M.Arch Final Thesis- Spatial Therapy by julian huang

Spatial Therapy Towards Clinical Spaces That Promote Health & Well-being BENV GA 05 Julian Huang 2012

Contents: Introduction

I-Diagnosis 1.1- Healthcare spaces as a threat to our health 1.2- Diagnosis of variable components that affect Health 1.3- Findings and Comparisons

10 14 26

II. Examination 2.1- Views, Views that Heal 2.2- Lighting, Day-light and its effects on health 2.3- Passive Ventilation, The Effects of Sick Building Syndrome 2.4- Sounds, The Negative and Positive Effects of Sound

30 31 34 36

2.5- Psychological components that affect health and well-being 2.5.1- Traditional Therapeutic Landscapes 2.5.2- Sense of place

37 39

III. Recovery 3.1- A New therapeutic landscape

IV. Conclusion

V. Bibliography

BENV GA 05 Diploma Thesis

Introduction

BENV GA 05 Diploma Thesis

[0] Introduction

Introduction: The purpose of this thesis is to assess the hypothesis that clinical spaces that utilise natural light, passive ventilation, views of nature and positive acoustics will harbour a positive sense of place that can offer better therapeutic qualities than clinics lacking them. 1.Illich. I, Medical Nemisis. The expropriation of health. (London: Calder & Boyars, 1975) p. 11.

2. Jencks. C, and Heathcote. E, The architecture of hope: Maggie’s Cancer Caring Centres. (London: Frances Lincoln, 2010) p. 78.

To develop the hypothesis, the investigation will first focus on how medical spaces have lost the humanistic approach to clinical design. With readings from ‘Medical Nemesis’, the idea that “the medical establishment has become a major threat to health”1 will be reinterpreted into a contemporary context, where adherence to hygiene and function in clinical design had triumphed over the needs of its occupants, the result is spatial ‘iatrogenesis’. The writing will chart the revolution of medical clinics since the post-war period. It will argue that many are the result of experiments of ‘studies and systems’,2 as a consequence of which the patient had become just another object, a part of a larger system that determines the dominant utilitarian outcome. The critique of modern clinical spaces will be put to the test by evidence gathered in a contemporary health clinic, where it will document the existence of the variable components: views of nature, day-light, passive ventilation and positive acoustics, and identify the sense of atmosphere the clinic offer to its occupants. The findings will be compared to published guidelines to give an objective indication on the state of health of the clinical space. Following the experiment, the main body of the research will comprise examinations in detail of each of the variable components, to reveal the effects they have on our health and how they can affect our well-being. The outcome from the examination will form a part of a wider framework that mediates the relationship between place and health. The notion of a Therapeutic Landscape will be explored through ideas and interpretations from health geography, in order to understand how a sense of place can determine our relationship with certain geographical entities, and how we can utilise landscapes as a part of the healing process.

3. Ibid. p. 54.

BENV GA 05 Diploma Thesis

The outcome from the examination will be critical in order to support the aim of the thesis: to propose ways in which clinical spaces could eventually become a form of treatment in themselves:3 Spatial therapy. This argument will be

further supported through the study of Maggieâ&#x20AC;&#x2122;s Centres and my own proposal for an alternative health care system in Peckham, in order to show how the variable components are applicable to contemporary and future medical clinics, and as a means of reinterpreting and also recovering an ancient healing tradition which we have forgotten, but not yet entirely lost. Methods: The thesis will employ interdisciplinary methods of research in order to gather the necessary evidence to test the hypothesis. The notion of health and well-being is the production of a wide range of disciplines, thus cannot be viewed through a single lens. Therefore the thesis will borrow ideas from social scientists, such as health and cultural geographers to grapple with notions of therapeutic landscape and sense of place; and contemporary architectural historians and critics, to chart the rise of modern healthcare facilities and to analyse smaller contemporary therapeutic clinics such as Maggieâ&#x20AC;&#x2122;s Centres; using empirical investigation, the thesis will document the presence of the variable components inside an existing health clinic; and through the lens of medical and health scientists, they will be examined under the microscope to understand the physical effects on our health and well-being. In this way, the thesis hopes to deliver a response thatâ&#x20AC;&#x2122;s applicable to a contemporary definition of health and well-being. Structure: To develop the hypothesis, the writing is divided into three main sections that are reminiscent of a medical procedure: Diagnosis, Examination and Recovery. The thesis will diagnose the variable components that affect our health and well-being, and the state of health of modern clinical spaces. The examination procedure will investigate how those variable components affect our health and well-being. And then finally the writing will propose methods of recovery of health and well-being in modern clinics.

BENV GA 05 Diploma Thesis

Diagnosis

BENV GA 05 Diploma Thesis

1. Entrances

Fig 1.1

2. Waiting Rooms

Waiting Room

Fig 1.2

Cooridors

3. Transistion Spaces Coridoors

Views There are conclusive evidences that indicates ‘visual exposure to plants and other nature lasting only a few minutes can foster considerable restoration or recovery from stress.’ This relationship can be explained from two different perspectives. Firstly, escapism. Scenes of nature, such as gardens, flowers, trees, provide us with visual stimulation; Fig 1.3 this allows the patient, whilst waiting for consultation or recovering from operation, a means of escaping the stress and anxiety as a result of experiencing illness and pain, thoughts of negativity and anxiety could be replaced by the interplay of nature and mind, creating an opportunity for day dream, the visual scenery of nature can physically, and mentally allow us to escape the bounded and restricted confinement that of a health clinic. illustrated Cooper-Marcus Barnes’s they observed and interviewed remarked: “It’s a good escape from what they put me through. I coTheAsspaces in by modern clinicsand that poseexperiment, the mosta patient threatwhom to their me out here between appointments. I feel much calmer, area less stressed” occupant: the clinical wards, and waiting and the transi-

tional spaces such ascontrol, the corridors. Third, privacy. Together with another major contributing factor to stress and anxiety in the medical environment is the lack of personal space. Health clinics are social spaces, whether it’s between patient and doctor, or patient to patient, or doctor to doctor, we are never alone in a medical facility. Yet sometimes we just want to be left alone, to think, to recover, to reﬂect, to grief. This is particularly relevant in time of illness, where psychological trauma and disease make us confront reality that’s often painful and arduous. In those situations we probably do not want to socialise or occupy a social space. In this context, nature and in particular, a garden provides intimate, close personal privacy that allows the act of reﬂection, recuperation and bereavement.

BENV GA 05 Diploma Thesis

[1] Diagnosis

Healthcare spaces as a threat to our health Modern architecture, in trying to achieve the perfect ‘machine’ for living in, has banished styles and kept out decorations. Modern clinical spaces perhaps epitomise the ideal machine architecture, where function dictates form, and the need to increase efficiency and to reduce iatrogenic infections means the absence of personality, identity and comfort. Our perception of health clinics is that of never-ending corridors punctuated by occasional white boxes equipped with surgical grade stainless steel equipment that glares at us as we shuffle past. The design of the spaces has been reduced to the focus on shifting patients in and out as fast as possible. The idea of a hospital as a place where the concept of hospitality originated, has all but vanished. As Roger Ulrich argues, “the strong emphasis on infection reduction, together with the priority given to functional efficiency, shaped the design of hundreds of major hospitals internationally – that are now considered starkly institutional, unacceptably stressful, and unsuited to the emotional needs of patients, their families, and even healthcare staff.”1 In this context, the thesis argues that the very institution that is supposed to eliminate disease and suffering from us is in fact actively threatening our well-being. How can this be? The debate on the dangers of healthcare facilities to our health began in 1975 in Ivan Illich’s seminal book ‘Medical Nemesis’ which critically claimed that “the medical establishment has become a major threat to health”.2 He argues the threat came from clinical, social and cultural ‘iatrogenesis’3 produced by the medical establishment and its over powered physicians, and the deepening ‘medicalization’ of our society.4 Illich proposed that to reverse the ill effects of medicalization, the “passive public” needs to recover its “will to self-care”.5 But fast forward forty years, where the public is no longer passive and possesses as much power as physicians, medicalization has on the contrary increased. Therefore, it’s not over -physicians and medicalization of society that’s a threat to our well-being, but the clinical environments themselves that are producing the iatrogenic ill-effects, as Roger Ulrich further pointed out: “despite the intense stress often caused by illness, pain, and traumatic experiences, little attention was given to creating environments that would calm patients or otherwise address emotional needs.”6

1. Ulrich. S. R, “Effects of healthcare environmental design on medical outcomes.” in Dilani, A. (ed.) Design and health: Proceedings of the Second International Conference on Health and Design. (Stockholm, Sweden: Svensk Byggtjanst, 2001) pp. 49-59.

2. Illich. I, Medical Nemisis. The expropriation of health. (London: Calder & Boyars, 1975) p. 11. 3. Ibid. p. 11 4. Ibid. p. 11

5. Ibid. p. 165

6. Ulrich. S. R, “Effects of healthcare environmental design on medical outcomes.” in Dilani, A. (ed.) Design and health: Proceedings of the Second International Conference on Health and Design. (Stockholm, Sweden: Svensk Byggtjanst, 2001) pp. 49-59.

BENV GA 05 Diploma Thesis

1. Jencks. C, and Heathcote. E, The architecture of hope: Maggie’s Cancer Caring Centres. (London: Frances Lincoln, 2010) p. 69.

2. Ibid. p. 67.

3. Ibid. p. 65.

4. Ibid. p. 78.

5. Ibid. p. 78.

6. Ibid. p. 78.

This, however, has not always been the case. Before the post-war era that saw the acceleration of the construction of modern health clinics we see today, medical facilities were housed in substantial Victorian or Classical structures, often reminiscent more of grand manor houses situated amongst gardens or countryside,1 examples such as the Royal Naval Hospital in Greenwich (then still part of the countryside), were strategically located and symbolised Religion and the power of its Empire. Its imposing medical facilities were laid out in the pavilion plan so that all the clinical spaces allowed the penetration of fresh air and natural light.2 They also commanded fine views of the surrounding scenery. It is said that Queen Mary herself commissioned the Hospital, after distressed sighting of soldiers returning from battle, which led to the building of the hospital and its subsequent humanistic approach to design of its clinical spaces.3 Since the discovery of the Germ theory, the humanistic approach to clinical design has become redundant. Gone are the symbolic healing structures to religion and power. Instead, modern clinics are symbols of hygiene, efficiency and function. The pavilion plan of classical medical clinics has been replaced by ‘urban super-blocks’, where the inclusion of food production, workshops, laundries and kitchens has rendered them into fully sufficient mini-cities.4 But the design of the medical ‘super-blocks’ was “governed by studies and systems,5 rather than the need, comfort and well-being of their patients. This emphasis on superiority of clinical medicine meant that once admitted patients became the subjects of physicians, the humanist relationship as a consequence was severed. This ‘adherence to efficiency and a blind faith in the results of research’ led to “a soulless architecture of dreary repetition and dehumanized dimness”.6 Where natural light, view and air don’t penetrate beyond its surface while the feelings, emotions and thoughts are confined within. These evidence supports the arguments put forward by many health care researchers such as Roger Ulrich demonstrates that modern medical spaces indeed pose a major threat to health. The main symptom of this threat is the over-institutionalised spaces in medical clinics that exacerbate the feeling of anxiety and stress, often caused by the bland and bleak lighting emitted by the florescent light used and the lack of natural light; the lack of views or access to natural stimulation; the over-reliance on mechanical ventilation; and the poor acoustic levels in clinical spaces.

BENV GA 05 Diploma Thesis

Fig 1.4: From the Classical medical clinics that were laid out on a pavilion plan that allowed the penetration of fresh air, day-light and natural views.

Fig 1.5: To modern medical â&#x20AC;&#x2DC;super-blocksâ&#x20AC;&#x2122; amidst the urban fabric that lacks fresh air, day-light and views of nature.

BENV GA 05 Diploma Thesis

Peckham & Camberwell PCT Locality Camberwell PCTward Locality This locality is NOT co-terminousPeckham with the ward&boundaries (as Livesey is split between Bermondsey & Rotherhithe locality and Peckham & Camberwell locality, and Nunhead ward is splitisbetween Peckhamwith & Camberwell locality and This locality NOT co-terminous the ward boundaries (as Livesey ward is Bermondsey & Rotherhithe locality and Green, Peckham & Camberwell Dulwich locality). Forsplit the between purposes of this report, ONLY Camberwell locality, and ward is split Peckham & Camberwell locality and Brunswick Park, Peckham, and Nunhead The Lane wards arebetween included in this locality. Dulwich locality). For the purposes of this report, ONLY Camberwell Green, Brunswick Park, Peckham, and The Lane wards are included in this locality.

1. Overview •

•

1. Overview Resident Population (2006) = 51,267 1 • Resident o Female 51.8% Population (2006) = 51,267 1 o Female 51.8% o Male 48.2%

Age Structure • o 0-14 years o 15-64 years o 65+ years

Male

48.2%

Age Structure 19.8% o 0-14 years 19.8% 71.2% o 15-64 years 71.2% 9.8% o 65+ years 9.8% Patient Service Area

DICKENSON

Peckham

Camberwell Green VARUGHESE

Peckham

ULLAH

SALAU ULLAH VIRJI ARU SALAU VIRJI KUMAR PATEL ARU MAUNG KUMAR DURSTON KUMAR PATEL MAUNG DURSTON KUMAR HOSSAIN Brunswick HOSSAIN Park Brunswick The Lane

Park

The Lane

NOORULLAH

12 Practices o ARUMUGARAASAH Lister Primary Care Centre 12 Practices o DICKINSON Sir John Kirk Close Surgery o ARUMUGARAASAH Lister Primary CareCamberwell Centre Green Surgery o DURSTON o HOSSAIN Primary Care Centre o DICKINSON Sir John Kirk CloseLister Surgery o KUMAR o DURSTON Camberwell GreenQueens SurgeryRoad o MAUNG Primary Care Centre o HOSSAIN Lister Primary CareLister Centre o NOORULLAH Sternhall Lane Surgery o KUMAR Queens Road o PATEL Giles Surgery o MAUNG Lister Primary CareStCentre o SALAU Gaumont House Surgery o NOORULLAH Sternhall Lane Surgery o ULLAH Lister Primary Care Centre o PATEL St Giles Surgery Parkside Medical Centre o VARUGHESE o SALAU Gaumont House Surgery o VIRJI St Giles Surgery •

o o o

SizePrimary of PracticesCare in Peckham & Camberwell Lister Centre Parkside Medical Centre St Giles Surgery

GLA Population Projections – scenario 8.07 8000 6000

4000

VIRJI

VARUGHESE

ULLAH

PATEL

SALAU

NOORULLAH

KUMAR

MAUNG

HOSSAIN

DURSTON

DICKINSON

GLA Population Projections – scenario 8.07 2000 ARUMUGARAASAH

ULLAH VARUGHESE 120 00 VIRJI 1 100 00 Number of registered patients

•

Fig 1.6: Medical Clinics in Peckham and the surrounding area. This graph shows Gaumont House Surgery (initial SALAU) has the largest number of patient in the Peckham area.

BENV GA 05 Diploma Thesis 2

Exeter – December 2005

[1.2] Diagnosis of variable components that affect Health

Diagnosis

The variable components identified that are threatening our health and well-being are not limited to major hospitals, but also across the spectrum of medical clinics from GP surgeries to Primary care clinics. To demonstrate just how widespread this threat is, an experiment was organized to document the variable components inside a GP surgery in Peckham, which is the site of the design project. The aim of the experiment is to find out precisely the state of health the clinical spaces are in. At the end of the experiment, the findings will be calibrated with a series of reports and design guidelines published by CABE for the design of future healthcare facilities. Gaumont House Surgery on Peckham High Street was chosen as the medical facility for the analysis. This surgery was chosen as it is the biggest clinic serving the local community in Peckham.1 It has over 8,000 registered patients,2 which means more than 1 in five of the local residents are served by the clinic. On the 2nd, 3rd, 4th, 5th, and 6th of April, 2012, the experiment documented the types of light used inside the surgery, and measurements of light levels, sound and temperature were taken inside its main patientâ&#x20AC;&#x2122;s waiting room, it also documented the sights and views from the waiting room, and the different spaces patients experience when visiting the surgery, to give an indication of what kind of sense of place the surgery conveys.

1. Locality health profile: Peckham and Camberwell, accessed from http://www.southwarkpct.nhs.uk/ documents/2575.pdf. pp. 4-5. 2. Ibid. p. 5.

Fig 1.7: External view of Gaumont House Surgery

BENV GA 05 Diploma Thesis

Lighting

Fig 1.8

Currently the only source of day-light comes from the entrance and two frosted panels of window alongside it. The main source of illumination comes from a combination of spot lights, fluorescent and reflected fluorescent light. (see fig. 2.18-2.21)

BENV GA 05 Diploma Thesis

Fig. 1.9-1.13: LUX levels measurements taken in the waiting room inside Goumont House Surgery

Monday 2nd April

Tuesday 3rd April

Wednesday 4th April

Light Condition on: 2nd April 08:20: 167.7 LUX 3rd April 10:35: 144 LUX 4th April 12:10: 126 LUX 5th April 14:40: 142 LUX 6th April 17:00: 107.8 LUX Weekday average LUX level: Thursday 5th April

137.5 LUX

Friday 6th April

Fig. 1.14-1.17: Different mechanical lighting sources in the waiting room inside Goumont House Surgery

Source 1: Fluorescent light

Source 2: Recessed fluorescent down light

Source 3: Reflected fluorescent uplight

Source 4: Sconce fluorescent uplight

BENV GA 05 Diploma Thesis

Fig. 1.18: Entrance and Exit to Goumont House Surgery

Thermal Comfort and Ventilation The ambient temperatures were taken at each day around different points inside the waiting area to give a general indication of the thermal comfort level of the surgery. Ventilation sources were also identified. (fig 1.24-1.25) The entrance is the only source of natural ventilation visible within the vicinity of the waiting area. This question was also put to the staff at reception but they werenâ&#x20AC;&#x2122;t able to confirm other sources of natural ventilation. On the suspended ceiling there are 3 units of mechanical ventilation and air vents visible. Therefore it is reasonable to make a presumption that these 3 units provide all the ventilation for the waiting hall of Gaumont House Surgery.

BENV GA 05 Diploma Thesis

Fig. 1.19-1.23: Light levels measurements taken in the waiting room inside Goumont House Surgery

Monday 2nd April

Tuesday 3rd April

Thursday 5th April

Friday 6th April

Wednesday 4th April

Fig. 1.24-1.25: Ventilation sources in the waiting room in Gaumont House Surgery

Ventilation Temperature recorded on: 2nd April:21.6 ˚C 3rd April: 18.2 ˚C 4th April: 22.1 ˚C 5th April: 22.6 ˚C 6th April: 22.4 ˚C

Weekday average ambient temperature:

21.3˚C

BENV GA 05 Diploma Thesis

Fig. 1.26-1.30: Highest recorded sound measurements taken in the waiting room inside Goumont House Surgery

Monday 2nd April

Tuesday 3rd April

Wednesday 4th April

Thursday 5th April

Friday 6th April

Sound Two types of sound were measured inside the waiting room of the Gaumont House Surgery. Ambient background sound and highest recorded sound. Ambient background sound is taken as an indication of the general background noises experienced in the surgery; these are sounds from the traffic outside, where there is a major road with heavy traffic, and sounds from mechanical components and conversations, etc. These are sounds that occur constantly or at regular intervals. Highest recorded sounds indicate the maximum decibel level recorded during the period of analysis on that particular day, this came from sound of infantsâ&#x20AC;&#x2122; crying, doors slamming, mobile phoneâ&#x20AC;&#x2122;s ringing, general laughter and shouting. These are sounds that do not occur at a regular interval.

BENV GA 05 Diploma Thesis

Fig. 1.31-1.35: Ambient sound levels taken in the waiting room inside Goumont House Surgery

Monday 2nd April

Tuesday 3rd April

Thursday 5th April

Friday 6th April

Sound level taken on:2nd April 08:20, ambient: 66.5 dB. 3rd April 10:35, ambient: 34.4 dB. 4th April 12:10, ambient: 45.4 dB. 5th April 14:45, ambient: 44.8 dB. 6th April 17:00, ambient: 53.5 dB. Weekday average decibel level: ambient:

48.9 dB.

Wednesday 4th April

Highest recorded: 79.0 dB Highest recorded: 87.3 dB Highest recorded: 82.5 dB Highest recorded: 78.8 dB Highest recorded: 70.4 dB Highest recorded:

79.6 dB

BENV GA 05 Diploma Thesis

Fig. 1.36: Receptionist’s desk

View & Access to Nature The surgery’s waiting room does not offer any natural views or simulation of nature. In fact the waiting room has no windows except for the entrance door. And the predominant sights in the waiting area are health information posters and notices. There are two electronic monitors, one for indicating to patients their appointment schedules and the other a television monitor which has the health channel (Life TV) on show. The potted plant shown in the above image on the receptionist’s desk represents the only hint of nature that one could see within the vicinity of the waiting room.

BENV GA 05 Diploma Thesis

Fig. 1.37-1.1.40: Health posters and leaflets on the wall, and TV screen that shows health related programmes.

Fig. 1.41: General view in the waiting room inside Goumont House Surgery

BENV GA 05 Diploma Thesis

Fig. 1.42: The waiting room inside Goumont House Surgery

Atmosphere The surgery conveys a sense of efficiency, function and transparency. From the see-through double fronted entrance doors to the open-plan waiting hall, all areas of the surgery are highly visible, even the staff room, usually hidden from public view, is highly visible to the public. There are no corridors in the clinic; all the consultation rooms are accessible direct from the waiting room. There are no nooks and crannies where one can hide from others. The walls, bare and white-washed, reminiscent of a typical clinicâ&#x20AC;&#x2122;s adherence to hygiene, even the chairs, reminiscent of the mass public seating areas seen in airports and train stations, convey a sense of function and efficiency.

BENV GA 05 Diploma Thesis

fig 1.43- 1.48: Sequence of spaces patient goes through in Gaumont House Surgery

The sequence of spaces a typical patient has to navigate: A: Main Entrance B: Secondary Entrance C: Reception area D: Reception E: Waiting room F: Treatment room

BENV GA 05 Diploma Thesis

Design with care: Design and neighbourhood healthcare buildings Designed with care: Design and neighbourhood healthcare buildings

Summary Future health: sustainable places for health and well-being

Fig 1.49-1.51: Three reports published by CABE relating to the design of future health care buildings.

Future Health: sustainable places for health and well-being.

BENV GA 05 Diploma Thesis

LIFT primary care buildings report LIFT Survey report

[1.3] Diagnosis

Using some key findings from three reports published by CABE regarding future health care facilities, comparisons are made to give an objective overview of the state of health of Gaumont House Surgery. All three reports share a similar theme, which are the emphasis on the importance of using passive ventilation or non-mechanically induced ventilation, the use of daylight for illumination, providing views of natural greenery and creating a positive sense of place. The following are some of the main points extracted from the reports that emphasize the promotion of health and well-being in future medical facilities: “Providing access to nature can reduce stress, improve mental well-being and relieve a sense of overcrowding in urban environments”1 “Use natural light and ventilation, and exploit views of greenery through well-placed windows, to help reduce stress, which is a barrier to healing.” 2

2. Ibid. p. 15. 3. Ibid. p. 15.

“Create places with strong identity and local character” 3 “Pleasant views make a positive contribution to the patient experience”

1. Future Health: sustainable places for health and well-being. CABE. 2009. p. 14. Accessed from :www.cabe.org. uk/files/future-health.pdf (March 2012)

“Natural light creates a calm and glare-free interior”5 “Offering glimpses of greenery can be as important as providing access to gardens” 6

4. LIFT primary care buildings report, CABE. 2008. p. 18. Accessed from : http://www.cabe. org.uk/publications/assessingdesign-quality-in-lift 5. Design with care: Design and neighbourhood healthcare buildings. CABE. 2006. p. 11. Accessed from: http://www.cabe. org.uk/files/designed-with-care.pdf 6. Ibid. p. 27.

Comparing these key points, one can say that Gaumont House Surgery does not meet the standard set out for promoting health and well-being in its clinical spaces. It does not have any of the variable components in place, which has resulted in an atmosphere that feels institutional. Its design focus on efficiency and hygiene has led to the lack of comfort, warmth and cosiness. As efficient as it may be, using this surgery is not a particularly pleasant experience.

BENV GA 05 Diploma Thesis

Examination

BENV GA 05 Diploma Thesis

Physiological Components that Affect Health & Well-being

[2] Examination

Chapter overview In the previous chapter, we have identified the current state of health inside a Peckham GP surgery. This chapter will examine how each of those variable components affects our health and well-being. By gathering evidence from medical and health sciences, the health effects of views, natural light, sound and ventilation is examined.

[2.1] Views

Views Views that Heal The experiment in Gaumont House surgery revealed that its patients’ waiting hall does not offer any views of nature. Instead, patients are bombarded by healthcare posters. According to Baker, this could cause ‘sensory overload’,1 which can have a negative impact on patients’ stress and anxiety levels. Views of nature provide us with therapeutic energy for healing, even a brief sighting of greenery can provide us with a tremendous sense of comfort and relief, as Roger Ulrich pointed out, “visual exposure to plants and other nature lasting only a few minutes can foster considerable restoration or recovery from stress.”2 To understand how views of nature affect our health, both qualitative and quantitative experiments were conducted. Some notable experiments include those of Cooper-Marcus and Barnes, who interviewed patients about how they interact to nature and gardens in Californian Hospitals,3 and Roger Ulrich, who studied the recovery periods of patients who underwent gall bladder surgery who had window views of trees and nature (in comparison to ones who had a view of a brick wall), and had shorter stays and required fewer strong painkillers,4 and the investigation of Nakamura and Fujii, who measured patients’ brain wave activity in response to looking at a plant hedge and a concrete wall that resembled it.5 Through the recorded electroencephalogram data, ‘they found that the green planted hedge elicited more relaxation while the concrete fake hedge created stressful conditions.’6 The ability of healing through views of nature can be explained from two different perspectives. Firstly, the biophilic relationship between natural systems and human evolution. Researchers have argued ‘humans possess a basic need for contact with nature.’7 The relatively recent developments in “agriculture, technology, industry and the city are a small fraction compared to the much longer period of human biological evolution,”8 something our modern environment cannot, yet, replicate. Therefore we are still at a stage of dependency on nature and natural systems “for fitness and survival.”9 And whenever we are struck by illness, we have a tendency to affiliate back to nature,10 as a means of recovering the health and well-being which had derived from the process of biological evolution.

1.Baker. C. F, “Sensory overload and noise in the ICU: Sources of environmental stress.” Crtitical Care Quarterly, Vol. 6. (1984) pp. 66-79. 2. Ulrich. R. S, “Health Benefits of Gardens in Hospitals.” Paper for Conference, Plants for People, International Exhibition Florida. (2002) p. 4. pp. 1-10, 3. Cooper-Marcus. C, Barnes. M. “Gardens in Health care facilities: Uses, therapeutic benefits, and design recommendations.” Martinez, CA: The Center for Health Design. (1995) 4. Ulrich. R. S, “Effects of health facility interior design on wellness: Theory and scientific research.” Health Care Design. Vol. 3. (2002) pp. 97-109. 5. Nakamura. R, & Fujii. E, “A comparative study of the characteristics of the electroencephalogram when observing a hedge and a concrete block fence.” Journal of the Japanese Institute of Landscape Architects, Vol. 55. (1992) pp. 139-144. 6. Ulrich. R. S, “Health Benefits of Gardens in Hospitals.” Paper for Conference, Plants for People, International Exhibition Florida. (2002) p. 4. pp. 1-10, 7. Kellert. S. R, and Wilson. E. O, The biophilia hypothesis. (Washington DC: Island Press, 1993) p. 42. 8. Heerwagen. J. H, “Nature and healing.” in Kellert, S. R (ed.), The science, Theory and Promise of Biophilic Design. (2006). P.6. Accessed from: http://courses. be.washington.edu, on 28.03.2012 9. Ibid. p. 6. 10. Kellert. S. R, and Wilson, E. O, The biophilia hypothesis. (Washington DC: Island Press, 1993) p. 61.

BENV GA 05 Diploma Thesis

1. Cooper-Marcus. C, & Barnes. M, “Gardens in Health care facilities: Uses, therapeutic benefits, and design recommendations.” The Centre for Health Design. (1995) p. 27.

Secondly: escapism. Scenes of nature, such as gardens, flowers, trees, provide us with visual stimulation. This provide the patient with a means of escaping the stress and anxiety caused by illness and pain. Thoughts of stress and anxiety could be replaced by the interplay of nature and mind, creating distractions and opportunities for day dreams. The visual scenery of nature can psychologically allow us to escape the restricted confinement of a health clinic. As illustrated by Cooper-Marcus and Barnes’s experiments, a patient whom they observed and interviewed remarked: “It’s a good escape from what they put me through […] I feel much calmer, less stressed.”1

[2.2] Lighting

2. http://www.hse.gov.uk/pubns/ priced/hsg38.pdf. p. 28. 3. ibid. p. 28.

4. ibid. p. 23. 5. ibid. p. 22.

6. Liberman. J, Light Medicine for the future. (New Mexico: Bear & Company, 1991) p. 57-8. 7. ibid. p. 57.

8. Edwards. L, & Torcellini. P, “A Literature Review of the Effects of Natural Light on Building Occupants.” (National Renewable Energy Laboratory. 2002) p. 6.

9. Terman. M, Fairhurst. S, Perlman. B, Levitt. J, McCluney. R, “Daylight deprivation and replenishment: A Psychobiological problem with a naturalistic solution.” International day lighting conference proceedings II. (November 4-7. Long Beach, C.A. 1986) pp. 438-443.

BENV GA 05 Diploma Thesis

Lighting

Day-light and its effects on health The experiment yielded an average of 137.5Lux over a five day period. While this level of lighting fulfils the standard set out by Health and Safety Executive (HSE) requirements for carrying out task that do not require detail,2 (see fig 2.?) in this case applicable to the patients. But 137.5Lux falls below the 200 Lux level required for staff to carry out tasks such as reading, typing and filing.3 Inadequate levels of illumination can lead to ‘eyestrain, causing irritation, itchiness, breakdown of vision, inflammation of the eyes and general headache and fatigue.’4 It also recommends maximizing the use of natural light with electrical light as support,5 which Gaumont House Surgery has failed to do. In fact the entire waiting space of the clinic relies on electrical lighting, and lacks any source of natural illumination. This according to Liberman, could pose a hazard to the human body both physically and psychologically.6 Electrical lights like fluorescent, incandescent and energy efficient-fluorescent does not contain the ultraviolet spectrum of light,7 which helps the initiation of important biological functions in the human body. This biological function varies in scale, from effects that control our rhythm of life, to microscopic cell divisions that alter our growth. A large scale example is the regulation of our Circadian Cycle, responsible for synchronising our internal body clock to within twenty four hours. Exposure to different types of light, and in this case particularly mechanical light, has been shown to cause significant alterations to our Circadian Cycles. Prolonged exposure to fluorescent light might induce abnormal Circadian rhythms because ‘the hypothalamic pace-making mechanism reacts to all the colour frequencies,’8 and if we are only providing a narrow spectrum of light to the body, the production of hormones which control our sleeping, eating and emotional moods, can be disrupted. Furthermore, experiments have shown that if human beings live in isolation with constant exposure to artificial light, their circadian cycles will extend beyond twenty four hours and would “pose the risk of continual lack of synchrony with the external world.”9

Fig 2.1: Views of nature such as greenery and flowers can drastically improve a patient’s recovery rate and relieve pain

Fig 2.2: Whereas man-made objects increases stress and anxiety levels

Fig. 2.3: The electromagnetic spectrum. Indicating the range of lights that are visible to the human eye and the range that are not visible which offer biological reactions in the human body

The range of light that mechanical The range of visible light and mechanical lighting do not contain, which are lighting offers essential in initiating the biological reactions in the human body

Fig. 2.4: Diagram showing how natural light can affect our autonmic nervous system, which regulates our endocrine system and pineal gland. According to Liberman: “Light enters the yes not only to serve vision, but to go directly to the body’s biological clock with the hypothalamus. the hypothalamus controls the nervous system and endocrine system, whose combined effects regulate all biological functions in humans. [...] hypothalamus controls most of the body’s regulatory functions by monitoring lightrelated information and sending it to the pineal, which then uses this information to cue other organs about light conditions in the environment. In other words, the hypothalamus acts as a puppet master who, quietly and out of sight, controls most of the functions that keep the body in balance.”1 1. Liberman. J, Light Medicine for the future. (New Mexico: Bear & Company, 1991) p. 35.

BENV GA 05 Diploma Thesis

1. Edwards. L, & Torcellini. P, “A Literature Review of the Effects of Natural Light on Building Occupants.” (National Renewable Energy Laboratory. 2002) p. 7-8.

2. Hathaway. W. E, & Hargreaves. J. A, Thompson, G. W. Novitsky, D. Alberta, “A study into the effects of light on children of elementary school age- A case of daylight robbery.” Policy and planning branch, planning and information services division, (Alberta Education. 1992)

Fig. 2.5: Table set out by HSE for general recommended levels of lighting for different tasks. The highlighted box represented the lighting requirements that are applicable to medical clinic’s waiting areas.

Day-light can also affect us down to microscopic levels. This can be illustrated in rickets, which is a disease caused by the deformation in the development of bones in young children due to lack of Vitamin D. One of the most important phototherapeutic discoveries in the late 19th Century was light can be used to cure rickets. Experiments have shown that the contact between skin and sunlight initiates a chemical reaction that leads to the production of Vitamin D; a crucial ingredient for the generation of calcium, a substance bone needs to grow.1 Therefore day-light also creates microscopic changes that our eyes could not detect, but the effects of which are visually evident. However, these microscopic chemical changes only occur in a specific range of light spectra, as Hathaway, et al. point out: “The photobiologic action spectra of greatest importance to humans range from 290 to 770 nanometres. [...] vitamin D synthesis occur in the range of 290 to 315 nanometres. Reduction of dental… [cavities] occurs in response to band light from 280 to 400 nanometres [...] Bilirubin degradation occurs in response to light in the 400- to 500- nanometres range (blue light).”2 Health and Safety Executive

Activity

BENV GA 05 Diploma Thesis

Average illuminance (lux) 1x

Minimum measured illuminance (lux) 1x

Movement of people, machines and vehicles

Lorry park, corridors, circulation routes

Movement of people, machines and vehicles in hazardous areas; rough work not requiring any perception of detail

Construction site clearance, excavation and soil work, loading bays, bottling and canning plant

Work requiring limited perception of detail

Kitchens, factories assembling large components, potteries

100

Work requiring perception of detail

Oﬃces, sheet metal work, bookbinding

200

100

Work requiring perception of ﬁne detail

Drawing oﬃces, factories assembling electronic components, textile production

500

200

Only safety has been considered, because no perception of detail is needed and visual fatigue is unlikely. However, where it is necessary to see detail to recognise a hazard or where error in performing the task could put someone else at risk, for safety purposes as well as to avoid visual fatigue, the figure needs to be increased to that for work requiring the perception of detail. The CIBSE Code for lighting 4 gives more information and recommendations based on scientific knowledge, practical experience, technical feasibility and economic reality. (b) The purpose is to avoid visual fatigue; the illuminances will be adequate for safety purposes (c) The purpose is to avoid visual fatigue; the illuminances will be adequate for safety purposes (d) The purpose is to avoid visual fatigue; the illuminances will be adequate for safety purposes (a)

Typical locations/ types of work

[2.3] Passive Ventilation The Effects of Sick Building Syndrome Gaumont House Surgery was found to rely on mechanical ventilation to regulate thermal comfort in its waiting room. This, according to Godish, can create a potentially dangerous source of indoor air pollutants and harbinger of deadly disease.1,2 Indoor air pollutants can be categorized into two different types, gaseous and particulates. Both contain a wide variety of biological and chemical compounds, which are emitted from building materials, furnishings, mechanical ventilation systems and air intake from external sources. While most are banal, some can be highly toxic and even pathogenic. These include formaldehyde, a highly irritant particulate indoor pollutant resulting from the use of urea-formaldehyde foam insulation and urea-formaldehyde bonded wood products.3 Formaldehyde levels in outdoor ambient atmosphere ranges between 0.0015-0.047 ppm, whilst indoors it can reach levels of 4ppm.4 Between the range of 61-610 µg/m³ (0.05-0.50 ppm), it can cause Sick Building Syndrome (SBS),5 resulting in a myriad of symptoms from headaches to skin allergies and eye, nose and throat irritations.6 This is the result of the defence reaction of the body’s trigeminal nerve against the air pollutant’s penetration of the respiratory system.7 Example of dangerous gas vapour air pollutants include hydrogen chloride, nitrogen dioxide, carbon monoxide.8 But the most common gas vapour contaminate is carbon dioxide (CO₂), a bioeffluent contaminate created by the human body.9 CO₂ in the ambient environment averages 355 ppm,10 but within a contained environment levels of CO₂ can reach in excess of 4500 ppm if the ventilation system is inadequate.11 In most cases, SBS as a result from CO₂ occurs between the concentration levels of 600-1000 ppm.12 Pathogenic air pollutants can exacerbate illness such as asthma and dermatitis,13 and in some cases, it can introduce new disease into the build environment, sometimes with fatal consequences. One such example is legionnaire’s diseases, a bacterium commonly found in rivers and lakes. Due to its tolerance to chlorine, it often ends up in HAVC systems, where warmth and moisture form an ideal incubating environment for the bacterium. According to Witherell et al. L. pneumophila is commonly found in cooling water towers,14 and when “warm water is pumped to the top of the cooling tower where it is atomized. As water gives off heat, small droplets coalesce into larger droplets and collect in a sump at the base from which it is recirculated. Large volumes of air are moved through the tower by mechanical fans to maximize cooling. Some of the aerosolized water is lost as drift, which has the potential to carry infective L. pneumophila into the building.”15

Ventilation

1. Godish. T, Sick Buildings: Definition, Diagnosis and Mitigation, (Florida, CRC Press, 1995) p. 68. 2. Ibid. p. 173. 3. Ibid. p. 148. 4. Marinelli. J, & Bierman-Lytle. P. Little, Your natural home. (New York: Brown & company, 1995) p. 3. 5. Godish. T, Sick Buildings: Definition, Diagnosis and Mitigation, (Florida, CRC Press, 1995) p. 145. 6. Ibid. p. 2. 7. Anderson. I, “Sick Buildings: Physical and psychosocial features, effects on humans and preventative measures.” In: Berglund, B; Berglund, U. Lindvall, T. Sundell, J. (ed.) Indoor air: Proceedings of the Third International Conference on Indoor Air Quality and Climate, Vol. 6, evaluations and conclusions for health sciences and technology; (August 1986 Stockholm, Sweden) Swedish Council for Building Research. pp. 77-81 8. Godish. T, Sick Buildings: Definition, Diagnosis and Mitigation, (Florida, CRC Press, 1995) p. 231. 9. Ibid. p. 140. 10. Ibid. p. 140 11. Ibid. p. 140. 12. Ibid. p. 140. 13. Ibid. p. 176.

14. Witherell. L. E, “Legionella in Cooling Towers.” Journal of Environmental Health, Vol. 49. (1986) pp. 134-139. 15. Godish. T, Sick Buildings: Definition, Diagnosis and Mitigation, (Florida, CRC Press, 1995) p. 174.

BENV GA 05 Diploma Thesis

mg/m3 ppm

< 0.05 0.04

0.05-0.10 0.04-0.08

>0.10 >0.08

SBS SBS

VOCs, mg/m3 Ozone mg/m3 ppm

< 0.05 < 0.03

0.05-0.10 0.03-0.05

>0.10 >0.05

Mucous membrane irritation

Hydrogen chloride mg/m3 ppm

< 1.4 <1

1.4-4

>4 >3

Mucous membrane irritation

Nitrogen dioxide mg/m3 Contaminant ppm

Low < 0.2

Medium 0.2-0.5 0.1-0.3

High >0.5 >0.3

Mucous membrane Eﬀects irritation asthma

< 0.05 0.04

0.05-0.10 0.04-0.08

>10 >0.10 >9 >0.08

Mucous membrane irritation, Genreal symptoms SBS SBS

<<700 0.05 < 0.03

700-1000 0.05-0.10 0.03-0.05

>1000 >0.10 >0.05

Stale air Mucous membrane irritation

< 200 <<10 1.4 <1

200-1000 10-30 1.4-4 1-3

>1000 >30>4 >3

Mucous membrane and skin irritation Mucous membrane irritation

< 0.2 < 0.1

0.2-0.5 0.1-0.3

>0.5 >0.3

none

sometimes

>10 constant >9

<<0.1 700

0.1-0.3 700-1000

>0.3 >1000

Mucous membrane irritation Stale air SBS

< 0.2 < 200 < 10

0.2-0.5 200-1000 10-30

>0.5 >1000 >30

SBS Mucous membrane and skin irritation

< 6x103

6-10x103

>10x103

< 1000

1000-3000

>3000

SBS Allergy, SBS, respiratory complaints SBS, allergy Allergy, SBS, respiratory complaints

<1 none

1-3 sometimes

>3 constant

< 100ng <<50.1

100-2000ng 5-100 0.1-0.3

>2000ng >100 >0.3

Carbon monoxide Formaldehyde mg/m3 mg/m3 ppm ppm Carbon Dioxide VOCs, mg/m3 ppm Ozone mg/m3 ppm Mineral fibers Air, f/m3 chloride Hydrogen Surface, mg/m3 f/m2 ppm Bacteria in air Nitrogen dioxide CFU/m3 mg/m3 Fungi in air ppm CFU/m3 Carbon monoxide mg/m3 smoke Tobacco ppm Dust (air)Dioxide Carbon mg/m3 ppm Floor dust Mineral fibers g/m2 Air, f/m3 Surface,in f/m2 Bacteria floor dust CFU/g Bacteria in air CFU/m3spores in floor dust Fungal

Fig. 2.6: Chart showing the different types of gaseous and particulate indoor air pollutants, and risks to our health.

CFU/g Fungi in air CFU/m3 Macromolecular organic dust mg MOD/g dust Tobacco smoke Dust mites Allergen/g Dust (air) dust Mites /g dust mg/m3 Floor dust g/m2

1-3 of risk Level

< 0.1

< 0.2

0.2-0.5

Allergy, SBS, respiratory complaints Mucous membrane irritation Allergy, asthmaSBS, respiratory complaints Eye Genreal irritation,symptoms SBS

SBS Eye irritation, SBS asthma MucousAllergy, membrane irritation SBS

Source: Kukkonen, E. et al. 1993. Nordtest Report NT Tech. Rep. 204.

>0.5

SBS

Bacteria ﬂoor dust values for community noise in speciﬁc environments. Table 1: inGuideline < 6x103 6-10x103 >10x103 CFU/g

Fig. 2.7: Chart indicating the recommended ambient noise level set out by the WHO. Note that 30dB requirement recommended for hospital wards, much lower than the findings from Gaumont House Surgery, which was at 48 dB.

Fungal spores in ﬂoor dust CFU/g Speciﬁc

environment

Dust mites Dwelling,dust indoors Allergen/g Mites /g dust

Inside bedrooms Outside bedrooms

Hospital, ward rooms, indoors

L Aeq [dB(A)]

>3000

Time L Amax base fast [hours] [dB] 16 SBS 16 16Allergy, asthma SBS, allergy

>3 55 Moderate annoyance, daytime and evening 50 < 100ng 100-2000ng Speech intelligibility & moderate annoyance,>2000ng35 5-100 >100 daytime<&5 evening Sleep disturbance, night-time 30 8 45 Source: Kukkonen, E. et al. 1993. Nordtest Report NT Tech. Rep. 204. Sleep disturbance, window open 45 8 60 (outdoor values) Speech intelligibility, 35 during disturbance of information extraction, class message communication Sleep disturbance 30 sleeping- 45 time Annoyance (external source) 55 during play Sleep disturbance, night-time 30 8 40 Sleep disturbance, daytime and evenings 30 16 -

Hospitals, treatment rooms, indoors

Interference with rest and recovery

Industrial, commercial shopping and traﬃc areas, indoors and outdoors Ceremonies, festivals and entertainment events Public addresses, indoors and outdoors

Hearing impairment

110

Hearing impairment (patrons:<5 times/year)

100

110

Hearing impairment

110

Music and other sounds through headphones/ earphones

Hearing impairment (free-ﬁeld value)

85 #4

110

Impulse sounds from toys, ﬁreworks and ﬁrearms

Hearing impairment (adults)

Hearing impairment (children)

140 #2 120 #2

Outdoors in parkland and conservations areas

Disruption of tranquillity

#1:

BENV GA 05 Diploma Thesis

1000-3000

Critical health eﬀect(s)

Macromolecular organic dust <1 1-3 evening mg MOD/gliving dust area Outdoor Serious annoyance, daytime and

School class rooms & pre-schools, indoors Pre-school bedrooms, indoor School, playground outdoor

< 1000

SBS

As low as possible.

Source: http://www.who.int/docstore/peh/noise/guidelines2.html.

[2.4] Sounds The Negative and Positive Effects of Sound The experiment yielded an average of 48.9dB ambient level of sound in Gaumont House Surgery. This is considered an acceptable level of noise in a work environment. Health and Safety Executive (HSE) stated a quiet office has an exposure between 40-50 dB level of noise.1 However, on the second and third day the measurement yielded a maximum level of exposure between 82 to 87dB, which is considered hazardous, as exposure to noise level above 90 dB starts to cause hearing loss.2 HSE recommended employees should not be exposed to noise level over 87dB on average,3 and with the average measurement of nearly 80 dB experienced in Gaumont House Surgery, patients and particularly staff are susceptible to both psychological and physiological damage. Physiologically excessive level of noise can ‘act as biological stressor eliciting reactions that prepare the body for a “fight or flight” response which triggers both endocrine and autonomic nervous system responses affecting the cardiovascular system,’4 causing elevated blood pressure and heart rate. This might help to explain some patients’ frustration to infants’ crying sound. Psychologically, excessive noise can act as a stressor causing the loss of concentration levels. As Goines and Hagler further pointed out, “noise pollution impairs tasks performance at work, increases errors, and decreases motivation. Reading attention, problem solving, and memory are most strongly affected by noise.”5 On the other end of the spectrum, there are certain sounds that actively contribute to our health. These include sounds of nature, and particular types of music. Guzzetta has found “music therapy effectively reduces anxiety, stress and the experience of pain.”6 This, according to Devlin and Arneill, is because our “emotional responses can be modified when music moves through the auditory cortex, it activates the limbic system, and in turn, affects emotional reactions,”7 Menegazzi et al. have conducted experiments that found patients exposed to music during a laceration operation reported less pain when listening to music.8 The disparity between noise and natural sounds and music can be explained by Baker, who defined noise as, “Nonperiodic waveforms, random in fluctuation, not harmoniously related, that interfere with desired signals”9 Whereas natural sounds and music are composed, rhythmic and harmoniously interconnected vibrations that corresponds with our own internal bodily rhythms.10

Sound

1. Noise at work, guidance for employers on the control of Noise at work, Regulation 2005. p. 2. Accessed from: http://www.hse. gov.uk/noise/regulations.htm. 2. Devlin. A. S, & Arneill. A. B, “Healthcare Environment and Patient Outcomes: A Review of Literature.” Environemental and Behaviour. Vol. 35. (September 2003) p. 677. pp. 665-694. 3. Noise at work, guidance for employers on the control of Noise at work, Regulation 2005. p. 3. Accessed from: http://www.hse. gov.uk/noise/regulations.htm. 4. Goines. L, & Hagler. L, “Noise Pollution: A Modern Plague.” Southern Medical Journal. Vol.100. No. 3. (March, 2007) p. 290. pp. 287-294. 5. Ibid, p. 291. 6. Guzzetta. C. E, “Effects of relaxation and music therapy on patients with coronary care unit with presumptive acute myocardial infarction.” Heart & Lung, Vol. 18. (1989) p.610. pp. 609-616. 7. Devlin. A. S, & Arneill. A. B, “Healthcare Environment and Patient Outcomes: A Review of Literature.” Environemental and Behaviour. Vol. 35. (September 2003) p. 679. pp. 665-694. 8. Mengazzi. J. J, Paris. P, Kersteen. C, Flynn. B, Trautman. D. E, “A randomised controlled trail of the use of music during laceration repair.” Annals of Emergency Medicine, Vol. 20. (1991) pp. 348-350 9. Baker. C. F, “Sensory Overload and Noise in the ICU: Source of environmental stress.” Critical Care Quarterly. Vol. 6. (1984) p. 69. pp. 66-79. 10. Black. D, Healing with sounds. The Healing Currents Series. p.2. Accessed via: http://www.jlgnet. com/dean/Healing_with_Sound.pdf

BENV GA 05 Diploma Thesis

[2.5] Examination

Psychological components that affect health and well-being

[2.5.1]

While the lack of natural views, day light, passive ventilation contributed to the institutionalised feel of Gaumont House Surgery, there is an underlying factor that contributed towards the negative feel of sense of place in its clinical space. This intrinsic connection we have with certain places is part of the definition of Therapeutic Landscapes, and using interpretations from health geographers, this chapter will explore the make-up of therapeutic landscapes, and what creates positive sense of place that makes some places more therapeutic than others.

Therapeutic Landscape

Traditional Therapeutic Landscapes 1. Gesler. M. W, “Therapeutic Landscapes: Theory and a case study of Epidauros, Greece.” Environment and planning D: Society and space Vol. 11. (1993) p. 171. pp. 171-189. 2. Gesler. M. W, “Therapeutic landscapes: medical issues in light of the new cultural geography.” Soc. Sci. Med. Vol .34. No 7, (Great Britain, 1992) p. 736. pp. 735-746. 3. Gesler. M. W, & Kearns. A. R, Culture/Place/Health. (London and New York: Routledge, 2002) p. 121.

4. Gesler. M. W, “Therapeutic landscapes: medical issues in light of the new cultural geography.” Soc. Sci. Med. Vol .34. No 7, (Great Britain, 1992) p. 735. pp. 735-746. 5. Ibid. p. 735. 6. Ibid. p. 736-38 7. Gesler. M. W, “Therapeutic Landscapes: Theory and a case study of Epidauros, Greece.” Environment and planning D: Society and space Vol. 11. (1993) pp. 171-189. 8. Khachatourians. A, “Therapeutic Landscape: A Critical Analysis.” Simon Fraser University. (Summer, 2006). p. 20. Accessed from: summit.sfu.ca/system/files/iritems1/3574/etd2429.pdf.

BENV GA 05 Diploma Thesis

For millennia, human civilisation has always had a profound interconnection with the landscape. The landscape not only promoted a sense of health and well-being, but also has “enduring reputation for achieving physical, mental, and spiritual healing”.1 These therapeutic places can be found across a range of topographic and geographic entities, from natural landscapes, such as springs, forests and meadows, to healing landscapes, such as Stonehenge, the river Ganges and Bath. The therapeutic properties of these places can be attributed to many factors and materials, whether it’s the fresh air, water, or magnificent scenery,2 or its ability to alleviate us from the stress of everyday life.3 The healing abilities of landscapes have been well documented since the days of antiquity. Yet, by simply describing places as therapeutic does not allow us to understand why they are therapeutic or how they came to be thought of as therapeutic.4 It is only by de-constructing the makeup of the therapeutic qualities of a therapeutic landscape that we understand how it operates. Wilbert Gesler, a cultural geographer first introduced Health Geography into the academic scene in 1992. His article, ‘Therapeutic Landscapes: Medical issues in light of the new cultural geography’ proved to be a seminal work that initiated the research into therapeutic landscapes. It draws ideas and interpretations from other fields of cultural and social studies that include anthropology, psychology, and sociology.5 Which helped to provide new concepts such as sense of place, authentic and unauthentic landscape and symbolic landscapes.6 With these, he was able to analyse and reveal the inner mechanics of a series of therapeutic landscapes. One such example is Epidaurus,7 an ancient healing landscape located on an Asclepian sanctuary developed in around 350AD. Its operation is based on the philosophies of Asclepius, the God of healing in ancient Greek religion.8

Fig 2.8: Stonehenge was an ancient therapeutic landscape

“Societies time have moulded the physical land[…]over landscape is […] the product of a particular society, constructions of people living in a particular place forms of scape tothe suit their needs by practising various and time. Thus, landscape is a social construct that arises agriculture, building cities, orestablishes. constructing sites. from the institutions a society As thesesacred institutions change, soisdoes landscape and people’s perspective of it. The emphasis onthethe material aspects of culture, those objects that are visible in the landscape. From this first perspective, a site might be perceived to be healthy if there is a good source of ground water, this might be enhanced by the building of a well. The observer, in this case, is objective and an outsider looking at a scene.”1

Fig 2.9: Varanasi, an important healing landscape that exisists till today.

“landscape is the product of a particular society, the constructions of people living in a particular place and time. Thus, landscape is a social construct that arises from the institutions a society establishes. As these institutions change, so does the landscape and people’s perspective of it.”2

1. Gesler. M. W, and Kearns. R. A, Putting Health into Place: Landscape, Identity, and Well-Being. (New York: Syracuse University Press, 1998) p. 7. 2. Ibid. p. 8.

BENV GA 05 Diploma Thesis

1. Gesler. M. W, “Therapeutic Landscapes: Theory and a case study of Epidauros, Greece.” Environment and planning D: Society and space Vol. 11. (1993) pp. 171-189.

2. Khachatourians. A, “Therapeutic Landscape: A Critical Analysis.” Simon Fraser University. (Summer, 2006). p. 20.

3.Ibid. p. 20. 4.Ibid. p. 29.

5. Gesler. M. W, “Therapeutic Landscapes: Theory and a case study of Epidauros, Greece.” Environment and planning D: Society and space Vol. 11. (1993) p. 186. pp. 171-189.

[2.5.2]

Epidaurus is surrounded by natural beauty, nestling amongst hills and greenery, criss-crossed by streams that provided clean water which was believed to have purification properties, which once sustained a great many bath houses around the site, also included temples, theatre and homes for priests and visitors to the sanctuary. Indeed its scenic location away from any daily stressors, greatly contributed to its healing property as a therapeutic landscape.1 However, besides the fact that the location of Epidaurus is tranquil and serene, there was a more fundamental element at work that makes Epidaurus a therapeutic landscape. It is the psychological belief that it contained supernatural healing powers.2 Long before Epidaurus was constructed, its location, on the site of an ancient Asclepian sanctuary, was already considered a sacred, ritualistic place.3 This can be illustrated by the description of the main treatment that was given to the visitors to Epidaurus, in which “‘day dream’ was performed on patients who would lie still and wait to be visited by the healing God Asclepius in a dream or ‘vision’. If they received a visit from Asclepius, he would diagnose and either treat or prescribe treatment for their illness.”4 Therefore both the physical setting and the psychological belief in the presence of a higher spiritual healer, combined to amplify and strengthen the therapeutic qualities of Epidaurus, as Gesler suggests: “[…] the natural surroundings, the built environment, symbol complexes, beliefs and expectations, sense of place, social relations and relative equality, everyday activities, and territoriality all influenced physical, mental and spiritual well-being.”5 It is only when both the physiological and psychological components in a landscape are working harmoniously, combining our senses, perceptions, and believes, can a therapeutic landscape materialise.

Sense of Place

Sense of Place 6. Gesler. M. W, “Therapeutic landscapes: medical issues in light of the new cultural geography.” Soc. Sci. Med. Vol .34. No 7, (Great Britain, 1992) p. 743. pp. 735-746.

7. Arbury. J, GEOG 726-Geographies of Health and Place. Essay: “Do ‘Therapeutic landscapes’ play a pivotal role in analyzing the relationships between ‘health’ and ‘place’? “(2008).

BENV GA 05 Diploma Thesis

Unravelling the make-up of a therapeutic landscape offered glimpses into the multi-faceted relationship between place and health; as well as a geographical entity, it’s also ‘processes, setting, situations and locales, occupying both the physical and psychological realm.’6 Some health geographers have argued, all places can theoretically become therapeutic landscapes if they have the right set of circumstance that can create a positive sense of place.7 But what is this right set of circumstances? And what are the prerequisites of a positive sense of place?

Fig 2.10

Fig 2.14

Fig 2.11

Fig 2.12

+ Fig 2.13

The healing properties of Epidaurus is a result of a combination of religious beliefs of a presence of a higher spiritual healer (2.10), and great natural scenery (2.11), physical therapeutic elements like clean water (2.12) and a highly organised social structure (2.13).

BENV GA 05 Diploma Thesis

1. Williams. A, “Therapeutic Landscapes in holistic medicine.” Soc. Sci. Med. Vol 46. No 9. p. 1197. pp. 1193-1203. (Ontario: Canada, 1998) 2. Gesler. M. W, and Kearns A. R, Culture/Place/Health. (London and New York: Routledge, 2002) p. 120.

3. Williams. A, “Therapeutic Landscapes in holistic medicine.” Soc. Sci. Med. Vol 46. No 9. p. 1197. pp. 1193-1203. (Ontario: Canada, 1998)

4. Ibid. p. 1198. 5. Gurney. C, & Means. R, “The meaning of home in later life,” in S. Arber & M. Evandrou (ed.) Aging, Independence and the Life Course. pp. 119-131. (London: Jessica Kingsley, 1993) 6. Martin. G. P, “Places like home? Physical, social and psychological aspects in the making of home and other environments in the healthcare of older people.” Doing, thinking, feeling home - 14/15, October, Delft, The Netherlands. p. 2. pp. 1-11.

7. Ibid. p. 2.

8. Taylor. S. E, “Hospital Patient Behaviour: Reactance, helplessness, or control?” Journal of Social Issues. Vol. 35. Issue 1. (April, 2010) p.157. pp. 156-184.

BENV GA 05 Diploma Thesis

A sense of place can be defined as “the identity, significance, meaning, intention, and felt value that are given to places by individuals.”1 This can be either positive, places that are associated with intimacy, comfort and well-being. Or it can be negative, places that are associated with fear and a sense of threat. Therefore, a sense of place is rather subjective; it’s simply ‘what is out there’ for us to register with our senses.2 As Allison Williams further points out: “It is through lived experience that moral, value, and aesthetics judgements are transferred to particular sites which, as a result, acquire a spirit or personality. It is this subjective knowledge that give such places significance, meaning and felt value for those experiencing them.”3 A sense of place requires ‘long-standing’ and ‘on-going’ relationship with certain places, which creates a strong level of ‘psychological rootedness’ that health geographers have argued is the quintessential component for the materialization of a positive sense of place.4 Psychological rootedness is a valuable source of identity and meaning, that mediates place and health. A typical place that entails a strong sense of psychological rootedness is our home. The notion of home is so intrinsically attached to health that the spatial and emotional language of home has often been reconstructed as a therapeutic environment in medical facilities. Places such as care homes, sheltered housing, and adapted hospital wards, they all mimic a homely environment. This is because home is often perceived as a place of ‘ontological security,’5 living at home is associated with independence, happiness and good health,6 qualities that we all associate with well-being. But what are the specific mechanisms that make a home happy and healthy? As the previous sections have explored, a therapeutic landscape is far more than what meets the eye. In the same way, a home is not just a dwelling, a location or geographical entity, it also consists of many personal and symbolic connotations. A home can be understood as a wider process that’s “created as much by the acts of those involved […] as by its immanent properties as a place.”7 To understand why home makes us feel rooted, we have to examine what a home provides us with. Besides being a shelter, home also provide us with security, memory and more importantly, freedom and control. Take a health clinic as an example; where we are confined to a bounded setting, we can only enter from a certain place, at a certain time. This renders us out of control, both spatially and physically. We have no control over what physicians do to us, and we cannot go into places where it’s off-limit to the patient. Do we have any choice in a health clinic? As Taylor has pointed out, a clinic “is one of the few places where an individual forfeits control over virtually every task he or she customarily performs.”8 But the notion of a home, is where we are in total control of our surroundings, over what we do, where we go, when to arrive, when to leave. In another sense, we have total freedom of a place.

In essence, health equates freedom; free from disease, free from pain, free to eat the food we desire. Furthermore, home “is perhaps that place where most of us experience true existential insidedness”1 This is the fundamental bond that develops which results in a strong sense of psychological rootedness, and consequently a positive sense of place.

1. Cosgrove. D, “Place, landscape, and the dialectics of cultural geography.” Canadian Geographer 22 (1), (1978) p. 69. pp. 66–72

BENV GA 05 Diploma Thesis

Recovery

BENV GA 05 Diploma Thesis

[3] Recovery

Recovering Health and Well-being in Modern Health Clinics Chapter Overview The final chapter will explore different methods of how these variable components, both physical and psychological can be adapted to contemporary clinical spaces, thus restoring an ancient tradition which we have very much forgotten but have not completely lost. The following will look at how Maggie’s Centres achieve a strong sense of place through utilising day-light, passive ventilation and views of nature to promote a sense of warmth and well-being. This reflection will be used as a barometer to calibrate my own proposed Ayurveda Health Clinic, which serves as a framework that can be used to develop future clinical spaces where the architecture itself becomes a mode of treatment.

[3.1] A New therapeutic landscape The changing landscape of healthcare across the country is revolutionising the way we access medical facilities. The rise of the primary-care clinics in the last decade has reduced hospitals to reserves for complex surgical procedures and emergencies. More and more, these smaller community health clinics are bearing the brunt of society’s healthcare responsibilities, from pre-natal care to palliative care. Yet this changing scale of medical spaces can be regarded at as a positive step towards creating clinical spaces that promote health and well-being. They emphasize more on healing and therapy, and require fewer restrictive building regulations. One example, above all, that has captured the public’s attention about just what health benefits can clinical spaces offer are Maggie’s Centres. Created as a consequence of Maggie Keswick’s experience as a cancer patient in the early 1990s, Maggie’s Centres offer support and advice for sufferers and their families and friends. Unlike hospitals and GP surgeries, the centre operates as a drop-in service, this ability of patients being able to access the clinic without making prior appointment, immediately created a much more accessible healthcare service, and it’s just one of the varieties of

BENV GA 05 Diploma Thesis

1. Jencks. C, and Heathcote. E, The architecture of hope: Maggie’s Cancer Caring Centres. (London: Frances Lincoln, 2010) p. 12.

2. Blakenham. M, “Maggie’s Centre, Marching on.” in Keswick, M. Jencks, C. (ed.) In A view from the front line, (London: 2007) p. 30. 3. Gurney. C, and Means. R, “The meaning of home in later life”, in S. Arber & M. Evandrou (ed.) Aging, Independence and the Life Course. pp. 119-131. (London: Jessica Kingsley, 1993)

4. Jencks. C, and Heathcote. E, The architecture of hope: Maggie’s Cancer Caring Centres. (London: Frances Lincoln, 2010) p. 38.

5.Ibid. p. 38.

methods they used to emphasize its patient-focused strategy, which is based on creating an informal, un-institutional and homely environment where patients would feel as though they are being given support and care in their own home. As Charles Jencks, co-founder of Maggie’s centre pointed out, “informal, like a home […] meant to be welcoming, domestic, warm, skittish, personal, small-scaled and centred around the kitchen or place to make coffee and tea.”1 This focus on domesticity in Maggie’s centres demonstrates the outcome of a positive sense of place where the previous chapter had explored. The creation of a psychologically rooted place that empowers the patients can facilitate a sense of control. This initiate a mentality of fight, rather than succumbing to the deadly effects of the disease, the sense of control metaphorically translates into literally taking control over the disease and one’s own life.2 Furthermore, spaces with a strong sense of place such as the domestic environment provide the patient with ‘ontological security’,3 so even though it may be the first time a patient encounters the centre, the feeling of homeliness, of deep psychological rootedness could be instantaneously established. Maggie’s Centres employ several methods to create their focus on domesticity, and even though each of the centres has its own distinct characteristics, a familiar theme unites them, it is the integration of communal areas, where patients and staff can participate in workshops and group activities, with smaller intimate spaces where patients can reflect and discuss with staff the psychological trauma of coping with the disease. This is probably best illustrated by the Maggie’s Centre in Hammersmith. Its spatial layout recalls that of late 19th century domestic architecture,4 where semi-open plan living areas juxtaposed and intertwined with transitional spaces, with sliding doors to provide visual and acoustic privacy, the focal point is centred around the kitchen-dining area or a fireplace. This is reminiscent of Frank Lloyd Wright’s 1889 Oak House, with its large hearth occupying the centre of the house. The resulting space in Maggie’s Centre is personal and private, but also public and communal.5 The integration of semi-open and intimate spaces is also represented in many of my own proposed alternative health clinics. One example, the Ayurveda clinic, which will be used in this section to calibrate with the Maggie’s Centres. The clinic is a part of a series of health centres that offer alternative treatments such as Ayurveda, Chinese and African Herbal Medicine across the London boroughs of Peckham. This proposal responds to the changing landscape of health care that’s taking place across Britain, especially with the ongoing threat of the privatisation of the NHS, it explores how we will access and interact with health care facilities in the future. It suggests future access to health care could become a part of everyday experience; Where going to the local supermarket could also mean a pit-stop at the dietician’s, or getting your hair cut in the local hairdresser’s mean a visit to the dermatologist to resolve scalp allergies.

BENV GA 05 Diploma Thesis

Fig 3.1

Fig 3.2

Fig. 3.4: The plan of Maggie’s Centre in Hammersmith in West London.

Fig. 3.3: The focal point of most of the Maggie’s Centre are around the domestic environment such as the kitchen and living room

Fig. 3.5: The plan of Maggie’s in Hammersmith recalls 19th century domestic architecture such as the Oak House by Frank Lloyd Wright.

BENV GA 05 Diploma Thesis

The privatisation of the NHS could see the commercialisation of health care facilities throughout our cities, where the sight of a clinic could become as ubiquitous as the local convenience store. This would create a much more dynamic and flexible health service. Just like the Maggie’s Centres, where patients can ‘drop-in’ at any time, the patients using the proposed alternative clinics can visit the health service as a part of their daily routine; shopping, haircut, going to the gym and so on. This would make health care even more accessible than Maggie’s, where medical facilities are fully integrated with the everyday experiences of the local community, where health clinic is not a destination, but a part of the everyday process we take part in. In this case the Ayurveda clinic becomes an extension of a salon, which it is attached to on Peckham Road. But instead of focusing around the kitchen and dining table as seen in Maggie’s, the Ayurveda clinic is focused around the hair dressing rituals, in particular, the hair washing facility, which is also doubled up as the waiting room of the health clinic. The semi-open waiting area and hair washing facility offer close encounters with nature and greenery in the form of an ‘upside down garden’. (see fig 4.?)This concept came from analysing how hair dressers operate, especially when customers first get their hair washed before their hair cut. During this process, the customer usually lies down in a semi-flat position, visually focused towards the ceiling. Interestingly, the ceiling is also one of the most institutionally symbolic aspects of health clinics, with its drab and bland tiling and florescent lighting, (as seen in Gaumont House Surgery), the stereotypical suspended ceiling and its fluorescent lighting came to symbolise all that is wrong with health care facilities. This inspired the proposal to offer a vertical view that is both calming and restorative, which resulted in a double skin ‘chimney’ (see fig 4.?) that offers a vertical view of a living green wall, an upside down garden.

1. Jencks. C, and Heathcote. E, The architecture of hope: Maggie’s Cancer Caring Centres. (London: Frances Lincoln, 2010) p. 182.

BENV GA 05 Diploma Thesis

As we have already identified in the previous chapters, the incorporation of nature and views of natural scenery help to create a sense of tranquillity and reduces stress and anxiety in patients. This strategy can be seen across the various Maggie’s Centres. Its strategic use of views and access to nature plays an integral part of the architecture, whether in framing a spectacular view, such as in Dundee, where the centre sits on top of a hill with breath taking scenery overlooking the River Tay and further to the City of Dundee, or its focus on ‘rooting’ the building into the natural environment,1 so that it can be registered as part of the landscape itself. This is achieved in Gartnavel, Glasgow. Developed on a gentle wooded slope, its focal point around a central courtyard, enables all the internal areas to have access to natural scenery, physically or visually, either inwards, towards the courtyard or outwards, into the small forest. Furthermore, the increase in the porosity of the building also results in an increase in passive ventilation. In Gartnavel, where each room has openings to either the courtyard or the forest, generates a circulation of fresh air movement around the building.

Fig 3.6: Drawing showing how the clinic is attached to the back to a salon, becoming a part of the urban fabric of the high street

(A).

Fig 3.7 (top) and 3.8: Maggieâ&#x20AC;&#x2122;s in Gartnavel focuses on framing the natural landscape, both inside of a courtyard and outside the forest

Fig. 3.9: Maggieâ&#x20AC;&#x2122;s in Dundee also frames the spectacular scenery with its architecture

BENV GA 05 Diploma Thesis

Fig 3.10: The view inside the waiting room of the Ayurveda clinic, which is also double up as the hair washing facility of the salon. While patients/ customers receive their hair washing, they will be able to see up inside the â&#x20AC;&#x2DC;upside down gardenâ&#x20AC;&#x2122; inside the chimney, which is also a day-light catcher and passive ventilation mechanism

BENV GA 05 Diploma Thesis

Fig 3.11: The dreaded walk through the never-ending white-washed corridors with bland and bleak fluorescent ceiling lights is replace by a curving staircase that takes patients up to the treatment rooms. The staircase wraps around a courtyard with trees and greenery, mimicking the journey through a canopy of a forest.

BENV GA 05 Diploma Thesis

This openness to the natural surroundings also enables the full use of natural light throughout the interior. Looking at the various Maggie’s Centres, each has a strong emphasis on utilising day-light. Gone are the dreaded white fluorescent ceiling lights, which drain the last breath of health from patients. 1. Jencks. C, and Heathcote. E, The architecture of hope: Maggie’s Cancer Caring Centres. (London: Frances Lincoln, 2010) p. 102.

Each Maggie’s Centre harnesses the maximum amount of natural light through large windows and roof openings, but it never overpowers an interior. Instead through ‘complex compositions’ of layers of openings and partitions,1 sunlight is filtered, bounced, reflected and refracted into a soft, warm and sensual glow that illuminates communal spaces, and shades more intimate nooks and crannies. This idea of playing with natural light is most evident in Edinburgh, where a long narrow sky-light provides daylight into the offices on the mezzanine floor and communal spaces below, but a series of threequarter height wall partitions hides a complex of personal seating spaces. The result re-emphasizes the language of domesticity. In my proposal, the ‘chimneys’ also act as daylight catchers. Each ‘chimney’ is tilted at a slight angle towards the south to maximize the amount of natural light coming into the building. The planting and greenery on the ‘upside down’ garden become filters for the direct sunlight to reduce glare. The resulting natural light coming into the waiting area of the clinic is reminiscent of that of a forest, with the ‘upside down’ garden metaphorically acting as the canopy. This is to further enhance the sensation of being in a natural environment. The ‘chimneys’ also serve another important function, which is to naturally ventilate the clinic. As we have seen in Gaumont House Surgery, too often medical facilities rely on mechanical ventilators for air exchange and regulation of thermal comfort. But these systems are also harbingers of disease such as Legionnaires, and further undermine our health. Maggie’s Centres serve as a catalyst for future health clinics to adapt passive methods of ventilation, not only to reduce the energy consumption of buildings, but also to avoid iatrogenic infections caused by the medical facility itself, such as sick building syndromes. Furthermore, as shown in Maggie’s in Gartnavel, passive ventilation is a natural consequence in providing sufficient day-light and access to nature, as the increase in porosity of the building increases the likelihood of passive ventilation, providing that the orientation of the building and openings correspond to prevailing wind directions.

2. http://en.wikipedia.org/wiki/ Windcatcher

BENV GA 05 Diploma Thesis

The passive ventilation system employed in the Ayurveda Clinic is inspired by the Iranian ‘malqaf’.2 These ‘chimneys’ contain openings at the top that aligns with the prevailing wind to attract a circulation of breeze into the building via one ‘chimney’ and out again via another.

The top of the chimneys have openings that correspond with the prevailing wind

Warm Air out Pipes inside directs natural air down to the clinic spaces and the waiting room Glaszing on the top of the central chimney allows day-light penetrate into the waiting area

Private/personal areas in the waiting room

Cool Air in

Main public waiting area that double up as the hair washing facility for the salon itâ&#x20AC;&#x2122;s attached to Staircase upto treatment rooms

Fig 3.12: Cut away section showing the waiting room and the raised treatment rooms, which are accessed by a staircase wrapping around the courtyard. The waiting room integrates both public spaces and more personal, intimate areas, which are housed in a series of pods. The structure of the chimney also serve as structural support for the treatment rooms. The chimney at the centre is a day-light catcher, while the other chimneys are passive ventilation mechanisms.

BENV GA 05 Diploma Thesis

Furthermore, the planting on the living wall acts as filters for the air coming into the building, combining with the scents from the herbs grown inside the chimneys, to create naturally aromatic fresh air, one variable component this report did not explore but could potentially have significant impact on our well-being. The various Maggieâ&#x20AC;&#x2122;s Centres illustrated in this final chapter and my own proposal have shown how clinical spaces donâ&#x20AC;&#x2122;t have to be institutional in feel to be efficient, hygienic and functional. Indeed, they have demonstrated how pleasant clinical spaces could be by putting in places the variable components, and drawing on ideas from our ancient healing practices which so many medical clinics seem to have forgotten. In the context, the Maggieâ&#x20AC;&#x2122;s Centre and my own proposal are not new typologies of health care facilities; rather, they are contemporary reinterpretations that aim to recover our ancient healing traditions that have been with us for millennia. A tradition that is fit for contemporary society and its cultural beliefs.

BENV GA 05 Diploma Thesis

Fig 3.13: Axonometric drawing of the Ayurveda Clinic and the salon it is attached to

BENV GA 05 Diploma Thesis

Conclusion

BENV GA 05 Diploma Thesis

Conclusion

[4] Conclusion

The thesis set out to assess the hypothesis that clinical spaces with variable components in place such as natural view, day-light, passive ventilation and positive acoustics can offer a better therapeutic environment than clinical spaces that are lacking in them. Clinical spaces lacking these components, the thesis has found, are the outcome of experiments of studies and systems, rather than answering the need of its occupants. The emphasis of hygiene and efficiency had triumphed over comfort and well-being. The result is the objectification of patients, no different to a surgical scalpel, or a life-support machine, a part of a bigger system that determines the design of a most efficient and functional outcome. These bland, cold and institutional clinical spaces pose a real threat to the health and well-being of their users. Soon after they appeared on our urban fabric, their ill-effects started to be documented by scientists and researchers. But somehow, the thesis has found the adherence to efficiency and function still prevails despite its known ill consequences. And till this day, these clinical spaces can still be found in contemporary facilities. This is supported by the evidence gathered in a local health clinic in Peckham, where the lack of natural light, view of nature and passive ventilation, created a highly institutional atmosphere, combined with the regular excessive noise experienced, the clinic offered a negative sense of place that increased the occupantsâ&#x20AC;&#x2122; stress and anxiety levels. Each of the variable components measured in the health clinic has been examined through the lens of medical science, which has successfully revealed how they promote a sense of health and well-being. Specifically, it has found that views of nature can significantly reduce stress levels and alleviate anxiety by re-establishing what researchers call the biophilic relationship, and providing visual escape away from the confinement of clinics. Natural light has been identified to be critical in the initiation of important biological reactions in the human body, preventing fatal diseases like rickets, while the lack of it can lead to the alteration of our circadian cycle, disrupting our sleeping and eating patterns. Passive ventilation has shown to be useful in the prevention of Sick Building Syndromes, which can cause a multitude of ill-health from headaches and asthma, to fatal diseases like Legionnaires. Positive acoustics have been shown to be able to reduce stress and pain in patients due to its rhythmic composition that corresponds with our own cellular structures, while noise is associated with the disturbance of our ability to concentrate. More seriously noise can affect the cardiovascular system, causing elevated blood pressure and heart rate.

BENV GA 05 Diploma Thesis

These physical variable components have been found to be a part of a bigger framework that contributes to the formation of a therapeutic landscape. As seen in Epidaurus, they combine with cultural and religious beliefs to form a positive sense of place that harbours ‘ontological security’. This help us to feel psychologically rooted. Similar to the domestic environment, it provide us with a sense of freedom and control, which in a clinical context, translates into relief from stress and anxiety, and promotion of health and well-being. The goal of the examination is to propose methods of turning clinical spaces into a form of medical treatment in itself. Using reflections from Maggie’s Centres and my proposal, this argument has been successfully demonstrated. It has shown how the variable components are applicable to contemporary clinical spaces which offer comfort, cosiness and warmth, and more importantly, they offer a sense of hope, an architectural equivalent of the placebo effect, which in itself, becomes a form of medical treatment.

BENV GA 05 Diploma Thesis

Bibliography

BENV GA 05 Diploma Thesis

Books Blakenham. M, “Maggie’s Centre, Marching on.” in Keswick, M. Jencks, C. (ed.) In A view from the front line, (London: Maggie’s Centres Foundation, 2007) Accessed from: www.maggiescentres.org/maggies/ dms/maggiescentres/.../VFTFL. (April 2012) Gesler. W. M, & Kearns. R. A, Culture/Place/Health. (London: Routledge, 2002) Gesler. M. W, and Kearns. A, Putting Health into Place: Landscape, Identity, and Well-Being. (New York: Syracuse University Press, 1998) Godish. T, Sick Buildings: Definition, Diagnosis and Mitigation, (Florida, CRC Press, 1995) Gurney. C, and Means. R, “The meaning of home in later life,” in S. Arber & M. Evandrou (ed.) Aging, Independence and the Life Course. (London: Jessica Kingsley, 1993) Illich. I, Medical Nemisis. The expropriation of health. (London: Calder & Boyars, 1975) Jencks. C, & Heathcote. E, The Architecture of Hope. (London: Frances Lincoln, 2010) Kellert. S. R, & Wilson. E. O, The biophilia hypothesis. (Washington DC, Island Press, 1993) Kellert. S. R, Building for life: Designing and understanding the Human-Nature Connection. (Washington DC, Island Press, 2005) Liberman. J, Light: Medicine of the future. (Rochester, Vermont, Bear & Company, 1991) Marinelli. J, and Bierman-Lytle. P, Your natural home. (New York: Brown & company, 1995)

Websites: Southwark Healthcare, Locality health profile peckham and camberwell, accessed from http://www. southwarkpct.nhs.uk/documents/2575.pdf. CABE, Future Health: sustainable places for health and well-being. (2009) Accessed from: http://webarchive.nationalarchives.gov.uk/20110118095356/http:/www.cabe.org.uk/files/future-health.pdf CABE, Design with care: Design and neighbourhood healthcare buildings. (2006) Accessed from: http:// webarchive.nationalarchives.gov.uk/20110118095356/http:/www.cabe.org.uk/files/designed-with-care. pdf CABE, LIFT primary care buildings report. (2008) Accessed from: http://webarchive.nationalarchives.gov. uk/20110118095356/http://www.cabe.org.uk/publications/assessing-design-quality-in-lift Health Safty Executive: http://www.hse.gov.uk/pubns/priced/hsg38.pdf. Noise at work, guidance for employers on the control of Noise at work, Regulation 2005. Accessed from: http://www.hse.gov.uk/noise/regulations.htm. Black, D. Healing with sounds. The Healing Currents Series. Accessed via: http://www.jlgnet.com/dean/Healing_with_Sound.pdf http://en.wikipedia.org/wiki/Windcatcher

BENV GA 05 Diploma Thesis

Articles/Journals: Anderson. I, “Sick Buildings: Physical and psychosocial features, effects on humans and preventative measures.” In: Berglund, B; Berglund, U. Lindvall, T. Sundell, J. (ed.) Indoor air: Proceedings of the Third International Conference on Indoor Air Quality and Climate, Vol. 6, evaluations and conclusions for health sciences and technology; (August 1986 Stockholm, Sweden) Swedish Council for Building Research. Arbury. J, “Do ‘Therapeutic landscapes’ play a pivotal role in analyzing the relationships between ‘health’ and ‘place’?” GEOG 726-Geographies of Health and Place. (2008). Available: http://portal.jarbury.net/ essay/therapeutic.html [April 2012] Baker, C. F. “Sensory overload and noise in the ICU: Sources of environmental stress.” Crtitical Care Quarterly, Vol. 6. (1984) pp. 66-79. Cooper-Marcus. C, & Barnes. M, “ardens in Health care facilities: Uses, therapeutic benefits, and design recommendations.” The Centre for Health Design. (1995) Available: http://www.healthdesign.org/chd/ research/health-and-nature-influence-nature-design-environment-care?page=11. (March 2012) Cosgrove. D, “Place, landscape, and the dialectics of cultural geography.” Canadian Geographer 22 (1), (1978) pp. 66–72 Devlin. A. S, and Arneill. A. B, “Healthcare Environment and Patient Outcomes: A Review of Literature.” Environemental and Behaviour. Vol. 35. no. 5. (September 2003) pp. 665-694. Available: http://eab.sagepub.com/content/35/5/665.full.pdf+html (April 2012) Edwards. L, & Torcellini. P, ‘A Literature Review of the Effects of Natural Light on Building Occupants’. National Renewable Energy Laboratory. (JULY 2002) Accessed from: http://www.nrel.gov/docs/fy02osti/30769.pdf Gesler. M. W. “Therapeutic landscapes: medical issues in light of the new cultural geography.” Soc. Sci. Med. Vol .34. No 7, (Great Britain, 1992) pp. 735-746. Accessed from: http://www.sciencedirect.com/science/article/pii/0277953692903603 [April 2012] Gesler M. W. “Therapeutic Landscapes: Theory and a case study of Epidauros, Greece.” Environment and planning D: Society and space Vol. 11. no. 2. (1993) pp. 171-189. Accessed from: http://www.envplan. com/abstract.cgi?id=d110171 (April 2012) Goines. L, and Hagler. L, “Noise Pollution: A Modern Plague.” Southern Medical Journal. Vol.100. No. 3. (March, 2007) pp. 287-294. Accessed from: http://journals.lww.com/smajournalonline/Fulltext/2007/03000/Noise_Pollution__A_Modern_Plague.16.aspx (April 2012) Guzzetta. C. E, “Effects of relaxation and music therapy on patients with coronary care unit with presumptive acute myocardial infarction.” Heart & Lung, Vol. 18. no. 6. (1989) pp. 609-616. Accessed from: http://www.ncbi.nlm.nih.gov/pubmed/2684920 (April 2012) Hathaway. W. E, Hargreaves. J. A, Thompson. G. W, Novitsky, D. Alberta, “A study into the effects of light on children of elementary school age- A case of daylight robbery.” Policy and planning branch, planning and information services division, (Alberta Education. 1992) Accessed from: http://www.eric. ed.gov/ERICWebPortal/search/detailmini.jsp?_nfpb=true&_&ERICExtSearch_SearchValue_0=ED343686 &ERICExtSearch_SearchType_0=no&accno=ED343686 (April 2012) Kellert. R. S, and Heerwagen. J. H, ‘Nature and healing: The science, theory and promise of biophilic design’, (2006) pp. 1-15. Accessed from: http://courses.be.washington.edu, on 28.03.2012 [April 2012] Khachatourians. A, “Therapeutic Landscape: A Critical Analysis.” Simon Fraser University. (Summer, 2006). Accessed from: summit.sfu.ca/system/files/iritems1/3574/etd2429.pdf. (April 2012)

BENV GA 05 Diploma Thesis

Journals/Articles Martin. G. P, “Places like home? Physical, social and psychological aspects in the making of home and other environments in the healthcare of older people.” Doing, thinking, feeling home- 14/15, October, Delft, The Netherlands. pp. 1-11. Accessed from: http://www.otb.tudelft.nl/fileadmin/Faculteit/Onderzoeksinstituut_OTB/Studeren/Studiedagen/Websites_internationale_congressen/Doing,_Thinking/Papers/doc/Conference_paper_Martin.pdf. [April 2012] Mengazzi. J. J, Paris. P, Kersteen. C, Flynn. B, and Trautman. D. E, “A randomised controlled trail of the use of music during laceration repair.” Annals of Emergency Medicine, Vol. 20. no. 4. (1991) pp. 348-350. Accessed from: http://www.unboundmedicine.com/medline/ebm/record/2003660/abstract/A_randomized_controlled_trial_of_the_use_of_music_during_laceration_repair_ [April 2012] Nakamura. R, & Fujii. E, “A comparative study of the characteristics of the electroencephalogram when observing a hedge and a concrete block fence.” Journal of the Japanese Institute of Landscape Architects, vol. 55. (1992 pp 139-144) Taylor. S. E, “Hospital Patient Behaviour: Reactance, helplessness, or control?” Journal of Social Issues. Vol. 35. Issue 1. (April, 2010) pp.156-184. Accessed from: http://onlinelibrary.wiley.com/ doi/10.1111/j.1540-4560.1979.tb00793.x/ [April 2012] Terman. M, Fairhurst. S, Perlman. B, Levitt. J, McCluney. R, “Daylight deprivation and replenishment: A Psychobiological problem with a naturalistic solution.” International day lighting conference proceedings II. November 4-7. Long Beach, C.A. (1986) pp 438-443. Ulrich. S. R, “Effects of health facility interior design on wellness: Theory and scientific research.” Health Care Design. Vol. 3. (2002 pp 97-109) Ulrich. S. R, “Health Benefits of Gardens in Hospitals”, in paper for Conference, Plants for People, International Exhibition Florida. (2002) pp1-10 Ulrich. S. R, “Effects of healthcare environmental design on medical outcomes.” in Dilani, A. (ed.) Design and health: Proceedings of the Second International Conference on Health and Design. (Stockholm, Sweden: Svensk Byggtjanst, 2001) Williams. A, “Therapeutic Landscapes in holistic medicine.” Soc. Sci. Med. Vol 46. No 9. pp. 11931203. (Ontario: Canada, 1998) Accessed from: http://www.sciencedirect.com/science/article/pii/ S027795369710048X. [April 2012] Witherell. L. E, “Legionella in Cooling Towers.” Journal of Environmental Health, Vol. 49. (1986) pp. 134139.

BENV GA 05 Diploma Thesis

References Images Chapter 1 1.1- http://www.insidegitmo.com/Images/WebReady/Gallery/Gitmo_hospital_ ward_big 1.2- http://www.dannold.com 1.3- http://a1100is/wordpress.com/2010/01/13/hospital/corridor/from/the/waiting/room 1.4- http://www.liu.se/ikk/english/course-webpages/norman-s-pictures-for-theexamination/architecture-pictures?l=en 1.5- http://www.skyscrapercity.com/showthread.php?t=524174&page=23 1.6- pp. 4-5. locality health profile peckham and camberwell, accessed from http:// www.southwarkpct.nhs.uk/documents/2575.pdf. 1.7- http://www.acorn-gaumont.nhs.uk/welcome,27560.htm 1.8- By author 1.9- 1.17- By author 1.18- By author 1.19-1.25- By author 1.26-1.30- By author 1.31-1.35- By author 1.36- By author 1.37- 1.41- By author 1.42- By author 1.43-1.48- By author 1.49- Design with care: Design and neighbourhood healthcare buildings. CABE. 2006. Accessed from: http://webarchive.nationalarchives.gov.uk/20110118095356/ http:/www.cabe.org.uk/files/designed-with-care.pdf 1.50- Future Health: sustainable places for health and well-being. CABE. 2009. Accessed from: http://webarchive.nationalarchives.gov.uk/20110118095356/http:/ www.cabe.org.uk/files/future-health.pdf 1.51- LIFT primary care buildings report, CABE. 2008. Accessed from: http://webarchive.nationalarchives.gov.uk/20110118095356/http://www.cabe.org.uk/publications/assessing-design-quality-in-lift

BENV GA 05 Diploma Thesis

References Image Chapter 2 2.1- By author 2.2- By author 2.3- http://www.coachingworks.de/workinprogress/2010/04/07/let-the-sunlight-in/ 2.4- Liberman, J. Light Medicine for the future. (New Mexico: Bear & Company, 1991) p. 35. 2.5- http://www.hse.gov.uk/pubns/priced/hsg38.pdf 2.6- Kukkonen, E. et al. 1993. Nordtest Report NT Tech. Rep. 204. 2.7- http://www.who.int/docstore/peh/noise/guidelines2.html. 2.8- http://visit-stonehenge.blogspot.co.uk/2010/10/stonehenge-expert-awardedobe.html 2.9- By author 2.10- http://upload.wikimedia.org/wikipedia/commons/e/e5/Pergamon_Museum_ Asclepius_-_Berlin%2C_Germany_-_2009_%28cropped%29 2.11- http://greecefleece.blogspot.co.uk/009_02_01_archive 2.12- http://nobloodforhubris.files.wordpress.com/2011/03/cleopatras-pool 2.13- http-www.wacphila.org/travelblog/wp/content/uploads/2011/07/SAM_1619 2.14- flickr.com/photo/patrickmayon/2247783148/size/0/in/photostream Chapter 3 3.1- P99. The architecture of hope: Maggieâ&#x20AC;&#x2122;s Cancer Caring Centres. Jencks, C. Heathcote, E. Frances Lincoln. London. 2010 3.2- http://www.dezeen.com/2011/01/04/maggies-centre-cheltenham-by-mjparchitects/ 3.3- P147. The architecture of hope: Maggieâ&#x20AC;&#x2122;s Cancer Caring Centres. Jencks, C. Heathcote, E. Frances Lincoln. London. 2010 3.4- http://www.richardrogers.co.uk/work/all_projects/maggie_s_centre/completed

BENV GA 05 Diploma Thesis

References Images 3.5- http://jgonwright.com/ep01Geo.html 3.6- By Author, adpated from Bing maps: http://www.bing.com/maps/ 3.7 -P187. The architecture of hope: Maggie’s Cancer Caring Centres. Jencks, C. Heathcote, E. Frances Lincoln. London. 2010 3.8- P181. The architecture of hope: Maggie’s Cancer Caring Centres. Jencks, C. Heathcote, E. Frances Lincoln. London. 2010 3.9- P10. The architecture of hope: Maggie’s Cancer Caring Centres. Jencks, C. Heathcote, E. Frances Lincoln. London. 2010 3.10- By Author 3.11- By Author 3.12- By Author 3.13- By Author

BENV GA 05 Diploma Thesis