RE-HUMANIZING HEALTHCARE MANUSHI SHETH | I.E.S. C.O.A. DESIGN DISSERTATION
UNIVERSITY OF MUMBAI
DESIGN DISSERTATION Submitted in partial fulfilment of the requirements of the degree of Bachelor of Architecture (B. Arch)
RE-HUMANIZING HEALTHCARE PROPOSAL FOR A LODGING & CARING INSTITUTE FOR CANCER OUTPATIENTS IN MUMBAI
SUBMITTED BY SHETH MANUSHI PIYUSH
IES COLLEGE OF ARCHITECTURE 2017-2018
DECLARATION OF PLAGIARISM I hereby declare that this written submission entitled ‘Re-Humanizing Healthcare’ represents my ideas in my own words and has not been taken from the work of others (as from books, articles, essays, dissertations, other media, and online) and where others ideas or words have been included, I have adequately cited and referenced the original sources. Direct quotations from books, journal articles, internet sources, other texts, or any other source whatsoever are acknowledged, and the sources cited are identified in the dissertation references. No material other than that cited and listed has been used. I have read and know the meaning of plagiarism, and I understand that plagiarism, collusion, and copying are grave and serious offenses and accept the consequences should I engage in plagiarism, collusion or copying. I also declare that I have adhered to all principles of academic honesty and integrity and have not misrepresented or fabricated or falsified any idea/data/fact source in my submission.
Manushi Sheth 18 th November 2017, Mumbai
ACKNOWLEDGMENTS First and foremost, I would like to express my gratitude to my thesis guide, Prof. Shilpa Chandawarkar for her constant guidance, support, and inspiration. This thesis would not turn out how it did if not for her faith in me. To Aayushi, Prachi and my sister Shweni, this project would not have materialized without your constant and unconditional support and encouragement. I am truly grateful to Yesha and Harsh for their help. Sincere thanks to Shreyas, Smriti, Anvi, Malav, Harsh G. and all my classmates and friends who have been a part of my life during the course of architecture. Finally and most importantly, I would like to thank my parents and sister for all their love and moral support through these 5 years.
Separation by Nunzio Paci
ABSTRACT The journey of anything tangible depends on its ability to evolve in response to its environmental context. Evolution is a never-ending process. Matter continually adapts to survive the ever-changing environment. Be it the evolution of man, that depends on the climate he lives in, the availability of resources he uses for survival, the culture he adopts, and the mutation of his genes; or the evolution of styles of design, art, buildings, etc. which change from time to time to create new trends and endure in the market. The evolution of tangible and intangible matter is in constant response to the other. It is an endless cycle. A classic example of which is climate. Man adapts to the climate he lives in, though it is none other than him who is responsible for the changes in the climate due to the resources he utilizes. The best reference for this is global warming. The immediate environment in which man lives, works, recreates, and rejuvenates influences his activities and capabilities. The design of a workplace can influence one’s intellectual or productive behavior. Design here consists of not just the aesthetic features but also the environment comprising of climate, nature, sound, light, etc. The thesis aims at studying this correlation between the environment and man and addressing its impact on the physique and psyche of man. It also intends to investigate the effect of psychology on physical well-being through control of the immediate built and unbuilt environment. The target study is focused on cancer patients and their needs and requirements during and after treatment.
P R PROCESS O C E S S EXPERIENCE
RESEARCH
INVESTIGATION
POSSIBILITIES
RESULT
An evening at the Shree Gadge Maharaj Dharamshala in Mumbai lead to the realization of problems faced by the ‘low-income medical migrants availing outpatient services’ or the ‘outpatients.’
Further, on conducting a study on cancer care in Mumbai, numerous shortfalls of the healthcare sector for these outpatients were revealed. The infrastructure and environments treating and housing them were found to be inadequate and unhealthy. Private and public charitable facilities lacked the funding and availability of space to resolve these issues. On a more advanced level, the needs and issues of the patients and their caregivers were not understood beyond the basic necessities of food, clothing, and shelter. The healthcare environments were not supportive of healing.
This lead to the question of ‘what could be the solution?’ Was it establishment of a medical institution in the city? Or in the rural areas? Was it need for a palliative and hospice care center? Was it need for more lodgings? Was it the shortage of charitable funds? Was it incorporating a healthy environment in all of these? If so, how to incorporate this ‘healthy environment?’ And which of these need to be prioritized?
Architecturally, the input is limited to control via design of the built and, to some extent, the unbuilt environment within a space. To resolve the imminent problems, it is essential to first understand healthcare and its features. The evolution of healthcare and the reason for its current situation along with its needs and requirements needed to be investigated before catering to the ‘outpatients.’
The resulting report starts with an understanding of healthcare environments and its therapeutic abilities; followed by a study of the intangible and tangible needs of cancer patients and their families along with an insight into cancer care facilities in Mumbai; and concludes with the need for a cancer caring center integrated into a lodging facility, located in the proximity of the Tata Memorial Hospital, incorporating design features derived from the previous studies.
CONTENTS
01
i Background of the study
02
ii Topic justification
03
iii Objective of the study
04
iv Hypothesis statement
05
v Methodology
06
vi Scope & Limitations of the study
07
vii Design intent & Site
08
viii The ‘Prologue’
09
SUBJECT OF RESEARCH
12
THERAPEUTIC ARCHITECTURE 1. What is Therapeutic Environment?
14
2. Healthcare Architecture through the Ages
17
3. Holistic Healthcare
29
4. Healing Landscapes
31
5. Psychological Impacts of Architecture
35
6. Environmental Factors & the Psyche
37
7. Architecture that’s built to Heal
45
8. The ‘Epilogue’
47
02 03
TOPICS OF RESEARCH
50
HEALTHCARE IN INDIA , CANCER, CANCER CARE IN MUMBAI 1. Healthcare in India
52
2. What is Cancer?
60
3. Cancer Care in Mumbai
86
DESIGN INTERVENTION
98
FUNCTIONS, SITE , BRIEF, APPROACH 1. Design Functions
100
2. Site
130
3. Deriving a Design Brief
142
4. Design Approach
146
References & Bibliography
150
List of figures
153
“I believe that the way people live can be directed a little by architecture.” - Tadao Ando
“We shape our buildings; thereafter they shape us.” - Winston Churchill
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BACKGROUND OF THE STUDY Hundreds flock to clinics, hospitals, and other healthcare facilities daily. These institutions treat ‘the body’ and the patients return home, content with the treatment received, eager to resume their routine life. Everyone is prepared to pay ‘as much as it takes’ to ensure a complete recovery, unaware of its reliability or after effects. In case of failure of treatment, they start preparing themselves for dysfunction of their body. The focus in all scenarios in case of any diagnosis is ‘the body.’ Numerous studies and researchers have established that the health of an individual is made up of not just the body but the mind and spirit as well. It is not enough to treat a person’s body while snubbing the mind and spirit. Is the function of a healthcare limited to diagnosing and treating an ailment physically? Does physical treatment ensure complete recovery in all cases? Who caters to the psychological and social aspect of treatment? The built and unbuilt environment of a healthcare facility has a direct impact on a patients medical outcome. This impact can be positive or negative; no impact is neutral. Typical planning for medical wards is based on the Church’s acceptance of healthcare responsibility and their priority to keep the ailing close to their spiritual self, back when they held the reins of administration. Thus, the large general wards with beds lined up on both sides of the altar are seen till date in our general wards with the altar replaced by the nurse’s station. Time has progressed, and priorities have changed, but healthcare planning remains persistent. The spatial quality is given minimal priority, or none in most government hospitals whereas in private hospitals the emphasis is on luxury. Few cater to the psychological and social needs of the patients or their family.
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TOPIC JUSTIFICATION A study through time and evolution of healthcare architecture reveals the importance that was laid on holistic treatment even before the concept of hospitals came around. Healthcare is not all about the treatment of the body, as signposted by some sectors of medicine. As described by Flavio Albanese, the meaning of ‘wellness’ is the balance of mind-bodyspirit. To attain this balance, it is essential to study the role that architecture plays in healthcare, in addition to the one played by the community and the ever-progressing technology.
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OBJECTIVE OF THE STUDY Spaces can create hope and positivity or gloom. They can boost the healing process or add further to an unhealthy environment leading to further amplification of an illness. For a person, undergoing physical and mental trauma due to his ailment, this space can have far-reaching effects. Thus, it is imperative to understand the concept of ‘healing spaces’ to efficiently integrate this pre-requisite in healthcare design. Treatment is complete only when all facets of health are addressed. The focus should be on holistic treatment and not solely on efficiency or functionality of the building as is the case in most existing healthcare institutes. This design of spatial atmosphere should not be limited to the time the patient spends in the healthcare center but extend to the home, workplace, and any other environment they spend quality time in. Thus, a study of healthcare environment extending to the home and work atmosphere of a patient is essential. The relation between space and health, vital as it is, is seldom addressed. If addressed correctly, it would be a turning point in the medical world. Hence, it is crucial to understand the psychological impacts of architecture on the human mind and body as also spatial therapy.
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4
to the materials of construction and ease of functionality but extends to intangible aspects
such
as
comfor t,
experience,
ability to heal and empower, etc.; both of which together ar ticulate a healing space.
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‘
‘
The architecture of healthcare is not limited
METHODOLOGY In an attempt to comprehend what ‘therapeutic spaces’ in terms of a healing environment for cancer patients stand for, the study has been broken down into two sections. The former encompasses research based on universal therapeutic environments while the latter narrows the study to cancer patients and their immaterial requirements. The research in the first section, being a theoretical subject, is qualitative and derived from research papers published by distinguished authorities and studies conducted by established institutions. The second section is quantitative as well as qualitative, comprising data based on interviews conducted personally and derived from news readings along with statistics. It also includes research on the intangible needs of cancer patients and the situation of cancer care facilities in Mumbai. The third section deals with a proposal for the manifestation of the conclusions from previous chapters. Function-based case studies are used to derive a detailed design programme and justify a site for the proposed project.
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SCOPE & LIMITATIONS OF THE STUDY Research on healthcare and its environment provides an opportunity to identify the missing elements in the prevailing system. With the community preparing for a change in healthcare and demanding a patient-oriented and holistic environment, this study helps to understand these concepts theoretically. It is to be kept in mind that it is not the building itself that fuels healing but the ethos of both the community and architecture along with technology that enhances the contribution of a built environment to the healing process. The built environment merely plays its role as one of the members, but only gives results when all the members perform together.
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DESIGN INTENT & SITE The executed study leads to a proposal for a cancer caring institute situated amidst the typical urban context to address the needs of medical migration. The proposed institute offers housing and a caring center for the medical migrants. The proposed project aims to avoid disruption of regular routine, at the same time provide a healing abode. On analyzing the statistical data of medical migration for cancer treatment and the shortcomings of the existing facilities, the proposed site is located in Mumbai.
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THE ‘PROLOGUE’ The existential purpose of architecture is primarily to be at the service of the body. We experience architecture every day, not sparing a thought to how the design of the built environment affects us physically, mentally and emotionally. Do we stop and take a note of how different spaces and atmospheres affect our emotions? David Leatherbarrow, in his book Architecture Oriented Otherwise, states, “An atmosphere, like a mood, impresses itself on experience...” As architects, how do we give shape to this experience? All our senses simultaneously engaged together help us to perceive the world. However, we currently live in a world where visual stimulation takes superiority over other senses and aspects such as emotion, perception, and remembrances are not accommodated in the design. Most often, what a building looks like is what matters in our assessment of architecture. Instead of it being understood as a space with different layers of experience, it is reduced only to the visual. As a result, there is a lack of sensuality and experience in our lives. With the dominance of vision over other senses, our perception of the world relies so predominantly on an image that our built environment has become sensually bland. What would our world be like if sensory response was treated as a critical design factor, equally as structure and programme? There exist multiple approaches to create an experiential space. Sensory architecture, therapeutic architecture, placebo architecture, lighting in architecture, environmental architecture, scale and proportion, etc. are different means of adding value, more than just aesthetics and functionality, to a built mass. Architecture is more than bricks and mortar, programme and budget. It is about the spaces we create. Spaces, unlike buildings, are not influenced by merely the physical matter. Factors such as
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quality and quantity of light, sound, scale, proportion, color, vegetation, use of materials, etc. woven together in an appropriate proportion create an experiential space. Spaces can arouse emotions. They can affect the quality of the planned activity. Spaces can stimulate targeted responses. “I don’t think that architecture is only about shelter. It should be able to excite you, to calm you, to make you think.” - Zaha Hadid Design should not limit itself to being able to produce beautiful looking buildings. It should be able to generate beautiful emotions. It should be able to give an impetus to the desired function of the space. Stephen Holl points out that while a picture or a film might give us some idea of space, ‘Only the actual building allows the eye to roam freely among inventive details; only architecture itself offers the tactile sensations of textured stone surfaces and polished wooden pews, the experience of light changing with movement, the smell and resonant sounds of space, the bodily relations of scale and proportions. All these sensations combine within one complex experience, which becomes articulate and specific. Some may say that the building speaks through the silence of its perceptual phenomena.’ The experience of an arbitrary building is exhausted within its first visit. However, buildings which incorporate experiential qualities can be visited many times. Attention to tangible and intangible details affect how a building is going to be experienced by those who inhabit it. (Derived from - Yvonne Osei, Exploring Sensory Design in Therapeutic Architecture, Carleton University, Ottawa, Ontario, 2014)
There are myriad ways to articulate an experiential space. Different programmes demand different experiences. As this thesis intends to investigate the aspect of healthcare, therapeutic architecture has been chosen as the medium of spatial design. RE - HUMANIZING HE ALTHC ARE |
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SUBJECT OF RESEARCH
CHAPTER 01 14 WHAT IS THERAPEUTIC ENVIRONMENT? A brief insight into the concept of Therapeutic Environment and its need.
17 HEALTHCARE ARCHITECTURE THROUGH THE AGES A study of the evolution of healthcare architecture to derive a conclusion for the current architectural healthcare needs. The Sanctuary of Asklepios at Epidaurus 19 The Church & Spiritual healing 21 The Pavilion system & Nightingale wards 23 Hospital as a Machine 25 The Origin vs. current requirement 27
29 HOLISTIC HEALTHCARE A short introduction to the principle of Holistic Healthcare and its relevance in architecture.
31 HEALING LANDSCAPES The requirement of ‘Healing gardens’ and their impact on healthcare backed up with a case study. The Elizabeth And Nona Evans Restorative Garden, Cleveland, Ohio 33
THERAPEUTIC ARCHITECTURE
35 PSYCHOLOGICAL IMPACTS OF ARCHITECTURE The effect of architecture and spaces on the human mind, supported by scientific experiments.
37 ENVIRONMENTAL FACTORS & THE PSYCHE The impact of various environmental factors on the human body and their consideration in architectural and spatial design. 39 Wayfinding 40 Acoustics 41 Color 42 Odor 43 Views 44 Natural light
45 ARCHITECTURE THAT’S BUILT TO HEAL Review of a TED Talk by Ar. Michael Murphy.
47 THE ‘EPILOGUE’ The conclusion.
Figure 1.1 Castle and I | by Tran Nguyen
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1.1 WHAT IS THERAPEUTIC ENVIRONMENT? 1.
Reduce or eliminate environmental
stressors such as noise, crowding, odors, PSYCHO-SOCIAL EFFECTS OF ENVIRONMENT
THERAPEUTIC ENVIRONMENT
EFFECTS OF ENVIRONMENT ON THE IMMUNE SYSTEM
pollution, etc. 2.
Provide
positive
distractions
for
example, view of nature from patient rooms, lobby, waiting and other ‘high stress’ areas; access to nature by means
HOW THE BRAIN PERCEIVES ARCHITECTURE
of healing gardens, chapel or meditation room; artwork, music, pets and other activities or elements that allow for a sense of stimulation which can help nurture a
Patients in a healthcare facility are often fearful and uncertain about their health, their safety and their isolation from normal social relationships. The complex environment of a typical healthcare center adds on further to the traumatic situation. Stress can suppress a person’s immune system and dampen their emotional and spiritual resources, thus, hampering their recovery and healing.
[1]
patient’s sense of positive well-being. 3. Enable social support by means of spaces where patients can engage with others
easily,
for
example,
non-fixed
seating, round tables, etc. 4. Offer a sense of control over the immediate environment such as quantity of light, noise, visual content, ability to locate, etc.
[2]
Researchers have identified four key factors that can measurably improve patient outcomes if implemented in the design of a healthcare environment: RE - HUMANIZING HE ALTHC ARE |
14
The term therapeutic architecture has
state-of-the-art medicine and technology,
evolved into a recognized concept as a
patient safety, and quality patient care, but
reaction against the austerity of modern
also to embrace the patient, family, and
treatment facilities. It does not propose
caregivers in a psycho-socially supportive
that architecture itself has the ability to
therapeutic environment.
[4]
heal, but that the architectural manipulation of space can provide the platform
The need for this soothing, healing
for other natural factors like sound, light,
atmosphere is not limited to the place
color, privacy, views, and even smell to
and duration of treatment. Patients
promote a healing environment that affects
need to be enveloped by this milieu
the physical and psychological healing of
all through their treatment process
patients.
until total recovery; physical as well as
[3]
psychological. Healthcare facilities should be designed not
only
to
support
and
facilitate
Figure 1.2 State of mind of a patient undergoing Trauma | by Disha Vanzara
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Figure 1.3 L’EsthÊtisme du Cri (the Aestheticism of the Scream) | by Antoine Stevens
The mind of a patient undergoing psychological or physical trauma experiences many painful and negative emotions. In order to counter these negative impacts, a therapeutic environment should be a prescribed pre-requisite for every healthcare facility.
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1. 2 HEALTHCARE ARCHITECTURE THROUGH THE AGES In recent decades new concepts have
This leads to the question of the absence
emerged for the design of healthcare
of these features in the existential crisis
institutes, seeking to offer the patients a
of deteriorating health care. Were these
homely atmosphere through architec-
factors never considered for the design
ture and interior design by incorporating
of healthcare? If so, what lead to their
the patient’s everyday representations in
elimination?
the design. These concepts also propose the integration of healthcare environments
In order to address the query of the current
with outer space as a promoter of healing.
catastrophe, it is essential to head back
Current research on the length of stay and
to the roots. A study of the evolution of
quality of care point to the humanization of
healthcare is required to comprehend
these environments to alleviate the suffering
when and how healthcare, in terms of
and anguish during hospitalization, adding
holistic treatment, began to fail and to
family
attain a better understanding of the current
life
practices
and
personalized
spaces, and involving professional teams
healthcare practices and requirements.
and families as care partners in offering therapies to achieve the desired cure.
Figure 1.5 Medieval home centered care system
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[5]
Figure 1.6 Religious institutions providing medical care to the common masses
Figur Main pool at Sweet Sp Spas an
Figure 1.4 Timeline of healthcare architecture | by Author
e 1.7 prings, Missouri, 1873 nd Baths
Figure 1.8 Mobile field hospital, United States Army, 1917 - Redeployable hospitals
Figure 1.9 Hospital Beaujon, near Paris, 1932 International style high-rise hospital RE - HUMANIZING HE ALTHC ARE |
18
1.2. 1 THE SANCTUARY OF ASKLEPIOS AT EPIDAURUS In ancient Greece and Rome, an Asklepion
The theatre of Epidaurus, a shell-like
was a healing temple, sacred to the Greek
structure with remarkable acoustics and
God of medicine Asklepios. The Sanctuary
harmonious
at Epidaurus comprising of the theatre,
visitors could attend performances and
the Temples of Artemis and Asklepios, the
‘escape’ from their debilitating problems.
architecture,
was
where
Tholos, the Enkoimeterion, the Propylaia, the Banqueting Hall, the baths as well
After the necessary cleansings, having
as the sports and hospital facilities is an
attained a calm and mentally relaxed state,
eminent example of a Hellenic architectural
they were led to the main therapeutic space,
ensemble of the 4th century BCE
the Abaton; a dome-shaped structure, with
[6]
It is
the earliest organized sanatorium.
corridors and complex circular mazes.
Archaeological evidence provides proof
This preparatory stage was followed by
that
antiquity
the main healing phase, known as enkoi-
what we nowadays call holistic health
mesis. During sleep in the Enkoimeterion,
care. Each activity that took place at
the patient allowed himself to dream of
Epidaurus was designed to harmonize
the God, who would visit him and offer the
the mind, body, and soul.
healing treatment that was needed.
Asklepieia
offered
in
Figure 1.10 The Sanctuary of Asklepios at Epidaurus
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PROPYLAIA
PORTICO OF KOTYS
CISTERN TEMPLE
ABATON
EPIDOTEION
DORIC FOUNTAIN ALTAR OF ASKLEPIOS
TEMPLE OF ASKLEPIOS THYMELE
ALTAR
TEMPLE OF ARTEMIS PROPYLON
GYMNASIUM
BANQUETING
HOSTEL BUILDING
HALL STADIUM
GREEK BATHS
THEATRE
Figure 1.11 Site plan, the Sanctuary of Asklepios at Epidaurus | by Author
N
The layout of the sanctuary served to
themselves.
focus the concentration of the patient
a patient from entertainment to sleep, from
and draw strength from his inner world.
physique to hygiene. Thus, it is the ultimate
The sanctuary, with its peaceful natural
example of holistic care.
[7]
It catered to all the needs of
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20
1.2. 2 THE CHURCH & SPIRITUAL HEALING Early in history, the sick were cared for in
institutions continued to provide most of
their homes. As the Roman Empire turned
the healthcare to the poor in large, open
to Christianity, the Church’s role in looking
wards, while physicians continued the
after the infirm within their churches or
practice of making house calls to the upper
cathedrals
class.
became
firmly
established.
After 400 AD, numerous monasteries were constructed, generally including accom-
The wards housing multiple patients
modations for travelers, the poor, and the
continued to expand and became the
sick. The Catholic Church became the
standard for the public hospitals for
most powerful provider of health care, and
hundreds of years. Often the wards
monastic orders were the caretakers for
were configured so the sick could see
the sick.
the altar to assist with their recovery. The cross-shaped plan achieved this
The
monarchs
of
the
6th
century
goal with the altar in the middle and
reinforced this role with emperors such as
multiple wards radiating from it. The
Charlemagne, who directed that a hospital
plan is similar to many hospitals today,
should be attached to every cathedral
with the nurse’s station instead of the
that was built in his empire. Religious
altar at the center.
[8]
Figure 1.12 The Carolingian Abbey of Saint Gall | by Johann Rudolf Rahn
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The Church emphasized in the healing
Thus, except for proximity of the altar, no
power of prayer and encouraged spiritual
other factors were prioritized for planning.
interventions as treatment procedures.
PHYSIC GARDEN DR’s HOUSE
HOUSE OF NOVICES
INFIRMARY
CEMETERY
BLOOD BANK ALTAR
SCIPTORIUM HIGH ALTAR
ABBOT’s HOUSE
VESTRY
NECESSARY
CALEFACTORY
REFECTORY
SCHOOL CLOISTER
NAVE
BAKE HOUSE CELLAR
KITCHEN BREW HOUSE
GUEST HOUSE
ALTAR
GUEST HOUSE
Figure 1.13 Diagrammatic ground floor plan, the Abbey of Saint Gall | by Author
PARAD ISE TOWER
MENIAL DEPARTMENT
TOWER
MONASTIC BUILDINGS
CHURCH
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1.2. 3 THE PAVILION SYSTEM & NIGHTINGALE WARDS TERRACE
In the late 1700’s a re-evaluation of the
light, air, landscape, attention to diet, as
hospital form was prompted by the new
well as a clean, sanitary environment.
recognition of clean hygienic WARD condiWARDair and WARD tions as agents of health, especially in hospital environments. Of the two architec-
[9]
WARD WARD WARD DINING The pavilion system incorporated with ROOMS
Florence Nightingale’s proposals took
tural proposals made, the pavilion system
shape. The general plan of these pavilion BATHS
prevailed.
style hospitals included a primary supply WARD
WARD
WARD corridor for circulation ofWARD people and LIBRARY
KITCHEN Florence Nightingale was a very influential
supplies with finger plan patient wards
figure in nursing following the Crimean war
that extend off of this linear spine. The
in 1854. Her approach towards a healing pavilion plan allowed light and fresh air ADMINISTRATION environment for patients not only looked at
to penetrate and created garden views
the physical surroundings but also at the
between the building crenellations. This
social welfare of her patients. She focused
design emphasized function over form.
on providing patients with access to natural
BATHROOM STORE
NURSE’S LOUNGE
BATHROOM
Figure 1. 14 Typical plan of a Nightingale ward | by Author
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LOBBY
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CORRIDOR
WARD
DAY ROOM
TERRACE
WARD
WARD
WARD
WARD
WARD
WARD
WARD
WARD
DINING ROOMS BATHS WARD
WARD
LIBRARY KITCHEN
ADMINISTRATION
Figure 1.15 Schematic ground floor plan, The Royal Herbert Hospital, Woolwich, London | by Author
BATHROOM STORE space in cities, the typology died out. It
extensive space, would have triumphed
was one of the most well-conceived ideas
through history. Due to its spread out
of healthcare architecture.
horizontality of DAY ROOM and the imminent crunch WARD
LOBBY RE - HUMANIZING HE ALTHC ARE |
BATHROOM
NURSE’S
CORRIDOR
The pavilion system, had it not required
24
HO
CI ITA
L
AD
RO TA L
II, Florence Nightingale’s original concept
in form related to human health, stress,
of hospitals was replaced by hospitals
and comfort.
AD
without evaluating how these changes
‘healing’ centers. They were taken over by
floor block (or platform) with a patient tower
equipment and machinery. With everything
placed on top (as a podium).
from ventilation to circulation mechanized, the only scope for architectural interven-
Building technology aided in this trans-
tion remained in the design of smooth
formation with a new ability to create
functionality to support the mechanics and
long-span
mechanically
the aesthetics. Thus, the huge chunks of
ventilated interior spaces, and movement
mass or rather the ‘platform and podium’
of
elevators.
transformed into decorated blocks of
Circulation patterns were confusing without
buildings from the outside as well as
any external cues of directionality, setting
inside.
structures, vertically
with
or hierarchy. Ultimately, the attitude of the hospital as a well-tuned machine took precedence over more humanistic factors for the patients, staff, and visitors to these facilities. Through time, with the progression of diagnostic and treatment facilities, this platform has gotten bigger and taller, limiting access to the aspects of natural air, light, and view that Nightingale attributed to her patient’s well-being. Designers and builders maximized the efficiency
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of
hospitals
Figure 1.16 The John Hopkins Hospital - Decorated blocks | by Author
TY
configuration became a deep span, multi-
CI
The hospitals no longer functioned as HO
comfort and healing. A typical hospital
RO
TA L
RO
[10]
SPI
that prioritized efficiency over human
25 |
AD
RO
SPI
AD
In the hospital boom following World War
machine-like
RO
HO
YR O CIT
HOSPITAL AS A MACHINE
people
TY
AD
1.2. 4
SP
Figure 1.17 Schematic site plan, King Edward Memorial Hospital, Mumbai Town within a hospital | by Author
N
SP
CI ITA
L
TY
RO
AD
RO
AD
AD RO TY CI
HO
SPI
TA L
RO
AD
CIT
P I TA
YR OA D HO S
LR O
AD
HO
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1.2. 5 THE ORIGIN VS. CURRENT REQUIREMENT The architecture of healthcare facilities has
Hospitals in the current times are home
undergone drastic changes along the way.
to machinery and designers attempts
During this evolution, the healing ability
to conceal this machinery. Healing is
of architecture is lost in the transition
prioritized from the medical and techno-
from healing spaces to functionalist
logical point of view. The psychological
buildings.
effects on the patients waiting in long dingy
corridors
or
family
awaiting
Healthcare today focuses on the ease
results of their loved ones in the dingy,
of functionality and has side-lined the
emotionless
well-being of the patients and caregivers in
considered relevant as opposed to the
architectural design and spatial planning.
efficiency and smooth functioning of the
Aesthetics of the building are given prece-
hospital.
waiting
rooms
are
not
dence over the quality of space. With the space crunch and high real estate rates, healthcare buildings have expanded vertically
without
consideration
of
therapeutic spaces.
“During the modern era, … the hospitals became more machine than monument, a stripped-down,
functional
series of boxes
accommodating the increasingly complex technical apparatus for prolonging life. Architecture flat-lined.” - Edwin Heathcote, Architect 27 |
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Greek sanctuaries of fered Holistic care
Healthcare at home enjoyed by the privileged while the commons looked to the church
CORRIDOR
PL ATFORM
WARDS
PODIUM Patient-oriented care of fered by the Pavilion system
The star t of stacking due to space crunch
The advent of machiner y lead to the star t of ver ticality in the form of the Podium and Platform
Contemporar y hospitals
DEPARTMENT E
DEPARTMENT C
DEPARTMENT D
DEPARTMENT B
DEPARTMENT A
The growing needs lead to ‘town within a hospital’ as a result of which the therapeutic needs of patients and caregivers were neglected to achieve optimum ef ficiency.
Figure 1.18 Evolution of healthcare architecture | by Author RE - HUMANIZING HE ALTHC ARE |
28
1.3 HOLISTIC HEALTHCARE Holistic healthcare is a form of healing that
The role of architecture in this concept is
considers the whole person - body, mind,
limited to the psychological impact it leaves
spirit, and emotions - in the quest for
on the human mind. Healthcare buildings
optimal health and wellness. According to
should be designed with the idea of
the holistic medicine philosophy, one can
holistic treatment in mind, in addition
achieve optimal health by gaining a proper
to treatment through technological and
balance in life.
scientific advances.
[11]
A holistic approach to healing goes beyond simply eliminating symptoms. In holistic medicine, a symptom is considered a message that something needs attention. The symptom is then used as a guide to look beyond the surface for the root cause. After which, what really needs attention can be addressed. Holistic
[12]
healthcare
is
an
ongoing
process. It is not a remedy to turn to in times of sickness but a principle to abide by through life. It consists of adopting various daily practices such as exercise, nutritional choices, meditation to achieve a calm state of mind, and many such factors.
29 |
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Figure 1.19 Holistic Healthcare
“Calling medicine’
holistic is
no
medicine
‘alternative
longer
appropriate.
The best approach now is ‘integrated medicine’ in which we take the best of both worlds.” - Candess M. Campbell, Ph.D. in Clinical Hypnotherapy
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30
1.4 HEALING LANDSCAPES Regardless of age or culture, man finds
negative comments from nurses, took less
nature restorative. It provides a sense of
pain medication and experienced fewer
relief from stress. Often man tends to lose
minor post-operative complications than
himself in nature. This ability of nature can
those with a view of a brick wall.
be used to the benefit of healthcare. Hence, the Pavilion system emphasized on the
The sound of the birds chirping in a
view of a garden from every patient’s
garden or that of water along with the
bed.
smell of the flowers and soil tends to mentally transport a patient to a world
Modern
advances
in
technology
away from the pain and sickness. It
towards healing have primarily dimin-
works as a distraction technique wherein
ished the importance of nature in the
one forgets about his worries and pain.
healing process, and this has been an unfortunate result of the ‘cure over care’ phenomena found within many aspects of the healthcare field.
[13]
Roger Ulrich, a professor, and director
2/3 rd
95%
PEOPLE
PEOPLE
of the Center for Health Systems and Design at Texas A & M University found that viewing natural scenes or elements fosters stress recovery by evoking positive feelings, thus, reducing negative emotions by effectively holding attention/interest and blocking or reducing stressful thoughts. Further research by Ulrich showed that surgical patients with views of nature had shorter post-operative stays, fewer 31 |
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Mood improved after Choose a natural setting spending time outside; to retreat to when changing from depressed, stressed stressed, and anxious to more calm and balanced.
Figure 1.20 Results of a study by researchers Clare Cooper Marcus (architect) & Marni Barnes (psychotherapist and architect) | by Author
Visually pleasing, accommodating light and portable furniture and water features
Appropriate scale of vegetation with respect to the built mass
Smooth transitions using natural materials with reservations for various private and social activities
Facilitating easy maintenance and barrier-free access
SCREEN
Figure 1.21 Features for the design of a Therapeutic garden | by Author
Balanced design (symmetric/asymmetric) with focal points for easy orientation
NOISE SOURCE
Use of noise absorbers to ensure the audibility of the sounds of nature
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32
THE ELIZABETH AND NONA EVANS RESTORATIVE GARDEN, CLEVELAND, OHIO
Built in 1998
Chestnut oak and Magnolia provide a
Landscape architects: Dirtworks
sense of enclosure and seclusion as it unfolds into three distinct rooms.
The
Location:
Cleveland
Botanical
Garden, located in the city’s University
The first is a quiet respite offering
Circle neighborhood, is a combination of
an elegant square lawn and a restful
indoor exhibits, housed in a glasshouse,
reflecting pool. A white-only palette of
and ten acres of diverse outdoor gardens.
flowers enhances the serenity here.
The Elizabeth and Nona Evans Restorative Garden is a part of the Cleveland Botanical
The second room is a multi-sensory
Garden.
sampler with both annuals and perennials to see, touch, and smell.
Purpose: The Elizabeth and Nona Evans Restorative Garden was a renovation and
The wall, or third area, is made of native
expansion of a Library Reading Garden.
stones, interesting plants in nooks, and
It serves as an outdoor classroom where
cascading water to hear and touch.
[15]
healthcare workers from across the country learn how to use plants and gardening to
Use: People with various disabilities and
improve the quality of life for patients in
health conditions visit the garden for horti-
their care.
culture therapy as it offers a lush refuge.
[14]
The balance of private and public space Design: Among the abundance of calming
reinforces a sense of respect and sensi-
greenery, the sounds of water, and the
tivity. This calming, life-affirming garden is
calming scents one can enjoy absolute
a place where one can relax the mind, invig-
solace in this garden. Large trees like
orate the senses and renew themselves.
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[16]
ROOM 3
ROOM 3
ROOM 2
ROOM 1 LIBRARY
Figure 1.22 Schematic plan, the Elizabeth and Nona Evans Restorative Garden, Cleveland, Ohio | by Author
ENTRY
N
Inference: Access to a similarly functioning,
it also acts as a pain relief system and
healing garden in a healthcare institute
imparts a positive atmosphere in a built
can result in multiple benefiting outcomes.
environment.
Along with boosting the healing process,
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34
1.5 PSYCHOLOGICAL IMPACTS OF ARCHITECTURE Experiencing architecture has less to do
Christopher Day is of the opinion that
with the aesthetics than its engagement
‘we don’t notice the noise, the bad air,
with all our senses. People experience
the harsh conflict of hard-edged shapes
a space with their entire body, through
and forms. We become immune to the
movement, memory, and imagination.
negative forces in our environment –
There exists a sub-conscious dialogue
and that is when they do us most harm!’
between a person and architecture.
These factors subconsciously reflect on
[17]
our emotions and mindset. In
architecture
and
spatial
design,
atmosphere refers to the sensorial quality that space limits. It is the impact of this atmosphere that affects the human mind and body.
‘Architecture
and
neuroscience are no longer two discrete
disciplines. Exploring the benefits of collaboration between neuroscience and perception, and architecture and the brain will yield a new dimension for design benchmarks, as human brains are continuously remolded by environmental forces and experiences.’ - A Design Index for Therapeutic Architecture, AIA 35 |
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COLOR OF A STOP SIGN COLOR OF A STOP SIGN
COLOR OF THECOLOR SKY OF THE SKY
RESULTS: at skills Subjects RESULTS: Subjects performed badly in RESULTS: Subjects were Subjects better at were skills betterRESULTS: performed badly in requiring accuracy to and attentionshort-term to detail memory short-term tasks.onThey scored on requiring accuracy and attention detail tasks. memory They scored COLOR COLOR OF COLOR AOF STOP A STOP OF SIGN A STOP SIGN SIGN COLOR COLOR OF COLOR THE OF SKY THE OFSKY THE SKY such spelling as catching spelling or tasks requiring imagination such as catching mistakes or mistakes tasks requiring imagination such as listing such as listing RESULTS: RESULTS: RESULTS: Subjects Subjects were Subjects were betterbetter were at skills better at skills atRESULTS: skills RESULTS: RESULTS: Subjects Subjects performed Subjects performed performed badlybadly in badly in in keeping random numbers in creative short-term creative uses a brick aor designing a keeping random numbers in short-term uses of a brick or of designing requiring requiring accuracy requiring accuracy and accuracy attention and attention andtoattention detail to detail to short-term detail short-term short-term memory memory tasks. memory tasks. Theytasks. They scored scored They on scored on on memory. toy outshapes. of geometric memory. child’s toy out child’s of geometric They shapes. They such such as catching such as catching as spelling catching spelling mistakes spelling mistakes or mistakes ortasksor tasks requiring tasks requiring imagination requiring imagination imagination such such as listing as such listing as listing REASON: People associate automatically generated associate double generated double ‘creative REASON: People automatically ‘creative outputs’ than outputs’ than keeping keeping random keeping random numbers random numbers innumbers short-term in short-term in short-term creative creative uses creative uses of a of uses brick a brick ofor adesigning brick or designing or adesigning a a redwhich with makes danger, them whichmore makes them more subjects in the red condition. red with danger, subjects in the red condition. memory. memory. memory. child’schild’s toy child’s out toy ofout toy geometric ofout geometric of shapes. geometric shapes. They shapes. They They blue color alert and aware.alert and aware. REASON: The REASON: blue colorThe doubled their doubled their REASON: REASON: People REASON: People automatically People automatically automatically associate associate associate generated generated generated double double ‘creative double ‘creative outputs’ ‘creative outputs’ than outputs’ than than imaginative power. imaginative power. red with red danger, with red danger, with which danger, which makes which makes them makes them more more them more subjects subjects in subjects theinred thecondition. in redthe condition. red condition.
alert and alertaware. and alertaware. and aware. REASON: REASON: REASON: The The blue blue color The color blue doubled color doubled their doubled their their Figure 1.23 Experiment on ‘How the color of interior walls influences the imagination’ by the psychologists imaginative imaginative imaginative power. power.power.at the University of British Columbia, 2009 | by Author
LOW CEILING LOW CEILING
HIGH CEILING HIGH CEILING
LOFTY CEILINGLOFTY CEILING
RESULTS:wereSubjects were Subjects RESULTS: Subjects excelledSubjects RESULTS: Subjects engaged RESULTS: Subjects RESULTS: excelled RESULTS: engaged quicker at solving atanagrams puzzlesthein in which quicker at solving anagrams puzzles inat which in more styles of morethe abstract stylesabstract of LOW LOW CEILING CEILING LOW CEILING HIGHHIGH CEILING HIGH CEILING CEILING LOFTY LOFTY CEILING LOFTY CEILING CEILING involving confinement such touches as answer involving confinement such as answer on the touches theme on the themethinking thinking RESULTS: RESULTS: RESULTS: Subjects Subjects Subjects were were were RESULTS: RESULTS: Subjects Subjects excelled Subjects excelled RESULTS: RESULTS: RESULTS: Subjects Subjects engaged Subjects engaged engaged bound, restrained, and such of as freedom such asexcelled liberated bound, restrained, and ofRESULTS: freedom liberated quicker quicker at quicker solving at solving at anagrams solving anagrams anagrams at puzzles at puzzles at in puzzles which in which in the which the the in more in more abstract in more abstract styles abstract styles of styles of of restricted. restricted. and unlimited. and unlimited. involving involving confinement involving confinement confinement such such as as such answer as answer touches answer touches on touches the on theme theon theme the theme thinking thinking REASON: Airy spaces prime thinking REASON: Airy spaces prime
bound, bound,restrained, bound, restrained, restrained, and andof freedom and ofusfreedom such freedom such as liberated such asfree. liberated usas toliberated feel to of feel free. restricted. restricted. restricted. and unlimited. and unlimited. and unlimited. REASON: REASON: Airy REASON: spaces Airy spaces Airy prime spaces prime prime us to us feeltofree. feel us to free. feel free.
Figure 1.24 Experiment on ‘The relationship between ceiling height and thinking style’ by psychologist Joan Meyers-Levy at the Carlson School of Management | by Author RE - HUMANIZING HE ALTHC ARE |
36
1.6 ENVIRONMENTAL FACTORS & THE PSYCHE Environmental factors such as noise,
enhance the soothing and calming qualities
crowding,
lighting,
of a space; inability to locate a particular
proportion, scale, colors, etc. affect the
room or facility may add to anxiety or stress;
immediate atmosphere of space.
crowding
odors,
pollution,
can
cause
uneasiness,
etc.
Consideration of these factors in design For instance, objectionable odors can
implementation can lead to life-changing
cause stress; artwork and aesthetics can
outcomes.
Figure 1.25 Factors affecting the human body in an enclosed environment | by Omar Youssef.
37 |
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‘Ar tificial ventilation may be necessar y, but it never can compensate for the want of the open window... Second only to fresh air, however, I should be inclined to rank light in impor tance for the sick... Among the kindred effects of light, I may mention, from experience, as quite perceptible in promoting recover y, the being able to see out of a window, instead of looking against a dead wall; the bright colors of flowers; the being able to read in bed by the light of a window close to the bed-head. It is generally said that the effect is upon the mind. Perhaps so; but it is no less so upon the body on that account.’ – Florence Nightingale, Notes on Hospitals, 1863 RE - HUMANIZING HE ALTHC ARE |
38
1.6. 1 WAYFINDING
An uncertainty of any manner can set off
destination.
negative emotions for a person undergoing
programme includes physical elements,
trauma. Inability to locate things or places
communications, and human interaction.
An
effective
wayfinding
can lead to anxiety. Landscaping, Healthcare complex
facilities
are
environments.
elements,
color,
texture, and pattern should all give cues, in
inherently The
building
addition to artwork and signage.
built
environment should provide clear visual cues to orient and guide people to their
ADMIN > Using walls for bold signages of contrasting colors and sizes at eye level
Using plaques at nodes
C
WAY TO C
WAY TO B
WAY TO A
D B A A
Color co-ordinated path markers
39 |
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C
E D
F
B E
F
Design of a straight-forward flow of movement
Figure 1.26 Design features for wayfinding in architecture | by Author
1.6. 2 ACOUSTICS Noise in healthcare environments can lead
The planning of a building should involve
to negative impacts including elevated
consideration
psychological
stress
to achieve a productive environment.
levels that can worsen other outcomes
Acoustical separation of activity zones
and contribute to poor sleep quality. At the
from zones requiring peace and quiet
same time, natural sounds such as birds
should be considered.
and
physiological
of
acoustical
impacts
and trees create a calming atmosphere thus, contributing to the healing process.
SERVICES
ADMIN SEMIPRIVATE ACTIVIT Y
PUBLIC
BUFFER PRIVATE
Figure 1.27 Design features for consideration of acoustics in architecture | by Author
PRIVATE
Acoustical separation of zones
Use of landscaping as noise absorbers
in planning
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40
1.6. 3 COLOR Hilary Dalke, professor at the Kingston
For example, the color blue automatically
University, London, has discovered that
triggers associations with the sky and
both architecture and color have the
ocean. One tends to think about expansive
ability to visually stimulate patients and the
horizons and diffuse light, sandy beaches
surrounding society.
and lazy summer days. This sort of mental relaxation makes it easier for one to
Colors can provoke and elevate positive
daydream and think in terms of tangential
or negative emotions. These emotions
associations thus, focusing less on what’s
are
mental
right in front of him and being more aware
perceptions of colors in relation to the
of the possibilities simmering in his imagi-
association of these colors with certain
nation.
triggered
through
our
[19]
past personal events or cultural beliefs. Society’s emotional response to color is
A careful selection of colors used in the
based on shared psychological associ-
interiors, on walls and ceilings, as well as
ations of certain emotions to certain
on the external facades of healthcare facil-
colors.
ities can affect patient outcomes.
[18]
W H I TE
RED
G RE E N
G RE Y
purity + hygienic + spatial sense +
love + power + energy + anger +
nature + fresh + tranquility + growth +
neutral + timeless + modern +
cold
defiance
stagnation
hibernation
B LACK
YEL LOW
B LUE
O RA N G E
elegance + power + bold + authority +
laughter + optimism + friendly + attention
serene + creative + reflective + loyal +
warm + vibrant + inviting + change +
oppression
seeking + anxiety
aloof
frivolous
Figure 1.28 The Psychology of Colors | by Author
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1.6. 4 ODOR The expression ‘it is a hospital smell’ is
performance.” This is proven by the use
familiar to most people because of the
of different incenses in spas to generate
smell associated with hospitals. Majority
a calming atmosphere.
scents
have
a
certain
emotion
or
memory attached to it. Though it may be
The smell of lavender has been proven as
subjective sometimes, typically a human
a successful pain relieving agent. It also
reaction to different smells is programmed.
has a powerful ability to treat insomnia.
The presence of these odors in a space
The smell of a freshly mowed lawn can
sets off emotional reactions associated
induce joyousness and relaxation. Citrus
with the idea of that smell.
can boost energy and awareness; vanilla can lift ones’ mood; peppermint boost
The executive director of the Smell
concentration whereas jasmine helps with
of Sense Institute says, “Scents can
depression.
[20]
have positive effects on mood, stress reduction, sleep enhancement, self-confidence, and physical and cognitive
“The act of smelling something, anything, is remarkably like the act of thinking. Immediately at the moment of perception, you can feel the mind going to work, sending the odor around from place to place, setting off complex repertories through the brain, polling one center after another for signs of recognition, for old memories and old connections.” – Lewis Thomas, Physician RE - HUMANIZING HE ALTHC ARE |
42
1.6. 5 VIEWS Roger S. Ulrich revealed the ‘power of the window’ through a science experiment that confirmed that patients in hospitals recovered faster when their rooms had a direct view of the external natural environment rather than a blank wall. A window is not seen merely as a functional necessity that provides light and ventilation, but also a gateway that has the ability to transport a patient from a harsh reality to a place of contemplation, serving as a temporary escape.
[21]
Numerous studies as also Nightingale’s ward have proved the success of this theory. In urban hospitals, sometimes the only view available for a patient is an artistic depiction of nature which comes without a breath of fresh air and natures sounds and smells. Windows allow sunlight and warmth inside a room while providing views to the outside, thereby adding a sense of openness, spaciousness, and orientation.
43 |
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Figure 1.29 Thong House by NISHIZAWAARCHITECTS
1.6. 6 NATURAL LIGHT The balance or imbalance of a space can
room that is not easily achievable with
easily be altered through the play of light
an electric illuminant. The warmth of
and in combination with forms, colors, and
sunlight cannot be replaced by artificial
natural elements. The quality of light can
lighting. Along with delivering vitamin
be manipulated and adapted to ultimately
D to the body, natural light also leads
create the ability to transcend individuals
to higher productivity; greater natural
into an alternate state of consciousness
light during the day can help stabilize
that could essentially be recollected in
circadian
memory, after its lived experience.
mood.
[22]
rhythms
and
improve
the
[24]
Fabrizio Benedetti, professor of physiology
The design of openings can control the
and neuroscience at the University of Turin
quality and quantity of light in a space.
Medical School, Italy proved that patients
Depending on the functionality of the space,
exposed to an amplified concentration
openings can be designed to control the
of natural sunlight perceive less stress,
mood of the space.
require less medication and even experience less pain.
[23]
A dark or dingy atmosphere generates a feeling of imprisonment, whereas an artificially lit space has no impact on the mood. The changing character of daylight adds a dynamic qualitative dimension to the ambiance of the
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44
1.7 ARCHITECTURE THAT’S BUILT TO HEAL TED TALK BY AR. MICHAEL MURPHY
Michael Murphy is the co-founder & CEO
for consultation on a broken leg but walked
of MASS Design Group, a non-profit archi-
out with tuberculosis due to the negligence
tecture firm that leverages buildings, as well
of basic designs for infection control. This
as the design and construction process,
led him to question the ignorance of archi-
to become engines for health, economic
tects and designers in healthcare design
growth, and long-term sustainability.
for the underprivileged.
REVIEW
In the design of Butaro hospital in Rwanda, with the guidance of Dr. Farmer,
Questioning the availability of the best, most
they implemented basic site oriented
innovative, and visionary architecture for
design strategies with a shift from the
the benefit of few, Michael Murphy comes
conventional model.
across as one of the architects who want to do more than just design masterpieces
He discusses the concept of ‘Ubudehe’
for a legacy.
which means community works for the community. Under this principle, they
He talks about architecture school where
attempted to involve the community as
he learned that “Recognition seemed to
much as possible from hand excavation
come to those who prioritized novel and
of the site to handcrafted furniture, with
sculptural forms.”
the involvement of at least 50% women laborers. Bruce Niveze, the engineer
A talk by Dr. Paul Farmer, attended by Mr.
attempted to use the process of building
Murphy, on healthcare for the poor shed
to heal the community as a whole.
light on a hospital in South Africa where people waited in an unventilated corridor 45 |
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They designed a sustainable hospital
by making use of simple techniques like
He went on to design multiple healthcare
planning hallways around the rooms,
facilities addressed towards answering
opening into the gardens, instead of
the problems of different localities through
corridors to ensure natural ventilation; at
architecture. His approach to architecture
the same time providing verandas. Beds
and built spaces backed up by the results
were reorientated with the bed-heads
his designs have achieved speak for
against each other in the center of the
themselves. His ideas prove that architec-
room, to facilitate views of the garden for
ture has the ability to resolve social issues.
the patients from their beds. The local
Buildings and spaces can do what
stone was used as a building material.
designers want them to do, not just
Though facing multiple stumbles in the
functionally and aesthetically but also
initial stages, the project eventually
socially.
executed still reaps the benefits of the design.
1. VERANDAS | 2. CROSS VENTILATION | 3. INOPERABLE VENTS | 4. INDUSTRIAL FANS | 5. ULTRA-VIOLET GERMICIDAL LIGHTS
Figure 1.30 Orientation of beds, Butaro Hospital, Rwanda
Figure 1.31 Sustainable design features, Butaro Hospital, Rwanda
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46
1.8 THE ‘EPILOGUE’ Healthcare today is broadly divided into
Implementation of these necessary design
hospitals
centers.
considerations will have a far-reaching
Though rehabilitation centers are, at
effect on the medical outcome of patients.
and
rehabilitation
times, designed with the idea of holistic medicine in mind, hospitals usually fail
Healthcare architecture needs to move
to do so.
beyond functionality and aesthetics, towards patient-oriented design. In a
Initiatives
undertaken
organizations,
studying
by
of the Greek sanctuaries, the Pavilion
been
system and Nightingale wards and the
successfully attempting to establish the
high-rise style in the town in a hospital
scientific
design
planning. This will not only provide a
features and their impact on health since
better environment for the patients but
the last two decades.
also reflect on their length of hospital
design,’
relationship
effects
way, we need to combine design features
of
‘evidence-based
the
numerous have
between
stays and treatment results, ultimately The discussed investigations lead to the
proving beneficial to both the patient
conclusion that architecture and the design
and the medical authorities.
of spaces play a colossal role in healthcare.
47 |
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48
49 |
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TOPICS OF RESEARCH
CHAPTER 02 52 HEALTHCARE IN INDIA A brief insight into the healthcare industry and non-communicable diseases in India. The Industry 53 The Boom of Chronic diseases 55 Need for Cancer Care 57
60 WHAT IS CANCER? Introduction to the disease and the patients and their families various requirements and care options. Issues and needs of The Patient 61 Physical + Psychological + Social & Spiritual Prevalent types of Cancer Care facilities 65 Hospital + Palliative Care Center + Hospice Care Center + Mukti Bhavan + Dharamshala + Caring Center & NGO Complementary Therapies 69 Animal-assisted therapy + Aromatherapy + Art therapy + Counseling + Horticulture + Massage therapy + Meditation + Music therapy + Support groups + Yoga & Exercise
HEALTHCARE IN INDIA , CANCER, CANCER CARE IN MUMBAI 73 77 79 81 83
A view from the front line Cancer and Economics The Caregiver Mapping Affordable Cancer treatment Medical Migration for Cancer Care
86 CANCER CARE IN MUMBAI A study of affordable cancer care options available in Mumbai for the ‘outpatient.’ 88 Treatment within means Tata Memorial Hospital + Indian Cancer Society + St. Jude India ChildCare Centres 93 Shortcomings of the city for the ‘outpatient’ 95 Needs of the ‘outpatient’
“Indian healthcare industr y is best described as islands of excellence in an ocean of inadequacy. The Indian model of healthcare is innovative and of affordable quality, as it has used efficiencies of the six sigma, smar t and innovative IT, quality engagement with clinicians, and good use of local pharmaceutical industr y as well as the medical technology and devices sector, which together are paving the way for healthcare of the future.� - Sangita Reddy, Chairperson, FICCI 51 |
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2 .1 HEALTHCARE IN INDIA India was ranked at 112 out of 190 countries
in rural areas and the concentrated
in a report published by the World Health
growth of healthcare services in the
Organization in 2000.
urban areas, internal medical migration is on the rise.
One
of
the
primary
reasons
for
the
backward lag of the healthcare sector in
This medical migration comes with its own
India is its rural-urban divide. There are
set of needs and requirements, which are
vast gaps between the facilities provided
not addressed due to the limelight being
to the rural and urban populations in India’s
focused on the rural-urban divide. While
healthcare system.
policies for the growth and development of healthcare need to be formulated for
Majority hospitals are centered in cities
rural areas, medical migration needs to
and urban areas, while the rural setup
be tackled too.
makes do with small hospitals or clinics. With 70% of India’s population residing
Figure 2.1 Healthcare in India - Rural vs. Urban
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52
1991
2.1. 1
Population growth: +450 Million
THE INDUSTRY
2016
210 awareness is a rapidly growing healthcare GROWTH IN BILLION $
1991
People living in Poverty: -50%
industry. Despite this fast growth, the Population growth: +450 Million
healthcare sector in India comprises the 100 lowest government 66spend and public
People living in Poverty: -50%
spend as a 22 proportion of the Gross 5 Domestic Product (GDP) and amounts to 2010 1990 2000 the lowest per capita health2015 spend –2020 China
100
spends 5.6 times more, and the USA, 125
GROWTH IN BILLION $
Figure 2.2 Population trend in India between 1991 & 2016 | by 210 Author
The 1991
66
period between 1991 and 2016, 22
5
known as that of rising prosperity 2010 2015 2020 1990
2016 times more.
2000
in India, has been marked by a dual disease burden; a continuing rise in communicable diseases and a spurt in
Population growth:
People living in -50%
non-communicable/chronic or ‘lifestyle’ +450 Million Poverty: diseases. Population
Infrastructure
Population
Infrastructure
GROWTH IN BILLION $
210
Insurance
Rural-Urban disparity
100
66 62%
5
22
Personal savings
1990
38% Insurance
2000 76%
2010 24%
Uninsured
Insured
Insurance
2015
2020
Figure 2.3 Growth trend of the healthcare sector in India | by Author
Rural-Urban disparity
Figure 2.4 Key roadblocks for India’s healthcare sector | by Author
62%
Personal savings
38%
Insurance
The Indian healthcare sector is divided The result of this disease burden on a
into private and public. While the private
growing and aging population, economic
76% healthcare 24%delivery sector dominates
development
Insured of the across theUninsured country, a majority
53 |
and
increasing
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Population
Infrastructure
health
Population growth: +450 Million
People living in Poverty: -50%
GROWTH IN BILLION $
210
1991
2016
100
66 population living Below the Poverty 22 Population growth: People Line 5(BPL) — the ability to spend `47
Government
contribution
to
insurance
living in at roughly 32%, as opposed to stands Million Poverty: -50% per 1990 day+450 in 2000 urban areas 32 per day 83.5 % in the UK. Estimates suggest that 2010 & ` 2015 2020 enrolling all BPL families in the country in
the under-financed and short-staffed
health insurance programmes would cost
public sector for its healthcare needs, 210
anywhere from `2,460 cr. to `3,350 cr.
GROWTH IN BILLION $
in rural areas — continues to rely on
as a result of which they remain unmet. Moreover,
the
majority
of healthcare 100 professionals happen to be concentrated 66 in urban areas, where consumers have a 22 higher5 paying power.
With a large number of people from
Population 2010 Infrastructure 2015 2020 1990 2000 India meets the global average in the
an emergence of ‘frugal innovation’ in the
number of physicians, but 74% of its
referring to stripping non-essential or
doctors cater to a third of the urban
luxury features from a product to make
population, according to a KPMG report.
it marketable in developing countries,
low-income groups turning to the private sector for treatment due to the shortcomings of the public sector, there has been private sector. [1] Frugal innovation, initially
has come to encompass the features of The country is 81% short of specialists at
a product offering a lower price than its
Rural Community Health Centers, and the
first world counterparts without compro-
private sector accounts for 63% of the
mising quality and placing the needs of
Population hospital beds, to 38% Government 62%according Infrastructure
the overlooked customer above all.
Insurance
Rural-Urban disparity
Health Personal and Family Welfare statistics. savings Insurance For the purpose of catering to the population living below the poverty line, at the
76% Uninsured
24%
same time leveling the quality of care
Insured
offered by the private and public sectors,
Figure 2.5 Insurance disparity Ratio of Indians availing Rural-Urban healthcare insurance | by Author
62% Personal savings
38% Insurance
frugal innovations in the healthcare sector are the need of the hour. [From IANS, India’s healthcare sector: A look at the challenges and opportunities faced by the $81.3 billion industry, Firstpost., 12th June 2017]
Figure 2.6 Source of healthcare expenses of Indians | by Author
76% Uninsured
24% Insured
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54
98.16 lakhs No. of deaths
2.1. 2
58.69 lakhs
60%
No. of deaths due to chronic diseases
THE BOOM OF CHRONIC DISEASES A chronic disease is a long-term medical
25 lakhs 12 lakhs and6.6chronic lakhs Although cardiovascular
condition that is progressive. In recent
respiratory
times, chronic/non-communicable diseases
Cancer Diabetes Chronicis responsible Cardioshare of deaths, cancer
have been the leading cause of deaths in
respiratory vascularmortality. for maximum diseases
India. Industrialization, socio-economic development,
urbanization,
diseases
have
a
higher
diseases
changing
1,74,693
age structure, and changing lifestyles have placed India in a position where
No. of cases registered
it is facing a growing burden of chronic
57,400
diseases.
32.6%
Mortality rate Figure 2.9 Cancer mortality rate in India, 2014 | by Author
No. of deaths
98.16 lakhs
of deaths due to chronic diseases No. ofNo. deaths
Figure 2.7 58.69 lakhs Ratio of deaths due to chronic diseases in India, 2014 No. of deaths due to chronic diseases | by Author
60%
25 lakhs
12 lakhs
12 lakhs
6.6 lakhs
Cardio-
Chronic
vascular
respiratory
diseases
diseases
Cardio-
Chronic
vascular
respiratory
diseases
diseases
Cancer
6.6 lakhs
1.9 lakhs
Cancer
Diabetes
1,74,693
Figure 2.8
1,74,693 Deaths to chronic diseases in India, 2014 | by No. ofdue cases registered No. of cases registered
57,400
Author
32.6%
32.6%HE ALTHC ARE 55 Mortality | RE - HUMANIZING rate 57,400
S
Mortality rate
14
PREDICTION
12
10
registries across the country by the Nation 8 Cancer Registry Programme in 2014, the 6 highest mortality rate was recorded in 4 2 Mumbai at 63.75%.
The 1.9 lakhs on
25 lakhs
14
Based on the data collected from 27 cancer 9.62 9.79
60%
58.69 lakhs
CANCER PATIENTS IN LAKHS
98.16 lakhs
0
2006 2007 2008 2009 2010
2015 2020
International Agency for Research Cancer’s
GLOBOCAN
project’s
prediction states that India’s cancer Diabetes burden will nearly double in the next 20 years, from slightly over a million new cases in 2012 to more than 1.7million by 2035.
1.9 lakhs
vascular
respiratory
diseases
diseases
1,74,693 No. of cases registered
57,400
32.6%
CANCER PATIENTS IN LAKHS
Mortality rate
14 PREDICTION
12 10
9.62 9.79
8
As of 2015, the predicted cases have crossed the estimated number. Cancer not only affects the patients and
6 4
their family and friends severely but also
2
the economy and development of the
0
2006 2007 2008 2009 2010
2015 2020
Figure 2.10 Cancer prevalence in India | by Author
nation. Thus, attention needs to be diverted towards cancer patients and their care and treatment.
RE - HUMANIZING HE ALTHC ARE |
56
2.1. 3 NEED FOR CANCER CARE
Cancer is becoming a common man’s
standards and inadequate medical facilities.
disease, the cure for which does not guarantee life. Hence, it is the ‘hyped’
It is essential to comprehend and address
disease overshadowing other diseases.
the needs and issues of these patients and to provide them with a better, more efficient
With less than 30% of Indian cancer
healing environment.
patients surviving five years or longer it is a disease with
With the shortfall of medical infrastructure
majority cases diagnosed in late stages
and the complexity of modern healthcare
and comes with an expensive treatment
facilities, cancer patients are more than
procedure. This makes it even harder for
ever in need of an architectural interven-
the patients, especially those below the
tion. Healthcare facilities need to be
poverty line.
designed to the benefit of the patient
after diagnosis,
[2]
and not just the system. The magnitude of cancer problem is increasing due to poor to moderate living
57 |
RE - HUMANIZING HE ALTHC ARE
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58
Figure 2.11 The before and after of a child suffering from cancer
59 |
RE - HUMANIZING HE ALTHC ARE
2.2 WHAT IS CANCER? Cancers are a group of diseases associ-
The
incidence
of
ated with abnormal growth of cells. Without
according to the geographical area,
any check, the disease may keep on
prevalent
progressing, ultimately leading to premature
socio-economic strata. For example, oral
death. They can arise anywhere in the
cancers are common in the Indian sub-con-
body and can affect people from all
tinent, because of higher consumption of
age groups, socio-economic strata, and
chewable forms of tobacco and cervical
race.
cancers are more common in women from
social
cancers
customs,
varies
and
the
lower socio-economic strata because of poor genital hygiene. Some of the treatments and therapies for curing cancer are: TOBACCO
SUPARI
POLLUTION OCCUPATIONAL HAZARDS
º º Surgery º º Radiation º º Chemotherapy
LIFEST YLE
ALCOHOL
OBESIT Y
BIO-HAZARDS
Figure 2.12 Causes of cancer | by Author
º º Immunotherapy º º Hormone therapy º º Stem cell transplant
Radiation and Chemotherapy can cause several side effects such as: º º Anemia
º º Edema
concentration
fertility problems
º º Appetite loss
º º Fatigue
problems
º º Skin and nail
º º Bleeding and
º º Hair loss
º º Nausea and
changes
bruising
º º Infection and
vomiting
º º Insomnia
º º Constipation
Neutropenia
º º Nerve problems
º º Urinary and
º º Delirium
º º Lymphedema
º º Pain
bladder problems
º º Diarrhea
º º Memory/
º º Sexual and
º º Prostheses
[3]
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60
2.2. 1 ISSUES & NEEDS OF THE PATIENT Every cancer patient’s journey is personal
to inhabit responsive spaces that have
due to their diagnoses as well as lifestyle
the potential to aid the healing process
and family backgrounds. No two patients
and to provide a space that reinforces
undergo the same level of pain and
respect, dignity, and security.
[4]
suffering. In its many forms, cancer can have a catastrophic effect on normalcy and daily life for individuals and families impacted
by
the
disease.
SOCIAL
However,
many cancer patients do share similar treatment
experiences
that
include
PHYSICAL
an array of physical trials, emotional challenges, and spiritual journeys. It is essential to understand the complete spectrum of journeys that cancer patients
PSYCHOLOGICAL SPIRITUAL
experience, to gain true empathy that informs the design of environments to more efficiently support their fight against cancer. Space can be uniquely designed
61 |
RE - HUMANIZING HE ALTHC ARE
Figure 2.13 Needs of a cancer patient | by Author
PHYSICAL NEEDS
muscle tone, creating limitations in activity and altering familiar daily life.
Most patients receiving invasive treatments such as surgery, chemotherapy,
Furthermore, patients are often burdened
and radiation face the after-effects of
with the financial impact of treatment. This
physical changes and changes in their
additional challenge can increase mental
sense of well-being. These procedures
stress, causing physical fatigue that may
often result in a weak and compromised
influence their ability to heal and even make
immune system. Susceptibility to other
decisions about their treatment.
[5]
diseases can disrupt the healing process, thus, affecting the ability to fight cancer.
To
counter
these
challenges,
some
architectural design features that can be A cancer patient’s newly conditioned
adopted are:
state of normalcy can result in an
º º Barrier-free design
overall feeling of sickness. Treatments
º º Easy and quick access to toilets
and even pain medications for intermit-
º º Private and social spaces for exercise
tent or chronic pain can cause them to
º º Clean, hygienic spaces
feel perpetually nauseous and trigger gastrointestinal issues. This may leave patients vulnerable to uncontrollable accidents, increasing their levels of stress and anxiety. Changes in physical appearance are a typical result of cancer treatment. Many patients experience hair loss, scars, skin changes, weight loss or gain, sensitivity to smells and temperature, and loss of
Figure 2.14 Coping with the physical changes faced by a cancer patient
RE - HUMANIZING HE ALTHC ARE |
62
PSYCHOLOGICAL NEEDS
of the course and can be a difficult adjustment. Short-term memory loss or experience of a general fogginess is frequently reported as a side effect of many treatments. Pride and independence are also disrupted. The burden of cancer and the imminent fight can weigh heavy on one’s psyche, leading to sadness and depression.
Figure 2.15 The psyche of a cancer patient
To
face
these
challenges,
patients
In addition to the physical impact, cancer
need to stay positive and find purpose.
treatment can also affect the patients mental
Positive focus, inspiration, and intro-
and psychological makeup. The journey
spection
can be an emotional roller coaster, with
renewed hope, uplifting energy shifts
peaks and valleys of personal progress
and rejoicing at milestones and small
and setbacks. These ups and downs
breakthroughs along the journey.
provide
opportunities
for
[6]
often lead to a general sense of losing control. The dual challenges of battling a
To
counter
these
challenges,
disease that has overtaken their body and
architectural design features that can be
not knowing the outcome of their personal
adopted are:
battle often lead to emotions of fear and
º º Spaces for private counseling and
uncertainty.
group sessions º º A library
Regardless
of
the
catalyst,
mental
º º Yoga and meditation spaces
fatigue is a common issue. A cancer
º º Provision for different levels of
journey can also result in degradation
privacy
of a patient’s dignity. Many patients
º º Pockets of breakout spaces with
struggle with the overall lack of privacy.
connection to nature
Being
º º Pleasing views
exposed,
probed,
prodded,
studied, and examined becomes part
63 |
RE - HUMANIZING HE ALTHC ARE
º º Use of wayfinding strategies
some
SOCIAL & SPIRITUAL NEEDS
reason to fight the fight. This daily battle often spans many months or years. If
Walking the tightrope of cancer treatment
the patient feels supported and stays
requires a safety net of family, friends,
positive, the overall result can enhance
caregivers, and for some individuals, a
their ability to heal.
[7]
spiritual footing. While not all patients believe in a higher power, it is essential for
To
counter
these
challenges,
some
them to find solace during their journey.
architectural design features that can be adopted are:
Support from and connection to others
ยบ ยบ Provision of a prayer room
and/or a higher power can assist them
ยบ ยบ Multiple pockets of social spaces
in finding comfort and give them a
Designing environments for the care and treatment of cancer patients requires a holistic and sustainable approach to design, encompassing empathy, operational knowledge, and creative design thinking. This includes addressing the many complex layers of issues and factors that must be addressed to produce an efficient and responsive cancer care facility. Only by addressing all the needs of the patients can one hope to deliver a holistic healing environment. RE - HUMANIZING HE ALTHC ARE |
64
2.2. 2 PREVALENT TYPES OF CANCER CARE FACILITIES HOSPITAL
any stage of an illness. Individuals usually receive palliative care at clinics, hospitals,
A hospital is the primary healthcare
or at home by visits from professionals.
[8]
facility for all cancer treatments. It offers medical treatments such as chemotherapy,
The action for palliative care is taken on
radiation, surgery, etc. with the option of
by various government and non-govern-
inpatient and outpatient wards, wherein
ment organizations in India. The current
the patients can either opt to live in the
approach is mainly through associ-
hospital, during their treatment, or visit the
ations of medical helpers, providing
outpatient department (OPD) from time to
home-based aid where a physical model
time for their treatment therapies.
is predominantly absent.
PALLIATIVE CARE CENTER
HOSPICE CARE CENTER
Palliative and hospice care are options for
Hospice is a form of palliative care that
facilitating the provision of care to individ-
seeks to optimize the quality of life at the
uals suffering from chronic diseases.
end of life, while neither hindering nor hastening the dying process.
Palliative care is the treatment of the discomfort, symptoms, and stress of
Individuals who receive hospice care
serious illness, with comfort and quality
refrain
of life as primary goals. It provides relief
their underlying disease. To qualify for
from distressing symptoms including pain,
hospice, an individual usually has six
shortness of breath, nausea, problems with
months or less to live.
from
curative
treatment
for
sleep, anxiety, and side effects of medications. It is available for any age and at
65 |
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Hospice caregivers control pain and other
symptoms and provide counseling, family
It is when one gives up all materialistic
support, and many other services. Hospice
pleasures and becomes one with the
can be provided in long-term care facilities,
‘Atman.’ Though it can be attained even
such as nursing homes, at home or in
while living, it is believed that attaining
hospital inpatient wards.
moksha on the death-bed frees one from
[9]
the cycle of life and death and the soul is Hospice care centers in India are seen as
free ever-after.
a last resort for patients whose families these
In order to attain this salvation, people wait
centers are usually run by charitable
to die in this charity-run hostel. It is not a
organizations offering free services.
place where people go to commit suicide.
cannot
afford
caregiving
as
Neither is it a place of mercy killing.
MUKTI BHAVAN
The 12-room hostel consists of a temple
The ‘Mukti Bhavan’ or Salvation House is a hostel in Varanasi, India. Devotees on their death-bed, due to whatever reason, enroll themselves in this hostel to attain ‘Moksha.’ Moksha is the Hindu concept of liberation from the trials and tribulations of life.
and a quarter for its priests. However, the guests are given only two weeks to die. After which they are asked to move on to make way for others. As of 2014, over 14,000 people have made use of the services of this hostel to breathe their last.
[10]
Figure 2.16 Mukti Bhavan
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66
The concept is very similar to the olden days
Most of these patients belong to BPL families
Kashi concept. When older people said
and cannot afford cancer treatment. They
they are going to Kashi, it was assumed
travel great distances to gain the benefit of
they would not return as they would spend
discounted or sometimes free treatment.
the remainder of their lives there and die
Thus, they are unable to provide such high
there in hopes of moksha.
rentals.
[11]
DHARAMSHALA
Some government and private organizations
Patients throng to cities serving as afford-
setting up ‘dharamshalas’ in the proximity of
able cancer care centers in hundreds on a
these hospitals. These temporary lodgings
weekly basis. They seek temporary accom-
are designed to accommodate a maximum
modation in the city during their treatment,
number of people and usually subsist on
which can last from a few weeks to six
the support of sponsors and donors.
have attempted to address this issue by
months or sometimes a couple of years. These facilities aim to house a maximum Cities are typically cramped, and its facil-
number of people at minimal costs.
ities are saturated due to migration and
Thus, they rarely provide amenities of
other factors. Accommodation in such
any kind. Nursing availability is also
cities can prove to be a costly affair.
compromised in most cases. They endure
Figure 2.17 Shree Gadge Maharaj Dharamshala, Mumbai
67 |
RE - HUMANIZING HE ALTHC ARE
due to social interventions by NGO’s and
medical treatments but instead focus on
financial help from generous donors.
the intangible aspects of healthcare.
CARING CENTER & NGO
These activities are sometimes undertaken by NGO’s who visit other healthcare
Cancer caring centers are rare but an upcoming provide
typology.
These
psychological,
sometimes
physical
centers
social
support
to
and the
patients undergoing cancer treatments or recovering from it, using various therapies and counseling programmes. They aim at providing a better life to
facilities and provide similar services. For example, Sanjeevini - Life Beyond Cancer, an NGO based in Mumbai, focuses on providing emotional and nutritional support to patients. UGAM by the Indian Cancer Society offers educational support, participates in creating awareness, raising funds, and counseling activities for cancer patients.
people who are and have been the victims of cancer. They do not engage in
RE - HUMANIZING HE ALTHC ARE |
68
2.2. 3 COMPLEMENTARY THERAPIES
Patients undergoing cancer treatments
strategies, and outcomes measures.
experience
with
Therapeutic experiences can include
tremendous mental trauma. To relieve them
walking, brushing, petting and caring
of these difficulties, various complementary
for an animal, as well as the experience
therapies, along with medical treatment,
of trying to accomplish a given task.
physical
pain
along
[12]
should be undertaken. Animals such as dogs and cats are loving Complementary therapies do not claim
creatures. They usually open the emotional
to cure cancer but assist in coping
gates for participants. Spending a couple
with the side effects of the medical
of hours every day with them can reflect
treatments. They typically help with
well on the emotional wellbeing.
restoring physical abilities and boosting emotional health.
AROMATHERAPY
ANIMAL-ASSISTED THERAPY
The use of natural oils extracted from plants for relaxation is called aromatherapy. They
Animal-assisted therapy aims at improving
are used during massage, in baths and
a
creams or through diffusers.
participants
functioning
with
social the
and aid
of
emotional domestic
animals.
Aromatherapy can be induced in design with the help of aromatic plants in
Pets allow for a sense of stimulation
gardens and open spaces and by using
that helps nurture a participant’s sense
diffusers in the facility. The aroma thus
of positive well-being. With targeted
circulated triggers the targeted emotions
activities and simply spending time
and produces a positive vibe in the spaces.
with an animal, animal-assisted therapy involves
69 |
specific
therapeutic
RE - HUMANIZING HE ALTHC ARE
goals,
ART THERAPY
HORTICULTURE
Concentration on creating art can help
Horticultural Therapy is a practice that
participants slow down, relax, and process
uses plants and the garden landscape to
their thoughts.
promote well-being for its participants.
The subconscious mind can express
The
feelings through pictures, colors, and
healing has already been established.
shapes that participants might struggle
Horticultural therapy helps in improving
to put into words. By doing so, they may
memory, cognitive abilities, task initia-
begin to gain a better understanding of
tion, language skills, and socialization.
relationship
between
nature
and
their emotions, which can further help to build their confidence.
In physical rehabilitation, horticultural therapy can help strengthen muscles
Feelings can then be discussed in groups
and improve coordination, balance, and
or individual counseling.
endurance. In vocational horticultural therapy settings, participants learn to
COUNSELING
work independently, solve problems, and follow directions.
[13]
More than often patients are in need of professional help to cope with their
MASSAGE THERAPY
emotions and sentiments. A massage is a form of structured theraThe patients need to let go of their emotional
peutic touch.
stresses and talk freely. Counselors are trained to listen and provide support and
Massage therapy can be used to relax
help. For this, it is essential to provide a
a participants mind and body, relieve
friendly atmosphere, where the patient
tension, and enhance the mood. It also
feels free to talk and not as if he is being
reduces physical pain, fatigue, anxiety,
interrogated or bombarded with advice.
and depression.
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70
MEDITATION
YOGA & EXERCISE
Meditation uses concentration or reflec-
Conventionally,
tion to deeply relax and calm the mind.
treatment for a chronic illness are often
This can help reduce feelings of fear,
instructed by doctors to rest and minimalize
pain, anxiety, and depression.
physical activity. This is appropriate if
people
undergoing
movement causes pain, rapid heart rate Regular meditation practice can help partic-
or shortness of breath. However, newer
ipants feel more in control of themselves
research demonstrates that exercise is
and their lives.
not just safe and possible during cancer treatment, but it also improves physical
MUSIC THERAPY Music connects people to their emotions and is often a satisfactory way to initiate social connections. Music therapy has been found to help reduce pain and discomfort, improve mood and diminish stress, increase the quality of life, and allow participants to better communicate their fears, sadness or other feelings.
[14]
SUPPORT GROUPS
functionality and quality of life. Excessive rest can lead to loss of body function, muscle weakness, and reduced range of motion. Psychologically, exercise improves self-esteem and lowers the risk of anxiety and depression. Light exercise routines such as yoga or aerobics should be inculcated during and after cancer treatment to regain control over one’s body. Yoga involves positioning the body in different
ways
and
doing
breathing
exercises. There are various types of Often communicating with people under-
yoga; some use very gentle stretches,
going the same problems can help one
movement, and meditation, others involve
cope better with the problem. Support
more vigorous physical movements and
groups aim to bring people together
dietary changes, for example, t’ai chi.
and enable them to communicate with and help each other.
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[15]
MIND - Increases gray matter - Cultivates will power - Builds focus and
BODY
- Reduces
Decreases pain -
depression
- Physically modifies Boosts immune system Lowers blood pressure the brain Eases inflammation -
concentration - Eases stress
- Boosts cognitive functions
Reduces heart risk -
& anxiety - Reduces
- Helps sleep
loneliness
- Fosters a
- Cuts emotional
healthy body
reactivity
image
SPIRIT
- Builds self knowledge - Increases compassion - Improves empathy
Figure 2.18 Benefits of meditation | by Author
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72
2.2. 4 A VIEW FROM THE FRONT LINE BY MAGGIE KESWICK JENCKS Maggie Keswick Jencks, an architect by
REVIEW
profession, was diagnosed with cancer in 1988. Five years after having a mastec-
A view from the front line is Maggie’s
tomy, it returned. She was told, that there
description of living a life with cancer. She
was nothing more to be done, and she only
talks about the various stages of experi-
had a few months to live.
ences starting from diagnosis.
It was during this period that she began
Maggie believes that ‘fear, compounded
to realize several key things which are
by ignorance and false knowledge is a
described in ‘A view from the front line.’
paralysing attack in its own right. The
This description inspired the formula-
myth of cancer kills as surely as the
tion of the Edinburgh Maggie’s Cancer
tumours.’ Having survived the diagnosis
Caring Centre.
by immediate treatment is not the end of cancer. It is just the start point of the many
The
center
would
offer
information,
to come ups and downs.
psychological support, advice on nutrition, exercise, and relaxation therapies. Each
Cancer tends to reoccur and cause fatal
person visiting the center would be
damages in several cases. As it happened
helped to find his or her own best way
with Maggie. The second time was it for
of coping with the disease. There was to
her. With a few months to live and the
be no ‘right way.’
medical opinion of ‘living the remaining days,’ Maggie and her husband Charles
The center was to be a haven, where the
were not yet ready to quit. After signing
range of use would extend from a cup of
up for clinical trials and prolonging the
tea that one could make themselves in a
pain, eventually, she decided to face the
friendly kitchen to attending weekly support
end and quit experimenting with medical
groups led by a clinical psychologist.
remedies.
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[16]
She compares the conventional and
Along with her immune boosting soup
unconventional treatment alternatives
and diet, she was more energetic than
to a parachute jump, where there is no
ever.
guarantee of the parachute opening. Moreover, even if it does open, a landing
Advice from the director of the Institute
into the thick fog of multiple options with
of Chinese Medicine in London, lead her
no idea what the way home is, leaves the
to exercise which helped her relax and
patient confused and without any directions
boosted her energy. Different therapies
or ability to make decisions. The patients
like reflexology and aromatherapy as
are left to figure their way out themselves.
also pain relief techniques like acupressure
‘How is the patient – utterly unequipped
and
acupuncture
helped
her
overcome her physical problems.
to deal with this barrage of suggestions and faced with doctors who, at worst are
All the different trials and therapies
downright anti any additional therapies
paired with her nutritional and physical
and, at best supportive but sceptical –
choices eventually brought down the
to proceed?’
cancer markers.
Further, the emotional suffering of her
The entire process convinced her of
family due to her pain had physical and
the role played by the mind in cancer
psychological implications for her. At this
treatment. She says that the mental state
point, she decided to educate herself
falls back on the immune system. Michael
about her disease and face it head-on.
Lerner, a knowledgeable and experienced cancer-carer, and the Australian cancer
Starting with a balanced nutritional diet had
survivor Ian Gawlor were both proofs of it.
psychological implications for her. Taking charge of making decisions for herself,
Numerous other studies proved that
helped her regain independency.
therapies
like
support
groups
and
meditation prolonged life and its quality She talks about her time in the hospital when
for cancer patients. Patients who took
she lost 15 kgs but regained it within three
an active interest in their treatments
weeks due to her diet and supplements.
seemed to fare better.
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74
She concludes with ideas to improve
evidence to suggest that patients who eat
the system. Suggesting adjustment
healthily, keep active and take steps to deal
time for cancer patients to accept
with stress and fear, feel fewer symptoms
their illness and a better delivery of
and less pain even in the final stages of
the death sentence by the doctors, as
their disease. Preparing to welcome death
start points, she describes the hospital
healthily and happily is as essential as
environments which seem to say ‘How
dealing with the disease.
you feel is unimportant. You are not of value. Fit in with us, not us with
Carrying Maggie’s ideas for cancer care
you.’
forward, her nurse Laura Lee and husband Charles Jencks laid the foundation for
She suggests change such that patients
Maggie’s Centres. The objective was to
look forward to visiting the hospital and
encourage people who feel frightened and
not dread them. The hospital environ-
anxious about coping with cancer, to feel
ment needs to say ‘Welcome! And
better by developing their sense of confi-
don’t worry. We are here to reassure
dence and resourcefulness.
you, and your treatment will be good and helpful to you.’
The atmosphere in a Maggie’s Centre is more ‘coffee morning’ than ‘cancer
She believes that ignorance breeds fear
ward.’ Due to the success of the Edinburgh
and fear affects the immune system.
Centre, several other centers have been set
Hence, a ready availability of infor-
up across the United Kingdoms and spilled
mation regarding cancer treatments
onto other continents as well.
and
complementary
therapies
is
deficiencies
As both Maggie and her husband were
caused in part by cancer, a crucial
architects, their friends and students,
step in treatment is often skipped by
some of whom were Frank Gehry and Zaha
most due to ignorance.
Hadid, designed a Maggie’s Centre each,
required.
Rectifying
pro bono. WIth world-renowned architects Lastly, it is of utmost importance to
designing Maggie’s Centres, they gained
not lose the joy of living in fear of
fast popularity.
dying. There is a reasonable body of
75 |
RE - HUMANIZING HE ALTHC ARE
The purpose of Maggie’s is to help
it creates spaces which make it easier
people who are feeling as if they have
to be with other people, by creating a
been kicked in the stomach by a cancer
comfortable balance between public
diagnosis, get on with their lives again.
and private, which makes one feel safe
The buildings set the scene for them to do
but at the same time stimulates one’s
just that.
imagination without them even noticing that such a thing is going on, then it has
A building has done a good job if it even
done even more.
[17]
lifts one’s spirits for a brief moment. If
“I mean to keep on marching, down the tail of the statistical curve and on, into the sunset, and then, when eventually I must die, to die as well as possible.” - Maggie Jencks
RE - HUMANIZING HE ALTHC ARE |
76
2.2. 5 CANCER AND ECONOMICS A diagnosis of cancer often leads to
of land in most cases. This has reper-
catastrophic personal health expenditures.
cussions on the treatment of cancer
Such expenditures can push entire families
making it extremely expensive.
below the poverty line. Although relatively cheaper than in the People with cancer are 2.65 times more
West, cancer treatment continues to be
likely to declare bankruptcy than people
unaffordable for poor and middle-class
Given that the poorest
Indians, who often do not have health
two-thirds of the population are in much
insurance. Dr. B.S. Ajaikumar, founder
greater need of better health-care provision
and Chairman of the Healthcare Global
than the wealthiest third, increased public
chain of hospitals, declared that “It
investment in health services needs to be a
could cost as low as � 2.5 lakhs for
public policy priority for India.
six months of treatment, with some of
without cancer.
the lowest priced generic drugs in the The expenditures of cancer patients
world, to as high as ` 20 lakhs, with
include
novel drugs and targeted medicines.”
both
direct
medical
and
non-medical costs. The direct costs include buying medicine, hospitalization,
While the incidence of cancer is rising,
pathological tests, medical practitioner
insurance is a big stumbling block. Only
consultancy, travel, and lodging while the
a small fraction of Indians have health
indirect costs are loss of income during
insurance and those who do, rarely have
treatment, premature death, and effect on
critical illness cover. Of the 40 million
the income of other family members, etc.
individual policies sold in 2011, the average
[18]
amount per policy was just �1.9 lakhs. A Doctors estimate that a 100-bed cancer
�10 lakhs policy would mean a �17,000 to
specialty hospital would need an invest-
�50,000 annual premium, depending on
ment of up to 100 cr., excluding the cost
the age of the policyholder.
77 |
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[19]
Hence, cancer care treatment and infrastructure for the poor and families living below the poverty line needs to be prioritized. Providing affordable options and
CHEMOTHERAPY �10,000-400,000 REQUIREMENT: AS PRESCRIBED
materializing these options sustainably is
HERCEPTIN �75,000/COURSE REQUIREMENT: UPTO 7 COURSES
the contemporary need.
ERBITUX �100,000/CYCLE REQUIREMENT: 7 CYCLES OR MORE
AVASTIN �100,000/CYCLE REQUIREMENT: 8 CYCLES OR MORE
Figure 2.19 Costs of some cancer treatments and drugs | by Author
“Health cover is very low and is taken by just four to five percent of the people who can afford it. The average cover that most people take is between 1 lakh and 2 lakhs,” - Tapan Singhel, M.D. and CEO, Bajaj Allianz General Insurance Company.
“I had just about Rs 1 lakh when I got my wife to Tata Memorial Hospital for treatment. On the first day itself, I had to shell out Rs 25,000 for various medicines.” - Suresh Shidke, husband of a blood cancer survivor.
RE - HUMANIZING HE ALTHC ARE |
78
2.2. 6 THE CAREGIVER
The primary caregiver for a patient is the
Constant worrying or concern for the
spouse, partner, parent or an adult child.
patient’s ability to look after themselves
When the family is not around, close
often causes a loss of independence for the
friends, co-workers, or neighbors may fill
patient. The patient’s needs are constant
this role. The caregiver plays a vital role in
and result in a fall in the caregiver’s
the patient’s care. Good, reliable caregiver
independent occupational engagement.
support is crucial to the physical and emotional well-being of the patient.
Along
with
the
emotional
implica-
tions of caring, side-effects of cancer Today, most
cancer treatments
are
medications
and
treatment
options
given in outpatient departments. Thus,
have physical implications for both the
someone needs to take the responsi-
patients and their caregiver. Managing
bility of nursing the patient at all times.
pressure sores and incontinence, cleaning,
As a result, caregivers have many roles.
cooking, traveling to and from appoint-
These roles change as the patient’s
ments, and other needs often result in
needs change during and after cancer
physical exertion and illness. The time
treatment. Caregivers may help feed,
and energy required for taking care of
dress, and bathe the patient. They
the patients’ health problems mean that
arrange schedules, manage insurance
sometimes, they are unable to look after
issues, and provide transportation. They
themselves, resulting in a deterioration of
are legal assistants, financial managers,
their health.
[20]
as well as housekeepers. Some
considerations
required
for
the
The caregivers are often emotionally or
caregiver in a healthcare programme are:
physically unable or professionally unquali-
º º Respite care
fied to provide the care needed. Also, they
º º Provision of physical and psycholog-
are faced with the emotional impact of
ical therapies
caring which sometimes consumes them
º º Provision of a temporary workplace
psychologically and physically.
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RE - HUMANIZING HE ALTHC ARE
“The facility near Tata hospital is much better off as there are nurses to perform basic emergency procedures and there are medical provisions for the caretakers too.” -Husband
of
a
patient
at
Shree
Gadge
Maharaj
Dharamshala, Mumbai.
“I had to leave my home and quit my job to come to Mumbai for my 5-year-old grandson’s cancer treatment. We had to live on the streets for a very long time as there was no space in the dharamshala. Now finally we have a room that we share with another family. My wife cooks food while I go to the hospital daily for treatments. There’s no time to work and earn money. We are running out of our savings also.” - Grandfather of a pediatric patient.
“This disease has ruined the life of my entire family. They sold everything we had to get me to Mumbai; I don’t know if we will ever go back home.” - A patient suffering from throat cancer.
RE - HUMANIZING HE ALTHC ARE |
80
2.2. 7 MAPPING AFFORDABLE CANCER TREATMENT
SKIMS
PATEL HOSPITAL
RAJIV GANDHI SUPER SPECIALT Y HOSPITAL
DELHI STATE CANCER INST. AIIMS
S.M.S HOSPITAL CANCER HOSPITAL & RESEARCH INST. THE GUJARAT CANCER & RESEARCH INST. KAILASH CANCER HOSPITAL & RESEARCH CENTER
KAMLA NEHRU MEMORIAL HOSPITAL
PT. JAWAHAR LAL NEHRU MEMORIAL MEDICAL COLLEGE RASHTRASANT TUKDOJI REGIONAL CANCER HOSPITAL
NORTH EAST CANCER HOSPITAL AND RESEARCH INST.
TATA MEDICAL CENTRE
INDIRA GANDHI GOVERNMENT MEDICAL COLLEGE & HOSPITAL
TATA MEMORIAL HOSPITAL
SRI SHANKARA CANCER HOSPITAL & RESEARCH CENTRE MAZUMDAR SHAW MEDICAL CENTER
KIDWAI HOSPITAL CANCER INST. CHRISTIAN MEDICAL COLLEGE
REGIONAL CANCER CENTRE
Figure 2.20 Mapping top public cancer hospitals in India | by Author
81 |
RE - HUMANIZING HE ALTHC ARE
N
NAME & LOCATION
KNOWN FOR
NO. OF B EDS & PATIENTS
SERVICES OFFERED
Delhi State Cancer
Radiation and
95 Beds; 800
250 Patients receive
Institute, Delhi, 2006
Chemotherapy
Patients attended to
Radiation and
offered free of cost
daily in the OPD
Chemotherapy daily
The Gujarat Cancer &
Offers medical
660+50 Beds;
50% Subsidy for
Research Institute,
treatment + palliative
30,000 New patients
general patients and
Gujarat, 1972
care
in the OPD annually
free treatment for B.P.L. patients
TATA Memorial
Leading under the
629 Beds; 67,000
Free treatment for
Hospital, Mumbai,
Rajiv Gandhi Jeevan
Cases registered
70% of its patients
1941
Arogya Yojana for
annually
patients B.P.L. Kidwai Hospital,
40-60% Discounted
429 Beds; 16,000
Lodging and daily
Bengaluru, 1973
cancer medications
Cases registered
meals offered on
annually
basis of sponsorship
Sri Shankara Cancer
Non-profit
360 Beds; 4250
In the last 2 years,
Hospital and
Organization
Cases registered
250 patients
annually
benefited 100% free
Research Centre,
treatment and 600
Bengaluru, 2008
patients received 50% concession Cancer Institute,
Research division +
535 Beds; 15,700
Free treatment for
Chennai, 1954
College of oncologi-
Cases registered
40% of its inpatients
cal sciences +
annually
Division of preventive oncology Free treatment for
200 Beds; 15,000
Regional Cancer
Availability of 20
Centre, Thiruvanan-
Government schemes Cases registered in
thapuram, 1981
and other Non-
2015
Government services
50% and subsidized rates for 25% of its patients
Figure 2.21 Affordable cancer care in India | by Author RE - HUMANIZING HE ALTHC ARE |
82
2.2. 8 MEDICAL MIGRATION FOR CANCER CARE Cancer care options for the well-to-do
patients,
are available in abundance as opposed
ally fully booked. Thus, patients have no
to affordable options for the financially
option but to opt for outpatient services.
disabled.
It falls upon the city’s infrastructure and
The
patients
belonging
to
the latter category face hardships and
[21]
inpatient beds are perpetu-
services to cater to these ‘outpatients.’
difficulties every step of the way from making their way to cities for affordable
Cancer is a costly as well as physically
treatment to survival in those cities
and psychologically wielding disease. With
during their treatment.
the horror of cancer already looming over the patient’s family, an additional factor
Patients who are traveling to a different
of financial burden worsens the situation.
city for affordable cancer treatment end
Thus, providing affordable and beneficial
up spending months in the city. Thus, they
facilities for them needs to be undertaken.
are medical or temporary migrants in the city. These patients sometimes opt for
On analyzing the stated data, it is
outpatient facilities when inpatient beds
evident that the TMH in Mumbai caters
are occupied.
to the largest group of low-income cancer patients. Thus, Mumbai has been
In hospitals such as the Tata Memorial Hospital (TMH) in Mumbai, where the daily load in the oncology OPD is 4,000
83 |
RE - HUMANIZING HE ALTHC ARE
chosen as the site for further study.
RE - HUMANIZING HE ALTHC ARE |
84
M I R A - B H AY A N D E R
THANE JUPITER HOSPITAL
MUMBAI SUBURBAN FORTIS HOSPITAL KOKILABEN DHIRUBHAI AMBANI HOSPITAL
HIRANANDANI HOSPITAL SEVENHILLS HOSPITAL
NAVI MUMBAI
LILAVATI HOSPITAL
SION HOSPITAL
ACTREC
HINDUJA HOSPITAL KEM
JASLOK HOSPITAL SAIFEE HOSPITAL
TATA MEMORIAL HOSPITAL
NAIR HOSPITAL JJ HOSPITAL
MUMBAI CITY
N
PRIVATE HOSPITALS PUBLIC HOSPITALS
Figure 2.22 Top cancer treatment hospitals in Mumbai | by Author
85 |
RE - HUMANIZING HE ALTHC ARE
2 .3 CANCER CARE IN MUMBAI CIT Y As the city of dreams, Mumbai caters to
limited to the benefit of the city dwellers
the needs of all, even in the healthcare
but extends beyond boundaries; offering
sector. With several multi-specialty as well
low-priced and quality cancer care
as cancer specialty private and public
programmes for all in India and also its
hospitals, it caters to all income groups.
neighboring countries.
Especially the renowned inexpensive
Thus, hundreds travel to Mumbai every
cancer treatment provided by the Tata
week with hopes of benefiting from afford-
Memorial Hospital (TMH), which is not
able quality cancer treatment.
‘The Parel hospital (TMH), treats around 67,000 new cancer patients from across the country every year and also attends to 4.5 lakh follow-up cases annually. People from the Middle East and Africa also seek medical attention here.’ - MumbaiMirror, 20 th Oct 2017 RE - HUMANIZING HE ALTHC ARE |
86
BHAK TI VEDANTA HOSPICE
M I R A - B H AY A N D E R
THANE
MUMBAI SUBURBAN
NAVI MUMBAI 12
9
13
SHANTI AVEDNA ASHRAM
7
10
INDIAN CANCER SOCIET Y
6 5
11
8
2 3
1 4
MUMBAI CITY
N
Figure 2.23 Mapping affordable cancer care facilities in Mumbai | by Author
87 |
RE - HUMANIZING HE ALTHC ARE
AT TENDANTS/
NAME & LOCATION
CAPACIT Y
TARIFF
1. St. Jude India ChildCare Centres, ICS, Parel
30 kids
Free accommodation and food
2
Private patients - ₹100 General patients - free
2
2. Nana Palkar Smruti Samiti's (NPSS), Parel
76
PATIENT
3. St. Jude India ChildCare Centres, Ajai Verma Centre, Parel
11 kids
Free accommodation and food
2
4. St. Jude India ChildCare Centres, Cotton Green Campus
165 kids
Free accommodation and food
2
5. St. Jude India ChildCare Centres, Dr. Mhaskar Hospital
8 kids
Free accommodation and food
2
6. The Bombay Mother & Child Welfare Trust, Lower Parel
80
15 Pediatric beds - free
2
7. Shree Gadge Maharaj dharamshala, Dadar
200
Accommodation+dinner - ₹50
2
163
30 patients B.P.L. - free General (4 patients) - ₹130
2
8. Bharat seva sadan, Dadar 9. Dr Ernest Borges Memorial Home, Bandra
Semi-private (2 patients) - ₹225 Private - ₹450 & Deluxe - ₹850 10. St. Jude India ChildCare
41 kids
Free accommodation and food
2
₹100
2
Free accommodation and food
2
Centres,ACTREC 11. Shree Gadge Maharaj dharamshala, Kharghar
80
12. Bharat Sevashram, Navi
95
Mumbai 13. Assam Bhavan, Navi Mumbai 16 (from Assam)
Figure 2.24 Lodgings for cancer patients in Mumbai | by Author RE - HUMANIZING HE ALTHC ARE |
88
2.3. 1 TREATMENT WITHIN MEANS THE TATA MEMORIAL CENTRE,
beds, 37 ICU beds and 25 operation
MUMBAI
theaters. It is renowned for prevention,
The Tata Memorial Hospital (TMH) was commissioned by the Sir Dorabji Tata Trust in 1941. After the transfer of authority to the Department of Atomic Energy in 1962, in its 25th year the Indian Cancer Research Centre, which was established in 1952, and the TMH were merged to form the Tata Memorial Centre. TMH is one of the best as well as most affordable cancer treatment hospitals in India, accommodating 629 inpatient
Figure 2.25 Growth of the TMH, Mumbai
89 |
RE - HUMANIZING HE ALTHC ARE
treatment,
education,
and
research
for cancer treatment. It is the leading hospital under the Rajiv Gandhi Jeevan Arogya Yojana for patients BPL initiated by the Government of Maharashtra. The hospital has expanded from 15,363 m 2 to over 53,890 m 2 and continues to do so with the upcoming Women and Children’s hospital and Hydrogen Beam Therapy facility. The Annual Budget which was `5 lakhs in 1941, today runs close to `200 cr.
AV E R AG E 4.5 LAKH FOLLOW-UPS
+
67,000 NEW CASES
+
REFERRALS
2 013 29,000 CASES DIAGNOSED Figure 2.26 Annual patient flow in TMH | by Author
4000
24,500
500
Depending on the financial capacity to
A large chunk of low-income patients
pay for treatment at TMH, patients fall
seeking affordable cancer treatment in
under the following categories:
Mumbai is treated at the TMH. Though
40
1. General Patients (Part paying):
: 60
º º C: Partly charged. (20% for investiga-
infrastructure
such
as
a rehabilitation center at the Indian
AVERAG E tions and consultations and the rest as 4.5 LAKH FOLLOW-UPS per actuals)
supporting
Cancer Society and various lodgings
+
67,000 NEW CASES are established in for the ‘outpatients’
º º NC: Minimal charges for few services; no
the vicinity of the TMH, they are always
2013 the rest as per actuals.
wait-listed as the demand is multiple
investigation or consultation charges and
29,000 CASES DIAGNOSED
+
º º BP (Below poverty): The Rajeev Gandhi
times the availability.
REFERRALS
Jeevan Yojana Scheme provides cashless
While the hospital keeps growing and
quality care to families with an annual 4000 income below 24,500 `1,00,000 for 500 an amount of
widening its programmes, the growth of these supporting facilities is stagnant.
`1,50,000/family/year. 2. Private Patients (Full paying)
40
[22]
: 60 Figure 2.27 Private:General ratio at TMH | by Author RE - HUMANIZING HE ALTHC ARE |
90
INDIAN CANCER SOCIETY
through accommodation, rehabilitation, and survivor support groups.
Mumbai based Indian Cancer Society (ICS)
ยบ ยบ Gathering and collating data through
was established in 1951 as Indiaโ s first
the Population Based Cancer Registry
voluntary, non-profit National Organization
and providing analytic and projected
for awareness, detection, cure, and survi-
reports on the incidence of cancer via the
vorship of those affected by cancer.
Mumbai Registry. ยบ ยบ Providing a medium for the dissemina-
Instead of limiting themselves to a specific
tion of information and research findings
set of functions, ICS is always looking for
to the medical fraternity through the
new ways to lend a helping hand to cancer
Indian Journal of Cancer.
patients throughout India. Approximately 32,000 people have benefited from its
The rehabilitation center at ICS provides
charitable programmes during the years
different
2013-2014.
easy tailoring workshops to dyeing,
programmes
ranging
from
hand weaving, assembly of bags, etc. The society is entirely dependent on
They
public support for its various activities
enable patients to be socio-economi-
which are:
cally self-reliant. They also manufacture
ยบ ยบ Creating nationwide awareness of
and supply Orthotic and Prosthetic
cancer, its risk factors and preventive
Appliances as a part of the rehabilita-
measures, encouraging regular check-
tion programme.
provide
vocational
training
to
[23]
ups, treatment options, and survivorship. ยบ ยบ Providing for early detection of cancer through cancer detection centers and mobile cancer detection camps across India, especially for the underprivileged. ยบ ยบ Providing funds for the treatment of cancer for poor cancer patients across India ยบ ยบ Providing support during and after treatment to poor cancer patients 91 |
RE - HUMANIZING HE ALTHC ARE
Figure 2.28 Tailoring workshop in the Rehabilitation center at ICS
COMMON ROOM
KITCHEN
ADMIN
ST. JUDE INDIA CHILDCARE
are provided with ration and supplements
CENTRES
on a weekly basis in case they prefer to cook their meals.
St. Jude’s aims at providing free hygienic accommodation to children undergoing cancer treatment from low incomes
TOILETS families with the help of patronages. Along with accommodation, they also provide free nutritional food and emotional support.
RECEPTION St. Jude’s has centers set up in several locations in Mumbai. They cater to 225 kids, i.e., 40% of the need for accommodation of financially challenged children who come to Mumbai, specifically to the
Tata Memorial Centre, for their treatment ROOMS/UNITS NURSERY
A child is allowed two attendants; usually
protocol.
[24]
only the parents are allowed. The families
TOILETS
COMMON ROOM
KITCHEN
1.8M
RECEPTION HIS TOILETS ROOMS/UNITS
1.8M
ADMIN
UNIT
NURSERY
HER TOILETS
Figure 2.29 Typical layout of a St. Jude India ChildCare Centre | by Author
1.8M
1.8M
UNIT
Figure 2.30 Typical unit layout, St. Jude India ChildCare Centre | by Author RE - HUMANIZING HE ALTHC ARE |
92
2.3. 2 SHORTCOMINGS OF THE CITY FOR THE ‘OUTPATIENT’ Due to the crunch of space in Mumbai city,
Some government and private organiza-
even though quality affordable healthcare
tions have set up dharamshalas, attempting
options are available, the infrastructure to
to provide stay at minimal or no costs. The
support medical migration is far less than
aim of these lodgings is focused on
required.
accommodating maximum numbers. In their attempt to do so, they compromise on
With the growth of healthcare insti-
the quality of living. Utilizing every inch of
tutes catering to the ‘outpatients,’ the
space leads to disregard for the need of
demand for supporting infrastructure is
amenities and nursing facilities. Despite
over saturated and incessantly growing.
these attempts, the numbers are not
Patients visiting the Tata Memorial Hospital
met, and many are forced to travel to
(TMH) for affordable treatment can barely
Navi Mumbai for cheaper accommoda-
afford two meals a day, let alone accom-
tions or set camp on the streets outside
modations in a high priced real estate area
the hospital.
such as Parel. Such is the case outside TMH, where
AVAILABILIT Y
patients reside on the footpath despite
+
else to turn to, they live by the roads
their medical conditions. With no one till they get ticked off the waitlist at
710
255
REQUIREMENT
the
dharamshalas.
Individuals
and
organizations have organized the distribution of food and other necessities as a daily routine for the benefit of these ‘outpatients.’ The footpath is abuzz with
4000 PATIENTS IN THE OPD DAILY Figure 2.31 Lodging availability vs. requirement in Mumbai | by Author
93 |
RE - HUMANIZING HE ALTHC ARE
activity and occupied at any point in time, day or night.
Figure 2.32 Daily activities on the TMH footpath; temporary settlements, sleeping by the roadside, waiting for transport, food distribution (from left to right, top to bottom)
“Though the treatment costs are subsidized, there are many other expenses that we need to meet on a day-to-day basis. We often have to visit the doctor twice a month. It is not possible for my family and me to return to our hometown in Bihar and return every time we have to visit the doctor. I am helpless. I have no option but to live on the street.” -Putun Devi, blood cancer patient from Bihar.
“We have a relative in Vasai, but we cannot travel with a cancer patient in the train. So we chose this footpath.” -Sushma Tiwari, wife of a throat cancer patient. RE - HUMANIZING HE ALTHC ARE |
94
2.3. 3 NEEDS OF THE ‘OUTPATIENT’ Patients keep pouring into the Tata Memorial
and shelter. Thus, providing housing, not
Hospital all year round, every year. Despite
just sheltering the patients and their
expansion from time to time, they are
attendants, but also facilitating holistic
unable to satisfy the growing need for
treatment via the design of spaces
affordable cancer care. Along with the
should be given utmost priority.
expansion of the hospital, the snowballing pressure on supporting infrastructure is
A cancer patient faces high levels of
tremendous.
emotional trauma. They require constant motivation and guidance to climb out of the
Addition of another treatment center
cancer pit. This care should be adminis-
will only add on to the already tenacious
tered during as well as after the treatment
issues. Hence, it is essential to first
via a cancer caring institute. This institute
address the existential crisis before
need not provide medical facilities, but
taking any other step towards the
rather facilitate pain relief therapies
provision of treatment.
and support for the social, physical, emotional and spiritual needs of the
The patients face low standards of living due to lack of basic necessity of food
95 |
RE - HUMANIZING HE ALTHC ARE
patients and their family.
RE - HUMANIZING HE ALTHC ARE |
96
97 |
RE - HUMANIZING HE ALTHC ARE
DESIGN INTERVENTION
CHAPTER 03 10 0 DESIGN FUNCTIONS A gist of the intended functions of the proposed programme with related case studies. A Therapeutic Home for the ‘outpatient’ 101 Providing Care to Cancer patients 103 Need for Sustainability 105 Maggie’s Centres, U.K. 107 Karunashraya, Bengaluru 115 Shree Gadge Maharaj Dharamshala, Mumbai 121 Hope Lodge, U.S.A. 125
130 SITE Site selection and study.
FUNCTIONS, SITE , BRIEF, APPROACH 131 Selection criteria Location + Accessibility + Context 137 Site analysis
142 DERIVING A DESIGN BRIEF Estimating User-ship + Proposed Programme
146 DESIGN APPROACH A conceptual design intent for the proposed project. Connection with Nature + Domestic Scale + Home-like Environment + Levels of Privacy + Vertical Design
Figure 3.1 Evolution of healthcare wards
99 |
RE - HUMANIZING HE ALTHC ARE
3.1 DESIGN FUNCTIONS The proposed cancer care facility is for
The study executed aims to relook at the
the benefit of the ‘outpatients’ in Mumbai
existing affordable cancer care facilities
city. It is a tool to address the issues of
in India and provide a solution based on
medical migration in Mumbai. Though it
the needs and requirements of not just the
is not a medical institute, it seeks to cater
patients but also their families.
to non-tangible aspects of healthcare via the architectural design of spaces.
The previous studies of therapeutic environments and needs of cancer patients, mainly
The primary aim of this facility is to
the ‘outpatients’ in Mumbai are used to
provide
derive the design functions.
a
healing
environment,
by
means of housing and a break from the unfriendly hospital atmosphere in a caring center.
With the help of positive and negative case studies, a study of the evolution of healthcare architecture, and an understanding of therapeutic spatial design, the proposed brief intends to ‘re-humanize’ healthcare, specifically, cancer care facilities.
RE - HUMANIZING HE ALTHC ARE |
10 0
3.1. 1 A THERAPEUTIC HOME FOR THE ‘OUTPATIENT’ The diagnosis of cancer is a disruptive,
co-morbidities and disease progressions.
life-changing event. Medical migration
They also have a diverse range of prefer-
roots the patients from the warmth of
ences, personalities and family support.
their home only to place them in an unknown and sometimes unwelcoming
Living with the side-effects of the medica-
accommodation during their treatment.
tion, pain and sometimes changes to their physical attributes, lead to troubling
A cancer patient undergoes tremendous
adverse
mental trauma during this treatment and
engagement in communal activities and
requires
his
their emotional well-being. It is essential to
friends and family. This situation is notably
provide a solace for their troubles as per
harder on the ‘outpatients’ who belong to
their preferences; social as well as private.
the
constant
support
of
outcomes
in
terms
of
their
the low-income category and leave their home and family, with limited finance, in
Current lodging facilities are a block of
aspiration of affordable or free treatment.
concrete, with rooms on both sides of
Even though they make their way to
a corridor running through its length.
treatment centers, they typically have to
There is no consideration for recreation
stay in what are often over-crowded and
or even basic medical aid. With the
unhygienic dharamshalas or lodging
patients spending a majority of their time
houses due to their financial limitations.
in this temporary home, it is essential to cater to their healing needs in addition
The patients seeking a home in these lodgings have a diverse range of cancers,
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to those of the basic necessities.
Requirements of a healing residence for cancer patients based on executed studies: º º Rooms &
º º Washing &
º º Workroom/
º º Services &
dormitories
drying areas
computer room
storage
º º Kitchen & dining
º º Nursing room
º º Therapeutic
º º Amenities/
º º Common hall
º º Prayer room
gardens
recreation area
º º TV room
º º Kids playroom/
º º Staff quarters
º º Toilets
nursery
º º Administration
“We are happy to have a roof over our head during these perilous times. If you set your mind to it, you will like everything without asking for more. This is the best we can afford. Hence we are satisfied with whatever little we get.” - A patient residing in the corridor due to unavailability of a room at the Shree Gadge Maharaj Dharamshala, Mumbai.
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102
3.1. 2 PROVIDING CARE TO CANCER PATIENTS Laura Lee, director of Maggie’s Centres,
sense of independence. A caring center
is of the opinion that, ‘The landscape
primarily offers social support and other
of cancer is changing, because more
therapies to help patients come to terms
people are surviving. Those with a
with their disease.
recurrence live longer. The need for these (caring) centers has never been
Rebuilding towards the routine life for
greater because people are living with
a cancer patient does not begin after
cancer as a part of life.’
the treatment but goes hand in hand with the treatment. It can be used as a
Cancer treatments affect physical, social,
tool to cure the side effects of cancer
and psychological abilities of the patients.
treatment through productive therapies.
Patients tend to rely entirely on their ‘carers’ due to side effects from the treatment and
Healing spaces should not promote the
loss of control over their body. This has
feeling of exclusion, but rather imitate a
psychological impacts too, leading to loss
society that embraces individuals through
of self-confidence.
an environment that fosters measured community
Availability of specialized care helps them to regain these abilities while restoring their
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reintegration.
interaction
and
gradual
Requirements of a caring center for cancer patients based on executed studies: º º Counseling
spaces
therapy
º º Massage room
rooms
º º Support group
º º Art therapies –
º º Social pockets
º º Exercise
sessions
weaving, stitching,
º º Administrative
programmes –
º º Horticulture
painting, crafts
offices
yoga, aerobics
therapy
º º A library
º º Toilets
º º Meditation
º º Animal-assisted
º º Music therapy
“Cancer hijacks your life and drops you into a situation where you have to learn a new language. Having a center within easy reach has been vital in helping me cope.” - Rani, visitor at Maggie’s London West Centre.
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104
3.1. 3 NEED FOR SUSTAINABILITY As the proposed facility caters to the finan-
generation can be implemented along with
cially challenged, it is set-up and run by a
a power management system.
non-profit organization. Thus, it needs to sustain itself financially.
Consideration for waste management systems to facilitate usage of biowaste to
Though dependent on sponsors and
produce biofertilizer, which can then be
patrons, it can adopt design features
used in horticulture therapies can go a long
that can help to minimize the reliance to
way.
some extent. Implementation of sustainable design features and services can
Water management systems might be
reduce the impact on maintenance costs
incorporated to assure a continuous supply
to a great deal along with generating a
of water without wastage.
clean and green environment. Use of passive design strategies to In a city like Mumbai, blessed with long
ensure natural lighting and ventilation can
summers, use of solar energy for electricity
reduce power consumption.
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PRECIPITATION
REDUCED POTABLE WATER CONSUMPTION
EVAPOTRANSPIRATION
WASTEWATER REUSE STORMWATER REUSE
Figure 3.2 Urban Water Management Systems | by Author
REDUCED WASTEWATER DISCHARGE
STORMWATER TREATMENT
RUNOFF
INFILTRATION NATURAL FACTORS POSSIBLE INTERVENTIONS BY MAN
ORGANIC WASTE BIOFERTILIZER/ BIOGAS
HAZARDOUS WASTE
INCINERATION DRY/RECYCLABLE WASTE
Figure 3.3 Waste Management Systems | by Author
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106
3.1. 4 MAGGIE’S CENTRES, U.K. “A Maggie’s Centre is a house which is not a home, a collective hospital which is not an institution, a church which is not religious and an art gallery which is not a museum.” - Charles Jencks, founder of Maggie’s
Maggie’s Centres are a unique typology,
emotional, social, and psychological
an idea envisioned by Margaret Keswick
support. They aim at positive outcomes
Jencks, a terminally ill woman who believed
through the domesticity of spaces in
that cancer treatment environments needed
their centers by creating an informal
good design. Combining spaces to rest
environment for patients to respond
and
positively to the work of caregivers.
reflect,
these
unique
buildings
include gardens, private rooms and gathering areas.
With more than 20 Maggie’s Centres
[1]
spread throughout the United Kingdoms, Maggie’s is a cancer caring organization
most of them designed by world-renowned
that aims at providing comfort to patients.
architects, all centers are designed by a
It is not a palliative care center nor a
set of design features laid out by the
hospice. Neither do they indulge in medical
organization. These features are observed
treatment.
in almost all the centers.
Maggie’s
Centres
Figure 3.4 Maggie’s London West Centre
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provide
Figure 3.5 Maggie’s Manchester Centre
MAGGIE’S ABERDEEN CENTRE Small, domestic scale; like a beacon of hope
Figure 3.6 Design features observed in Maggie’s Centres | by Author
MAGGIE’S MANCHESTER CENTRE Landscape on the sides of the path leading to the center to shed stress.
MAGGIE’S LONDON WEST CENTRE Contrast from a typical healthcare building, creating a kind of curiosity. The centers are bold as well as inviting and safe.
MAGGIE’S LANARKSHIRE CENTRE Constant connection with nature for the user to step out into nature either through a window view, a courtyard, or a garden.
The red striking red wall of Maggie’s London
The ceiling heights and room sizes are
West Centre by Rogers Stirk Harbour +
kept similar to those in a typical house. The
Partners acts as an optimistic, energized,
partition walls fall short of the ceiling as
restorative feature that psychologically
this allows, according to Jencks, ‘spaces
communicates the influence that the
to flow into each other while allowing a
centers intends to envelop a patient
datum of visual privacy.’
into. It creates its own little world in the midst of the busy city life.
The kitchens in all the centers are perceived as the heart of a home where the table
Though small, Maggie’s Centres comprise
is a place to sit and read, talk to other
an intriguing architectural complexity. The
people, and find support from profes-
interior spaces are subdivided in a way as
sional experts. One can walk into Maggie’s
to allow for private as well as communal
at any time, make themselves a cup of tea,
spaces at the same time allowing users
sit down at the kitchen table to think, talk,
to feel part of the whole building.
laugh, cry, or take a quiet moment.
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108
Frank Gehry’s homely center in Dundee
º º Nutritional advice with specialist
looks as if a child made its roof out of
support for managing hair loss and skin
folded foil while Zaha Hadid’s in Fife, with
care.
its shark-like exterior made of sparkling
º º Emotional support/counseling
silicon carbide grit, allows its visitors to
with stress reduction and relaxation
move, in a bold metaphorical way, from
workshops.
darkness to light.
º º Support groups to focus on the
[2]
Maggie’s Centres aim
to build spaces that inspire people to
emotional impact of cancer.
explore the things they can do to help
º º Gardening groups to participate in
themselves to live with, through and
horticultural activities.
beyond cancer in their lives.
º º Courses and talks on exercise, healthy eating, emotional wellbeing, managing
A Maggie’s Centre is a friendly place to
post-treatment challenges, partnering
meet other people as well as a calming
with the medical team, and keeping up
space simply to sit quietly with a cup of
momentum.
tea and reflect. The centers are uplifting
º º Different methods of relaxation
places with professional staff on hand
such as controlling anxious thoughts,
to offer the support people need. The
meditation, creative writing, bereavement
therapies offered at a Maggie’s Centre are:
support, expressive art, and exercise.
Figure 3.7 Maggie’s Lanarkshire Centre - Counseling room
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Figure 3.8 Maggie’s Fife Centre - Kitchen table
[3]
The spatial requirements laid out by
layout space for table(s) for ten people
the organization in its architecture and
with storage space for folding chairs and
landscape design brief are:
yoga mats.
1 Maximum possible natural light.
10 For workshops and sessions, a table to
2 The entrance should be welcoming, with
seat 12 people. It should be private and
a place to hang the coat and leave the ‘brolly.’
not be looked in on.
3 The welcome area as a ‘pause’ space,
11 Sitting/counseling room for up to 12
from which a newcomer can see and
people with a fireplace or stove.
assess what’s going on without the feeling
12 Two small sound-proof and private
of having to jump right in with somewhere
consultation rooms for counseling, with
to sit, preferably with a shelf of books.
windows looking out to grass/trees, or at
4 Office space should be discreet (no
least a bit of sky. One of the rooms should
reception desk) with three main worksta-
accommodate a treatment bed.
tions and six smaller workstations.
13 Two toilets with washbasins and
5 The kitchen should have room for a
mirrors, which should be big enough to
table to seat 12 and a large ‘island’ with
take a chair and a bookshelf and one of
additional seating for two or three people
them must have disabled access. They
and space for setting up food. Space for
must be private enough to cry.
two dishwashers, a large fridge, one and
14 A very small, quiet retreat space to
a half sinks, an oven, and a hob on the
have a rest or a lie-down.
counter.
15 The ability to look out and even step
6 Computer desk for people visiting the
out from as many of the internal spaces
center to access information on cancer online.
as possible even if it is only into a planted
7 Library to find books and information
courtyard. It not only gives a focus to look
on cancer and a space to look at them
out at but also filter privacy in a room with
comfortably. This could be integrated with
glass doors or windows to the outside. The
the ‘pause space’ or be an extension of it.
garden, like the kitchen, should be a space
8 Three sitting rooms which can be shut
for people to share and feel refreshed by.
off from each other or opened up.
16 The interior should not be vulnerable
9 For relaxation groups, t’ai chi, yoga,
from the outside such that people inside
lectures or meetings, a space sufficient to
feel watched or unprotected.
accommodate 12 people lying down and
17 Parking.
[4]
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110
Figure 3.9 Ground floor plan, Maggie’s Manchester by Foster + Partners
Figure 3.10 Mezzanine floor plan, Maggie’s Manchester by Foster + Partners
111 |
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112
Inference: The programme and design
for the accomplishment of the design
of the center are carefully tailored as to
and programmes offered. A center like
provide the most appropriate as well
Maggie’s Centre is required in or around
as desirable atmosphere to patients
every hospital offering cancer treatment.
battling cancer. Every aspect and detail of the design and space within the center
Providing a cancer caring center, with a
is controlled and designed with the idea of
similar programme and design features,
providing a home-like, comforting place for
in Mumbai can be the start of a series of
the patients.
caring centers.
The success of these centers speaks
“Maggie’s provided me with a refuge - a sanctuary - part of the real world but somehow detached. The world hadn’t changed but cancer had totally changed who I was and I needed help to learn how to live again.” - Isobel, visitor
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Figure 3.11 Maggie’s’ Dundee Centre, Maggie’s Aberdeen Centre, Maggie’s Manchester Centre, Maggie’s London West Centre, Maggie’s Lanarkshire Centre, Maggie’s Oxford Centre (from left to right, top to bottom)
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114
3.1. 5 KARUNASHRAYA, BENGALURU irrespective of a patients economic or social backgrounds, in a space that induces healing and peace of mind. The center is designed with healing as
B E N G A L U R U KARUNASHRAYA
the central concept. It is a haven of lush greenery, birdsong, and peace, in the midst of the hustle and bustle of a metropolitan city. The activities of the organization are managed by the CEO and a team of four
Palliative & Hospice center Architect: Sanjay Mohe Year: 1999
departmental heads. There are 150 staff members consisting of nurses, consultants and doctors in palliative medicine, social workers, physiotherapists, and occupaB E N G A L U R U
Karunashraya, a joint project by the Indian Cancer Society (Karnataka Chapter) and NO. OF USERS: 225 the RotaryPLOT ClubAREA: of Bangalore 8200M 2 Indiranagar, DENSIT Y: 0.02 provides professional hospice care for advanced stage cancer patients. The center is run solely on donations
tional and complementary therapists who KARUNASHRAYA
work alongside fundraisers, housekeeping team, catering staff, maintenance workers, administration staff, and a team of more than 60 volunteers who give their time tirelessly in all manner of roles. It is a 75 bedded, fully staffed facility.
and sponsorships by generous entities. Admission is granted to patients who are not on any active curative treatment. Karunashraya provides a free service for an active and dignified end to life,
115 |
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NO. OF USERS: 225 PLOT AREA: 8200M 2 DENSIT Y: 0.02
[5]
The facilities provided for in the center are: º º Pain and
º º Kitchen
º º Auditorium
treatment plant
symptom control
º º Daycare
º º Conference
º º Solar water
º º Complementary
º º Laundry room
room
heater and lighting
therapies
º º Prayer hall
º º Administration
º º Open ground
º º Counseling &
º º Meditation room
º º Reception
º º Water bodies &
bereavement
º º Indoor game
º º Morgue
gardens
º º Physiotherapy
space
º º Rainwater
º º Parking
º º General wards &
º º TV room
harvesting system
private rooms
º º Nurse’s quarters
º º Bore-wells
º º Dining hall
º º Charity shop
º º Sewage
The word ‘serene’ acquires a new meaning
natural lighting and ventilation. The
here; every nook and corner is designed to
patients can relax with a view of
invoke calmness and peace in one’s inner
greenery on one side and water on the
self - the greenery, water bodies aglow with
other of their ward.
waterfalls and chirping birds playing in the background music.
The all-around ambiance is kept simple and green without any loud colors for the
The wards are surrounded by water
psychological comfort of the patients.
bodies and greenery. They are designed
The water body plays a pivotal role in
in a way such that all the wards receive
offering serenity.
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116
Figure 3.13 Ground floor plan, Karunashraya | by Author
117 |
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1. 2. 3. 4. 5.
WARDS NURSE’S STATION TOILE TS RECEPTION ADMINISTR ATION
6. DAYC ARE 7. PRIVATE ROOM 8. DOUBLE ROOM 9. MEDITATION ROOM
10. 11. 12. 13. 14.
DRYING ARE A L AUNDRY KITCHEN STAFF DINING PR AYER ROOM
15. 16. 17. 18. 19.
PARLOUR AUDITORIUM MORGUE NURSE QUARTERS PARKING
Figure 3.12 Site plan, Karunashraya | by Author RE - HUMANIZING HE ALTHC ARE |
118
Observations:
Though the center provides for a small
º º Use of natural materials as building
group, it does so up to a standard that has
elements.
not yet been achieved by most institutes
º º Presence of a therapeutic environment.
in India. It is successful in delivering a
º º Catering to all needs – physical, social,
healing atmosphere due to both, its
emotional.
architecture as well as the team running
º º Barrier-free design.
the facility.
º º Horizontally spread out design. º º The water seems murky due to ineffi-
The design incorporates features specially
cient maintenance.
suited to the needs of cancer patients. The architectural features observed in
Inference: Despite being situated in a
Karunashraya should be incorporated in
metropolitan
every healthcare facility, be it a hospital
city,
Karunashraya
is
an
abode offering the much-required healing
or any other.
environment. Thus, crossing beyond the limitations of a typical urban context.
‘The main attempt through this (water bodies) is to try and capture the feeling of tranquility and sense of calm to soothe the nerves of the patients undergoing excruciating pain. As the built form recedes into the background the vast surface of the water becomes a stage upon which the ever-changing light, breeze, and rain perform and the reflections on the water create a metaphor for reflecting on a life slowly but steadily drawing to a close.’ – Architect’s office
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Figure 3.14 Water bodies and verandas, Karunashraya
“It is like being in a resort, I forget I’m a cancer patient, I’m blessed to spend this valuable time of my life here.” -Ayesha, resident at Karunashraya.
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120
3.1. 6 SHREE GADGE MAHARAJ DHARAMSHALA, MUMBAI for patients who ‘temporarily migrate’ to the city for affordable cancer treatment. A group of less than 20 social helpers and hired administrative and maintenance help run this facility. The facility, a five-storeyed building, is located on a small plot with a mixed-use context surrounding it. Thus, the scope
M U M B A I
for expansion is limited to verticality, which
will
be
exhausted
after
the
ongoing construction of the additional two floors.
SHREE GADGE MAHARAJ DHARAMSHALA
Currently, the Dharamshala accommodates 200 patients with two attendants per M U M B A I
patient. After NO. OF USERS: 620the expansion, they will be PLOT 900M 2 for another 80 patients. ableAREA: to provide DENSIT Y: 0.6
SHREE GADGE MAHARAJ DHARAMSHALA
Shree Gadge Maharaj Foundation, a charitable trust, runs numerous facilities for the poor and underprivileged in various sectors throughout the country. The Dharamshala in
Dadar, Mumbai was set up with the purpose of providing inexpensive accommodation
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NO. OF USERS: 620 PLOT AREA: 900M 2 DENSIT Y: 0.6
The facilities provided for in the Dharamshala are: º º Reception &
on each floor
tap on each floor
(general + ladies)
administration
º º Children’s
º º Common kitchen
º º 2 Lifts
º º Main kitchen
playroom
on each floor
º º 100 Double
º º Common toilets
º º Drinking water
º º 2 Dormitories
sharing rooms
The residents of this Dharamshala are
double shared room and `40 per person
patients at the Tata Memorial Hospital
for the dormitory. Meals are available at
(TMH). Rooms are granted by a letter of
the mercy of a sponsor or a `5 coupon
recommendation issued by the TMH and a
system. For patients with special dietary
proof of income.
requirements, a ration card is provided to purchase supplements at rates set by
Each patient is allowed two attendants.
the government.
The current tariff is `50 per person for a
45M
DN
ROOM
ROOM
3M
HIS TOILETS
HER TOILETS
+ BATH
+ BATH
20M
PLAYROOM
5M
CHILDREN’S
ROOM
ROOM
ROOM
ROOM
ROOM
ROOM
UP
ROOM
ROOM
ROOM
ROOM
COMMON KITCHEN
ROOM
ROOM
DADASAHEB PHALKE ROAD
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N
Figure 3.15 Schematic first floor plan, Shree Gadge Maharaj Dharamshala, Mumbai | by Author
122
Observations:
º º Schooling sessions after 6 pm, after all
º º People reside in the passages and
the patients are back from the hospital.
convert the common kitchens into dormitories due to unavailability of rooms.
Inference:
Shree
Gadge
Maharaj
º º Even though lifts are present, they do
Dharamshala is an example of a typical
not function, thus, barring movement for
lodging facility available for patients from
the physically disabled.
BPL families. Though it satisfies the
º º No dining hall or common room.
needs of food and shelter, the condi-
º º No amenities.
tions in which the patients live are not
º º No medical aid.
recommendable for patients undergoing
º º Cooking activity in the rooms due to
cancer treatment.
unavailability of common kitchens. º º Water supply is controlled and available
Not only is there a complete absence of
only for a few hours in the day.
the therapeutic or healing environment
º º The building is clean and well maintained
but also a lack of recreational activities,
with renovations conducted by various
medical aid, and privacy.
Lions and Rotaract clubs. º º Every room has a window.
The facility provides merely a roof over the
º º Availability of daily bus service from the
patient’s heads but fails to cater to any other
TMH to the Dharamshala.
needs of the patients or their caregivers.
“I don’t like it here, I miss home and my brother back home” -Deep, patient at TMH from Bangladesh.
“I haven’t had a bath for 3 days because every time I’m off to the hospital with my wife they let out water and we don’t get access to it” - Caregiver and husband to Rukmini, blood cancer patient. 123 |
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Figure 3.16 Spaces in Shree Gadge Maharaj Dharamshala; children’s playroom, common kitchen, room, dormitory, people living in the building premises due to unavailability of beds, ongoing construction (from left to right, top to bottom)
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124
NO. OF USERS: 64 PLOT AREA: 3200M 2 DENSIT Y: 0.02
3.1. 7 HOPE LODGE, U.S.A. The Hope Lodge programme by the American Cancer Society is a nationwide network of residential facilities
HOPE LODGE, OMAHA, NEBRASKA
that provides free lodging to cancer patients and their caregivers who travel
Architects: Trivers Architecture
away from home for treatment. There are
Under construction
32 Hope Lodges spread throughout the
Provision for 64 cancer patients
U.S.A. Hope Lodge aims at forming a unique community
of
hope
and
support
by
providing a home away from home in a comfortable, nurturing environment, thus, allowing the patients to focus on getting better.
NO. OF USERS: 64 PLOT AREA: 3200M 2 DENSIT Y: 0.02
It provides temporary residence for adults who are in complete control of their body. They are referred by social workers from
2
2
the medical centers.
2
2
2
2
2
2
1
2
The lodge provides a shelter while other
2
requirements of food, toiletries, etc. are to be taken care of by the residents for themselves. The lodges are set up and run on the stands of donations and sponsorships. Appointed
Figure 3.17 Site plan, Hope Lodge, Nebraska | by Author
administrative and maintenance staff and volunteers manage the daily functions.
[6] 2
1
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2
2
2
2
2
2
2
2
2
3
6
NO. OF USERS: 64 PLOT AREA: 3200M 2 DENSIT Y: 0.02
6
5
NO. OF USERS: 64 PLOT AREA: 3200M 2 DENSIT Y: 0.02
5
3
1 2 3 4 5 6 7
2 2
13
2
2
2
2
2
13 13
12
2
2
2
2 2
2
2
ROOM 8 MEDITATION ROOM 9 CONFERENCE 10 MOVIE ROOM 11 COMMON TOILETS
13 12 13 12
13 13
1
2
11
13
13
13 13
2
2
2
10
11
RECEPTION DINING KITCHEN ADMINISTRATION LIBRARY LIVING ROOM MULTI-PURPOSE
13 13
13 2
11
1
3
Figure 3.18 Ground floor plan, Hope Lodge, Nebraska | by Author
11
4
10
9
8
7
4
1
9
8
7
12
2
13 13
1
13 13 13 13
13 13
2
12
2
12
13
13
13
13 Figure 3.19 Typical floor plan, Hope Lodge, Nebraska | by Author
13 13
13 13
13 13
12 DAY CARE 13 TWIN SHARING
ROOM
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126
Observations:
Inference: Hope Lodge is primarily a motel
º º Segregation of private and public
with a homely, healing atmosphere. They
spaces.
are designed in different cities as per the
º º Provision for various amenities.
needs and requirements of the city in terms
º º No consideration for kids.
of numbers.
º º The kitchen and dining are designed with a similar character as Maggie’s
From the examples of Maggie’s Centres
Centres.
and Hope Lodge, it is evident that
º º Meant for independent patients probably
providing
in the early stages of cancer, who can
possible only on a controlled scale.
look after themselves.
Thus, a design catering to large groups
º º Mass grouping such as dormitories or a
needs to be broken down into multiple
dining mess has been avoided to maintain
small-scale
a domestic scale.
domestic environment.
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domesticity
sections
in
to
design
maintain
is
a
Figure 3.20 Hope Lodge Nebraska, Hope Lodge Phoenix, Kitchen at Boston Hope Lodge, Guestroom in Houston Hope Lodge, Living room in Manhattan Hope Lodge
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128
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3. 2 SITE
I N D I A M A H A R A S H T R A
I N D I A
M A H A R A S H T R A MUMBAI MUMBAI
MAHARASHTRA MAHARASHTRA
N
N
N
N
TATA MEMORIAL HOSPITAL
TATA MEMORIAL HOSPITAL
M U M B A I
The proposed project primarily caters to the
other states, cities and even countries. It
lodging needs of patients from the low-in-
also offers a cancer caring center. Thus,
come group, traveling to the Tata Memorial
the site for the proposed facility is located
Hospital for free/affordable treatment, from
in Mumbai, India.
M U M B A I
F/S WARD
F/S WARD N
F / S
W A R D
N
N
F / S
W A R D
N
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MUMBA
HARASHTRA
3.2. 1 SITE CRITERIA LOCATION
therapies can prove to be a strenuous routine. Also, the caring center should be
During cancer patients usually I Ntreatment, D I A undergo radiation therapy multiple times
placed near the Tata Memorial Hospital
N
in a week. Traveling to and fro from
(TMH). Thus, the proposed site is located M A H A R A S H T R A in the vicinity of the TMH which lies in
the accommodation to the hospital,
the F/S ward. MUMBAI
in Mumbai traffic after these rigorous
MAHARASHTRA
TATA MEMORIA HOSPITAL
N
M U M B A I TATA MEMORIAL HOSPITAL
M U M B A I
F/S WARD F/S WARD
N
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N
F / S
W A R D
N
F / S
W
ACCESSIBILITY
a quick route to the hospital in case of emergency.
In order to minimize travel time after treatment procedures, the site should be
Proximity in terms of the highway, railway
located within a 1km radius of the TMH.
stations, and major transport routes is preferable to allow easy availability of public transport systems.
It should be easily accessible to facilitate
DADAR
PAREL ELPHINSTONE
TATA MEMORIAL HOSPITAL
SEWRI
MAJOR ROAD NET WORKS RAILWAY STATIONS
N
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PAREL ELPHINSTONE
TATA MEMORIAL HOSPITAL
CONTEXT
To facilitate a maximum number of patients SEWRI with their attendants in the residential
Though located in the heart of the city,
quarters, along with amenities and thera-
the site should be cushioned from the
NET WORKSof land is peutic services, a large chunk
noise, traffic, and pollution of the city
required.
MAJOR ROAD RAILWAY STATIONS
to accomplish the intention of providing a healing environment.
TATA MILLS
TATA MEMORIAL HOSPITAL
HAFFKINE INSTITUTE
Figure 3.21 Site options within a 1 km radius from the TMH | by Author
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N
N
Haffkine Institute is one of the oldest
Women’s and Children Hospital and a
biomedical
Hydrogen Beam Therapy facility.
research
institutes
in
the
country. It has emerged as a multi-disciplinary Institute engaged in training,
Thus, the proposed plot will practically
research and testing of various aspects of
be a part of the TMH, making it very
infectious diseases.
convenient for the users.
The selected plot is very conveniently
Haffkine Institute has previously engaged
located from the TMH. From the selected
in charitable lending of land within its
plot of Haffkine Institute, 5 acres of land
premises for healthcare benefits. Thus, this
has been reserved for the extension of
site is proposed for locating the healing
the TMH, who are going to utilize it for a
and cancer caring center.
TATA MEMORIAL HOSPITAL
K.E.M. HOSPITAL WADIA HOSPITAL
PROPOSED SITE
HAFFKINE INSTITUTE
TMH EX TENSION
N
Figure 3.22 Site context | by Author
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Figure 3.23 Proposed site
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GD ENTRY
AMB
EDK
AR M ARG
HAFFKINE INSTITUTE
PROPOSED SITE
TMH EX TENSION
HAFFKINE INSTITUTE
Figure 3.24 Site plan | by Author
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3.2. 2 SITE ANALYSIS Haffkine Institute, Parel
Physiography and Soil Type: The broad physiography feature of the
Latitude: 19-00N
district is broad and flat terrain flanked by
Longitude: 72-50E
north-south trending hill ranges. The hill
Elevation: 18 m
ranges form almost parallel ridges in the eastern and western part of the area.
Climate: The climate of the district is characterized
The soil comprises basalt rock. The soil in
by an oppressive summer, dampness
the district is medium to deep black and
in the atmosphere nearly throughout
reddish soil.
the year and heavy south-west monsoon rainfall from June to September.
Travel time from Tata Memorial Hospital: 8 minutes walking (650m)
Rainfall: The regular annual rainfall over the district
Plot area: 14,515 m 2
varies from about 1800 to 2400 mm. The
Permissible F.S.I.: 5
rainfall gradually increases towards the
Permissible built-up area: 72,575 m 2
north and reaches a maximum of 2382.0 mm.
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Figure 3.25 Annual weather averages, Mumbai RE - HUMANIZING HE ALTHC ARE |
138
Figure 3.26 Sun path diagram, Mumbai; 21st June, 21st September, 21st December, 21st March (left to right, top to bottom)
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Figure 3.27 Wind direction distribution, Mumbai
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3.3 DERIVING A DESIGN BRIEF The proposed programme is broken down into two sections viz. the residence for the ‘outpatient’ and the cancer caring center.
ESTIMATING USER-SHIP
3,749 15
As per the lodging availability and requirement data (figure 2.31), the current facilities satisfy 17.75% of the requirement, if all
19,097 :
78
1,625 :
7
Figure 3.28 Ratio of age groups within the new non-Mumbai cases registered in 2013 in Tata Memorial Hospital | by Author
the OPD patients are assumed to be non-Mumbai residents. It is impossible
Thus, a reverse calculation of permissible
to provide for the remaining 82.25% in
built-up area and the design will lead to
one facility.
the number of users accommodated in the facility.
With each patient being allowed two attendants at the most, the number of people housed in the facility triple, making this a high-density project.
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DETAILED PROPOSED PROGRAMME
THE SPACE
AREA REQUIREMENT
1. Welcome area
45 m2
2. Entrance
20 m2
3. Administrative office
50 m2
4. The kitchen
75 m2
architectural brief and Maggie’s Manchester
5. Computer desks
20 m2
Centre.
7. Sitting room
CANCER CARING CENTER The programme and areas for the caring center have been derived from Maggie’s
35 m2 x 3
8. Therapy room
55 m2
It is a proposal for one of the many such
6. Library
40 m2
centers to come. The caring center will
9. Workshop space
30 m2
cater to approximately 120 people at a
10. Counseling room
25 m2
time. The built-up area of 725 m 2 will be
11. Consultation room
15 m 2 x 2
distributed as follows:
12. Toilets
7 m2 x 2
13. Retreat space
15 m2
14. Circulation + decks/open spaces
200 m2
15. Parking 16. Therapeutic gardens
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HEALING RESIDENCE
The second shall be the common usage and administrative section which will
The residential section of the facility is
serve as common amenities for all the
segregated into two sections.
modules. It shall incorporate the following spaces:
The first being a cluster of modules, each
º º Common kitchen
accommodating 90 people which will
º º Common dining/ hall
include all the housing and domestic facil-
º º Administrative offices
ities. This module will be multiplied as
º º Staff living quarters
per the need and design and serves as
º º Common toilets
a scope for future expansion.
º º Children’s playroom º º Counseling rooms
The spaces accommodated in one module
º º Multipurpose space
will be:
º º Meditation space
º º 10 Double sharing rooms + 2 toilets +
º º Amphitheater/social spaces
bath (2 patients + 4 attendants/room)
º º Charity shop
º º 2 Dormitories (4 patients + 8
º º Massage rooms
attendants/dormitory)
º º Therapeutic gardens
º º Ladies dormitory (6 patients and
º º Services
attendants)
º º Parking
º º 1 Set of common toilets (men + women) º º Washing and drying area º º Kitchen º º Dining room º º Living room º º Multipurpose space º º Workspace º º Medical room º º Prayer room º º Terrace garden º º Services and storage
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3.4 DESIGN APPROACH CONNECTION WITH NATURE Based on the research on therapeutic architecture and the impact of nature and environmental factors on the human body and its healing capabilities, the proposed project aims to maintain a strong and constant connect with nature in any possible manner. This connection can be achieved in multiple ways ranging from simple window views to physical presence. Due to the project being sited in the heart of the city, where the levels of noise and pollution are relatively high, the intended connection with nature may need to occur in an enclosed environment or a space buffered from these disturbing factors.
Figure 3.29 A greenhouse, Rehabilitation Centre Groot Klimmendaal, Farnsworth House (from top to bottom)
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DOMESTIC SCALE
HOME-LIKE ENVIRONMENT
Though the proposed project is a high-density housing facility, it aims to achieve a domestic scale within its internal spaces in an attempt to enable the user to connect with them.
Lodge as also research on Evidence-Based Design indicates a faster healing process if the patient is surrounded by a home-like environment.
To achieve this, the facility is broken down into modules. This design feature attempts
The design of Maggie’s Centres and Hope
to
avoid
mass
gatherings
where the user would feel unimportant as one among hundreds, due to the size of the gathering. However, at the same time, it is essential to maintain communal activities on a smaller scale. Hence, each module will be designed for a group of 90, for it to be economical as well as communal while avoiding the ‘mass’
The presence of a familiar environment adds to the comfort and enables the user to settle right in. The proposed design aims to achieve this homely atmosphere within the modules to create a more friendly, easy-to-live-in environment by maintaining a similar scale of rooms and spaces as would be in a home.
LEVELS OF PRIVACY
grouping. Cancer patients experience a constant breach of privacy due to their treatment procedures and loss of control over their body. It is crucial to help them retain some private, intimate moments which may help them to cope with the disease emotionally. Social spaces are equally necessary to enable the patients and caregivers to maintain a constant communal connect. Figure 3.30 Habitat 67
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The design of the healing environments
aims to maintain a domestic scale,
will accommodate variations of private
connection with nature and a home-like
and semi-private spaces to enable the
environment.
user to retreat into a private space or enter a social zone whenever he wishes to.
Figure 3.31 Paley Park, Manhattan
VERTICAL DESIGN The proposed project will have a very high footfall along with provisions for future
expansion.
With
the
availability
of a high permissible built-up area and need to accommodate maximum possible numbers, the design may need to formulate vertically. In spite of this verticality, the project
Figure 3.32 Penda Towers, Toronto, Hotel Golden Holiday, Vietnam
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REFERENCES AND BIBLIOGRAPHY 01
1 Ron Smith & Nicholas Watkin; Ph.D., AIA Academy of Architecture for Health, Therapeutic Environments Forum – Article on Whole Building Design Guide, 22nd September 2016. 2 ibid. 3 Grinde, et al., Biophilia: International Journal of Environmental Research and Public Health, published by Multidisciplinary Digital Publishing Institute, 2009. 4 Ron Smith & Nicholas Watkins; Ph.D., AIA Academy of Architecture for Health, Therapeutic Environments Forum – Article on Whole Building Design Guide, 22nd September 2016. 5 Elza Maria Alves Costeira, Healthcare Architecture: History, Evolution and New Visions, October 2015 – Publication on ResearchGate. 6 UNESCO, World Heritage Centre, World Heritage List, Sanctuary of Asklepios at Epidaurus. (website) 7 Greek National Tourism Organisation, Visit Greece, Sanctuary of Asklepios at Epidaurus. (website) 8 Admin, The History of Hospitals and Wards, Healthcare Design Magazine, 11th March 2010. 9 Heather Burpee, History of Healthcare Architecture, Integrated Design Lab Puget Sound, 2008. 10 ibid. 11 David Keifer; M.D., What is Holistic medicine, WebMD, 05th January 2015. 12 Suzan Walter; M.B.A., Holistic Health, American Holistic Health Association. (website) 13 Betsy Severtsen, Healing Gardens, January 2006 – Publication on ResearchGate. 14 Elizabeth and Nona Evans Restorative Garden, Case studies, Institute for Human centered design. (website) 15 Cleveland Botanical Garden. (website) 16 Elizabeth and Nona Evans Restorative Garden, Case studies, Institute for Human centered design. (website) 17 Yvonne Osei, Exploring Sensory Design in Therapeutic Architecture, Carleton University, Ottawa Ontario, 2014. (Thesis) 18 Hilary Dalke, Lighting and Colour for Hospital Design, A Report on an NHS Estates Funded Research Project, published by The Stationery Office, 2004. 19 Psychologists at the University of British Columbia, 2009. 20 Lindsay Holmes, 11 scents that can do wonders for your living, The Huffington Post, April 2009. 21 Roger S. Ulrich, View through a window may influence recovery from surgery, published by American Association for the Advancement of Science, May 1984. 22 Robert N. Golden; M.D., et al., The efficacy of light therapy in the treatment of mood disorders: A Review and Meta-Analysis of the Evidence, published by The American Journal of Psychiatry, 1st April 2005. 23 Francesco Benedetti, et al., Morning sunlight reduces length of hospitalisations in bipolar depression, Journal of Affective Disorders, published by Elsevier, February 2001. 24 Carla Davis, Shining light on what natural light does for your body, Sustainability, North Carolina State University, March 2014. RE - HUMANIZING HE ALTHC ARE |
150
02
1 IANS, India’s healthcare sector: A look at the challenges and opportunities faced by the $81.3 billion industry, Firstpost., 12th June 2017. 2 Mohandas K Mallath, et al., Cancer burden and health systems in India 1, The growing burden of cancer in India: epidemiology and social context, published on TATA Memorial Center website, 11th April 2014. 3 TATA Memorial Hospital, What is cancer? (website) 4 Fundamentals of Cancer Center Design: The Patient, Healthcare Design Magazine, 13th January 2014. 5 6 7 ibid. 8 End of Life Washington, End-of-Life Options. (website) 9 ibid. 10 Poulomi Das, This Varanasi hostel lets people check-in to die, Business Insider, India, 23rd August 2016. 11 Rutu Ladage, Mukti Bhavan - The hotel where people check-in to die, India, 11th September 2015. 12 CRC Health, What is animal assisted therapy? (website) 13 American Horticultural Therapy Association, Horticultural Therapy, History and Practice. (website) 14 Alex De Alvarado, et al., Music Therapy Helps People with Cancer, The University of Texas MD Anderson Cancer Center, 14th March 2011. 15 American cancer society, Physical Activity and the Cancer Patient. (website) 16 Foreword, A view from the front line, by Marcia Blakenham, 2007. 17 Maggie’s Centres: Marching on, A view from the front line, Marcia Blakenham, 2007. 18 Prof. Imran Ali, et al., Cancer scenario in India with future perspectives, Cancer Therapy, November 2011. 19 E. Kumar Sharma, Killer costs, Business Today, 17th February 2013. 20 American Cancer society, Caregivers and Family. (website) 21 Dr. Ganesh B., Hospital Based Registry, TATA Memorial Hospital. 22 Tata Memorial Hospital, History. (website) 23 ICS Annual Report, 2013-14. 24 St. Jude India ChildCare Centres, About. (website)
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03
1 Eric Baldwin, The Architecture of Healing: 12 Maggie’s Centres by Gehry, Hadid, Heatherwick and More, Architizer, 26th April 2016. 2 Kate Kellaway, Maggie’s centres: how one woman’s vision is changing cancer treatment, The Guardian, 20th February 2011. 3 Maggie’s evidence based programme, obtained from Maggie’s website. 4 Maggie’s Architecture and Landscape Brief, obtained from Maggie’s website. 5 Karunashraya, Bangalore Hospice Trust, About us. (website) 6 American Cancer Society, Hope Lodge. (website)
DOCUMENTARIES 1 Architecture that’s built to heal - TED talk by Ar. Michael Murphy. 2 Mukti Bhawan (Hotel Salvation), directed by Shubhashish Bhutiani, 2017. 3 Building Hope: The Maggie’s Centres, BBC Documentary, 2016.
THESES 1 Yvonne Osei, Exploring Sensory Design in Therapeutic Architecture, Carleton University, Ottawa Ontario, 2014. 2 Emily Borrett, The Maggie’s Centres: Architecture and Healing, University of Brighton, Interior Architecture, 16 th January 2013.
LITERATURE 1 Innovations in Hospital Architecture, by Stephen Verderber. 2 A view from the front line, by Maggie Keswick Jencks.
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LIST OF FIGURES 01
1.1 Art by Tran Nguyen. 1.2 Sketches by Disha Vanzara. 1.3 Street art by Antoine Stevens. 1.4 Illustrated by Author with reference from ‘Innovations in Hospital Architecture,’ by Stephen Verderber. 1.5 - 1.6 Sourced from Google images. 1.7 - 1.10 Sourced from ‘Innovations in Hospital Architecture,’ by Stephen Verderber. 1.11 Illustrated by Author. 1.12 Sketch by Johann Rudolf Rahn. 1.13 - 1.18 Illustrated by Author. 1.19 Illustration by Sunstar Suisse. 1.20 - 1.24 Illustrated by Author. 1.25 Illustration by Omar Youssef, University Of Arizona. 1.26 - 1.28 Illustrated by Author. 1.29 - 1.31 Sourced from Archdaily.
02
2.1 Sourced from Google images. 2.2 - 2.6 Illustrated by Author with reference from India’s healthcare sector: A look at the challenges and opportunities faced by the $81.3 billion industry, Firstpost., 12th June 2017. 2.7 - 2.8 Illustrated by Author with reference from Over 20% of Indians suffer from chronic diseases: report, Livemint, 04th Oct 2016. 2.9 Illustrated by Author with reference from Population Based Cancer Registry report, 2014 by the National Cancer Registry Programme. 2.10 Illustrated by Author with reference from Cancer scenario in India with future perspectives, Cancer Therapy, November 2011. 2.11 Sourced from Google images. 2.12 - 2.13 Illustrated by Author. 2.14 - 2.15 Sourced from Google images. 2.16 Sourced from Mukti Bhavan - The hotel where people check-in to die, India, 11th September 2015. 2.17 Shot by Author. 2.18 Illustrated by Author with reference from LOOK: What Meditation Can Do For Your Mind, Body And Spirit, Healthy Living, The Huffington Post, 16th May 2014. 2.19 Illustrated by Author with reference from Killer costs, Business Today, 17th February 2013. 2.20 Illustrated by Author. 2.21 Illustrated by Author with reference from data obtained from respective hospital websites and newspaper articles. 2.22 - 2.24 Illustrated by Author. 2.25 Sourced from Tata Hospital Handbook.
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2.26 Illustrated by Author with reference from Hospital Based Cancer Registry report of TATA Memorial Hospital, 2013. 2.27 Illustrated by Author with reference from TATA Memorial Hospital, History. (website) 2.28 Shot by Author. 2.29 - 2.30 Illustrated by Author. 2.31 Illustrated by Author with reference from figure 2.24 and Hospital Based Cancer Registry report of TATA Memorial Hospital, 2013. 2.32 Shot by Author.
03
3.1 Sourced from Google images. 3.2 - 3.3 Illustrated by Author. 3.4 Sourced from Maggie’s website. 3.5 Sourced from Archdaily. 3.6 Illustrated by Author. 3.7 - 3.8 Sourced from Maggie’s website. 3.9 - 3.10 Sourced from Archdaily. 3.11 Sourced from Maggie’s website and Archdaily. 3.12 - 3.13 Illustrated by Author. 3.14 Sourced from the official website. 3.15 Illustrated by Author. 3.16 Shot by Author. 3.17 - 3.19 Illustrated by Author. 3.20 Sourced from Google images. 3.21 - 3.22 Illustrated by Author. 3.23 Sourced from Bing maps. 3.24 Illustrated by Author. 3.25 Sourced from weather-and-climate.com. 3.26 Sourced from Andrew Marsh. 3.27 Sourced from Windfinder. 3.28 Illustrated by Author. 3.29 - 3.32 Sourced from Google images.
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