reconnect with nature can be seen in the health resorts of 19th-century Switzerland, in Otto Wagner’s landscaped villas for the mentally ill at Steinhof, and in Alvar Aalto’s light-bathed treatment centre of Paimio in Finland from 1933. The latter is a reminder that the Modern Movement in architecture was rooted in the power of nature to heal – hence the sun-filled terraces of sanatoriums, outdoor domestic balconies, large glass sliding windows, whiteness and sparseness. 

More recently, the same desire to reconnect with nature was manifest during the Covid pandemic. On all counts, the dense, compact, walkable city is the model for the future, based on its present and past success. The carbon footprint is half that of the car-dependent city of freeways and spread-out dormitory suburbs. Additionally, the traditional pedestrian-friendly city, in survey after survey, is voted the most “liveable”. 

Because walking is healthier than driving, it is perhaps not surprising that the city that encourages exercise is naturally the healthiest. If we relate health to longevity, then exercise is one of three determinants – the others are diet and social contact. Loneliness can be a killer and the close-knit neighbourhoods that are typical of the compact city encourage social contact. 

The importance of this is recognised by the government of Singapore to the extent that their housing programme offers incentives for couples who elect to live near their parents. This is not only good for the health of the family, but also the nation’s health service. There is another link to health in the importance of biodiversity. The cause of conservation is laudably linked to the preservation of habitat, and the animals and wildlife that thrive on it. Less newsworthy is its importance to humans, not just through the health benefits of access to nature, but the reduction of infectious disease – two-thirds of known varieties are shared from animals. The World Health Organization has drawn attention to our dependence on biodiversity and healthy ecosystems for our well-being and survival. One hundred nations have signed up to the 30x30 initiative to designate 30 per cent of the Earth’s land and oceans as protected areas by 2030. The imperative to preserve nature is yet another reason to advocate for the compact city with its inherent conservation of land. This is not just for new cities but also for the expansion of existing cities. 

The master plan of Greater London (incidentally conceived at the height of World War II) reinforced the concept of a protective and accessible green belt surrounding the metropolis. Despite the constant threat of intrusions, it has preserved the precious nature of a small island and countered unsustainable low-density sprawl. This holds true, in microcosm, for the individual buildings that collectively form our towns and cities. The history of architecture is the history of technology, and the evolution of hospital design is rooted not just in technology but in the pivotal role of individuals of conscience and learning who exercise leadership. 

The story of the pioneering nurse Florence Nightingale and the engineer Isambard Kingdom Brunel is as inspirational and relevant today as it was more than a century and a half ago. In November 1854, Nightingale arrived at an army hospital in Scutari, Turkey, during the Crimean War. She found the conditions filthy and shocking beyond belief. Through her analysis of data, she showed that more soldiers were dying of disease than from their wounds. This was largely a direct consequence of the hospital design and the operating procedures. Her report back to London created such a scandal that it caused the government to fall. The incoming Lord Palmerston sent out a sanitary commission and in February 1855, Brunel was asked to design a prefabricated hospital that could be quickly manufactured in England and sent out for assembly in the Crimea. Within six days, Brunel had designed a system of wooden fabricated components that could create a hospital for 1,000 patients in wards of 25. The design incorporated innovative cross ventilation, revolutionary water closets, baths, basins, drainage and mechanisms for the rudimentary control of temperature. Just over a month after Brunel’s six-day design exercise, the first of 20 shiploads left Southampton docks.  The mortality rate was one-tenth that of the hospital of Scutari. Brunel later summarised the effort, with characteristic understatement, as “just a sober exercise of common sense”. Aside from a parable of design and design management, this response to a crisis helped to lay the foundations of modern hospital planning, particularly with its emphasis on hygiene. Returning to the important connection between health and nature, I started practising as an architect at the beginning of the 1960s with a firm conviction that capturing natural light, views and air would not just improve the quality of life but would be good for you. The difference between then and now is that these subjective beliefs have been scientifically researched and proven. 

For example, the studies by Professor Joseph Allen of the Harvard School of Public Health from 2016 demonstrated the health and performance benefits from a “green” building – with more light, air and outside awareness – compared with a conventional code-compliant building. Similar studies have shown that patients recovering from surgery in a room with a view use 60 per cent less pain medication and leave a day earlier than those without. How do we ensure the sharing of such knowledge in the critical process of decision-making, whether that is in the realm of city planning or a complex building such as a hospital? The ideal is a bottom-up approach rather than the imposition of a design from above. If in a controlled manner the different interest groups can be encouraged to participate in the process, then the result is not only going to be better, but it will gain acceptance from the start. In the recent project for a major hospital in Philadelphia, I argued the case to make a full-size plasterboard mock-up of an entire floor of the hospital. Accordingly, a huge warehouse on the outskirts of the city was requisitioned for the task. In the ensuing weeks, the layout was visited by squads of nurses, doctors, surgeons, administrative staff and maintenance crews. Emergencies were simulated and everyone was invited to record their observations, criticism and recommendations. This narrative has meandered from the scale of a metropolis down to the detail of an individual building and the meetings of minds that have shared it. One of the most important conclusions is that what is good for the health of the planet is good for the health of our society and the individuals who comprise it.