m.arch final thesis- spatial therapy

Towards Clinical Spaces That Promote Health & Well-being

BENV GA 05Julian Huang 2012

Spatial Therapy

Contents:

2 BENV GA 05 Diploma Thesis

Introduction

I-Diagnosis1.1- Healthcare spaces as a threat to our health 1.2- Diagnosis of variable components that affect Health 1.3- Findings and Comparisons

II. Examination2.1- Views, Views that Heal2.2- Lighting, Day-light and its effects on health2.3- Passive Ventilation, The Effects of Sick Building Syndrome2.4- Sounds, The Negative and Positive Effects of Sound

2.5- Psychological components that affect health and well-being2.5.1- Traditional Therapeutic Landscapes2.5.2- Sense of place

III. Recovery3.1- A New therapeutic landscape

IV. Conclusion

V. Bibliography

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BENV GA 05 Diploma Thesis 3

Introduction


[0] Introduction

Introduction:

The purpose of this thesis is to assess the hypothesis that clinical spaces that utilise natural light, passive ventilation, views of nature and positive acoustics will harbour a positive sense of place that can offer better therapeutic quali-ties than clinics lacking them.

To develop the hypothesis, the investigation will first focus on how medical spaces have lost the humanistic approach to clinical design. With readings from ‘Medical Nemesis’, the idea that “the medical establishment has be-come a major threat to health”1 will be reinterpreted into a contemporary context, where adherence to hygiene and function in clinical design had tri-umphed over the needs of its occupants, the result is spatial ‘iatrogenesis’.

The writing will chart the revolution of medical clinics since the post-war period. It will argue that many are the result of experiments of ‘studies and systems’,2 as a consequence of which the patient had become just another object, a part of a larger system that determines the dominant utilitarian outcome.

The critique of modern clinical spaces will be put to the test by evidence gathered in a contemporary health clinic, where it will document the exist-ence of the variable components: views of nature, day-light, passive ventila-tion and positive acoustics, and identify the sense of atmosphere the clinic offer to its occupants. The findings will be compared to published guidelines to give an objective indication on the state of health of the clinical space.

Following the experiment, the main body of the research will comprise ex-aminations in detail of each of the variable components, to reveal the effects they have on our health and how they can affect our well-being. The out-come from the examination will form a part of a wider framework that medi-ates the relationship between place and health. The notion of a Therapeutic Landscape will be explored through ideas and interpretations from health geography, in order to understand how a sense of place can determine our relationship with certain geographical entities, and how we can utilise land-scapes as a part of the healing process.

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

1 2 3

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

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

3. Ibid. p. 54.


further supported through the study of Maggie’s Centres and my own pro-posal for an alternative health care system in Peckham, in order to show how the variable components are applicable to contemporary and future medical clinics, and as a means of reinterpreting and also recovering an ancient heal-ing tradition which we have forgotten, but not yet entirely lost.

Methods:

The thesis will employ interdisciplinary methods of research in order to gather the necessary evidence to test the hypothesis.

The notion of health and well-being is the production of a wide range of disciplines, thus cannot be viewed through a single lens. Therefore the thesis will borrow ideas from social scientists, such as health and cultural geogra-phers to grapple with notions of therapeutic landscape and sense of place; and contemporary architectural historians and critics, to chart the rise of modern healthcare facilities and to analyse smaller contemporary therapeu-tic clinics such as Maggie’s Centres; using empirical investigation, the thesis will document the presence of the variable components inside an existing health clinic; and through the lens of medical and health scientists, they will be examined under the microscope to understand the physical effects on our health and well-being. In this way, the thesis hopes to deliver a response that’s applicable to a contemporary definition of health and well-being.

Structure:

To develop the hypothesis, the writing is divided into three main sections that are reminiscent of a medical procedure: Diagnosis, Examination and Recovery.

The thesis will diagnose the variable components that affect our health and well-being, and the state of health of modern clinical spaces. The exami-nation procedure will investigate how those variable components affect our health and well-being. And then finally the writing will propose methods of recovery of health and well-being in modern clinics.


Diagnosis



Fig 1.1

Views

1. Entrances

2. Waiting Rooms

3. Transistion SpacesCoridoors

Entrance

Waiting Room

Cooridors

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

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

Fig 1.2

The spaces in modern clinics that pose the most threat to theiroccupant: the clinical wards, and waiting area and the transi-tional spaces such as the corridors.

Fig 1.3

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

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

3. Ibid. p. 11

4. Ibid. p. 11

5. Ibid. p. 165

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

Healthcare spaces as a threat to our health

Modern architecture, in trying to achieve the perfect ‘machine’ for living in, has banished styles and kept out decorations. Modern clinical spaces per-haps epitomise the ideal machine architecture, where function dictates form, and the need to increase efficiency and to reduce iatrogenic infections means the absence of personality, identity and comfort. Our perception of health clinics is that of never-ending corridors punctuated by occasional white boxes equipped with surgical grade stainless steel equipment that glares at us as we shuffle past. The design of the spaces has been reduced to the focus on shift-ing patients in and out as fast as possible.

The idea of a hospital as a place where the concept of hospitality origi-nated, has all but vanished. As Roger Ulrich argues, “the strong emphasis on infection reduction, together with the priority given to functional efficiency, shaped the design of hundreds of major hospitals internationally – that are now considered starkly institutional, unacceptably stressful, and unsuited to the emotional needs of patients, their families, and even healthcare staff.”1

In this context, the thesis argues that the very institution that is supposed to eliminate disease and suffering from us is in fact actively threatening our well-being. How can this be? The debate on the dangers of healthcare facili-ties to our health began in 1975 in Ivan Illich’s seminal book ‘Medical Nem-esis’ which critically claimed that “the medical establishment has become a major threat to health”.2 He argues the threat came from clinical, social and cultural ‘iatrogenesis’3 produced by the medical establishment and its over powered physicians, and the deepening ‘medicalization’ of our society.4

Illich proposed that to reverse the ill effects of medicalization, the “passive public” needs to recover its “will to self-care”.5 But fast forward forty years, where the public is no longer passive and possesses as much power as physi-cians, medicalization has on the contrary increased. Therefore, it’s not over -physicians and medicalization of society that’s a threat to our well-being, but the clinical environments themselves that are producing the iatrogenic ill-effects, as Roger Ulrich further pointed out:

“despite the intense stress often caused by illness, pain, and traumatic ex-periences, little attention was given to creating environments that would calm patients or otherwise address emotional needs.”6

1 2 3 4 5 6

[1] Diagnosis



2. Ibid. p. 67.

3. Ibid. p. 65.

4. Ibid. p. 78.

5. Ibid. p. 78.

6. Ibid. p. 78.

This, however, has not always been the case. Before the post-war era that saw the acceleration of the construction of modern health clinics we see to-day, medical facilities were housed in substantial Victorian or Classical struc-tures, often reminiscent more of grand manor houses situated amongst gar-dens or countryside,1 examples such as the Royal Naval Hospital in Greenwich (then still part of the countryside), were strategically located and symbolised Religion and the power of its Empire. Its imposing medical facilities were laid out in the pavilion plan so that all the clinical spaces allowed the penetra-tion of fresh air and natural light.2 They also commanded fine views of the surrounding scenery. It is said that Queen Mary herself commissioned the Hospital, after distressed sighting of soldiers returning from battle, which led to the building of the hospital and its subsequent humanistic approach to design of its clinical spaces.3

Since the discovery of the Germ theory, the humanistic approach to clinical design has become redundant. Gone are the symbolic healing structures to religion and power. Instead, modern clinics are symbols of hygiene, efficiency and function. The pavilion plan of classical medical clinics has been replaced by ‘urban super-blocks’, where the inclusion of food production, workshops, laundries and kitchens has rendered them into fully sufficient mini-cities.4

But the design of the medical ‘super-blocks’ was “governed by studies and systems,5 rather than the need, comfort and well-being of their patients. This emphasis on superiority of clinical medicine meant that once admitted pa-tients became the subjects of physicians, the humanist relationship as a con-sequence was severed. This ‘adherence to efficiency and a blind faith in the results of research’ led to “a soulless architecture of dreary repetition and dehumanized dimness”.6 Where natural light, view and air don’t penetrate beyond its surface while the feelings, emotions and thoughts are confined within.

These evidence supports the arguments put forward by many health care researchers such as Roger Ulrich demonstrates that modern medical spaces indeed pose a major threat to health. The main symptom of this threat is the over-institutionalised spaces in medical clinics that exacerbate the feeling of anxiety and stress, often caused by the bland and bleak lighting emitted by the florescent light used and the lack of natural light; the lack of views or ac-cess to natural stimulation; the over-reliance on mechanical ventilation; and the poor acoustic levels in clinical spaces.

1 2 3 4 5 6


Fig 1.5: To modern medical ‘super-blocks’ amidst the urban fabric that lacks fresh air, day-light and views of nature.

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


Peckham & Camberwell PCT Locality

This locality is NOT co-terminous with the ward boundaries (as Livesey ward is split between Bermondsey & Rotherhithe locality and Peckham & Camberwell

locality, and Nunhead ward is split between Peckham & Camberwell locality and Dulwich locality). For the purposes of this report, ONLY Camberwell Green, Brunswick Park, Peckham, and The Lane wards are included in this locality.

1. Overview

• Resident Population (2006) = 51,2671

o Female 51.8% o Male 48.2%

• Age Structure o 0-14 years 19.8% o 15-64 years 71.2% o 65+ years 9.8%

The Lane

Brunswick Park

PeckhamCamberwell

Green SALAU

KUMARKUMAR

MAUNGVIRJIPATEL

ARU

HOSSAIN

ULLAHVARUGHESE

NOORULLAH

DURSTON

DICKENSON

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

1 GLA Population Projections – scenario 8.07

4

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


Peckham & Camberwell PCT Locality

This locality is NOT co-terminous with the ward boundaries (as Livesey ward is split between Bermondsey & Rotherhithe locality and Peckham & Camberwell

locality, and Nunhead ward is split between Peckham & Camberwell locality and Dulwich locality). For the purposes of this report, ONLY Camberwell Green, Brunswick Park, Peckham, and The Lane wards are included in this locality.

1. Overview

• Resident Population (2006) = 51,2671

o Female 51.8% o Male 48.2%

• Age Structure o 0-14 years 19.8% o 15-64 years 71.2% o 65+ years 9.8%

The Lane

Brunswick Park

PeckhamCamberwell

Green SALAU

KUMARKUMAR

MAUNGVIRJIPATEL

ARU

HOSSAIN

ULLAHVARUGHESE

NOORULLAH

DURSTON

DICKENSON

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

1 GLA Population Projections – scenario 8.07

4

Patient Service Area

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

2. Ibid. p. 5.

[1.2] Diagnosis

Fig 1.7: External view of Gaumont House Surgery

Diagnosis of variable components that affect Health The variable components identified that are threatening our health and well-being are not limited to major hospitals, but also across the spectrum of medical clinics from GP surgeries to Primary care clinics.

To demonstrate just how widespread this threat is, an experiment was or-ganized to document the variable components inside a GP surgery in Peck-ham, which is the site of the design project. The aim of the experiment is to find out precisely the state of health the clinical spaces are in. At the end of the experiment, the findings will be calibrated with a series of reports and design guidelines published by CABE for the design of future healthcare facili-ties.

Gaumont House Surgery on Peckham High Street was chosen as the medical facility for the analysis. This surgery was chosen as it is the biggest clinic serv-ing the local community in Peckham.1 It has over 8,000 registered patients,2 which means more than 1 in five of the local residents are served by the clinic. On the 2nd, 3rd, 4th, 5th, and 6th of April, 2012, the experiment docu-mented the types of light used inside the surgery, and measurements of light levels, sound and temperature were taken inside its main patient’s waiting room, it also documented the sights and views from the waiting room, and the different spaces patients experience when visiting the surgery, to give an indication of what kind of sense of place the surgery conveys.

1 2


Fig 1.8Lighting

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


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

Weekday average LUX level: 137.5 LUX

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

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

Monday 2nd April Tuesday 3rd April Wednesday 4th April

Thursday 5th April Friday 6th April

16

Source 1: Fluorescent light

Source 2: Recessed fluorescent down light

Source 3: Reflected fluorescent uplight

Source 4:Sconce fluorescent uplight

BENV GA 05 Diploma Thesis

Fig. 1.18: Entrance and Exit to Goumont House Surgery

Thermal Comfort and Ventilation

The ambient temperatures were taken at each day around different points inside the waiting area to give a general indication of the thermal comfort level of the surgery.

Ventilation sources were also identified. (fig 1.24-1.25) The entrance is the only source of natural ventilation vis-ible within the vicinity of the waiting area. This question was also put to the staff at reception but they weren’t able to confirm other sources of natural ventilation. On the suspended ceiling there are 3 units of mechanical ventilation and air vents visible. Therefore it is reasonable to make a presumption that these 3 units provide all the ventilation for the waiting hall of Gaumont House Surgery.


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



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

Weekday average ambient temperature: 21.3˚C

Ventilation

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


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



Sound

Two types of sound were measured inside the waiting room of the Gaumont House Surgery. Ambient background sound and highest re-corded sound.

Ambient background sound is taken as an indication of the general background noises experienced in the surgery; these are sounds from the traffic outside, where there is a ma-jor road with heavy traffic, and sounds from mechanical components and conversations, etc. These are sounds that occur constantly or at regular intervals. Highest recorded sounds indicate the maximum decibel level recorded during the period of analysis on that particular day, this came from sound of infants’ crying, doors slamming, mobile phone’s ringing, gen-eral laughter and shouting. These are sounds that do not occur at a regular interval.


Sound level taken on:2nd April 08:20, ambient: 66.5 dB. Highest recorded: 79.0 dB 3rd April 10:35, ambient: 34.4 dB. Highest recorded: 87.3 dB 4th April 12:10, ambient: 45.4 dB. Highest recorded: 82.5 dB 5th April 14:45, ambient: 44.8 dB. Highest recorded: 78.8 dB 6th April 17:00, ambient: 53.5 dB. Highest recorded: 70.4 dB

Weekday average decibel level: ambient: 48.9 dB. Highest recorded: 79.6 dB

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




Fig. 1.36: Receptionist’s desk

View & Access to Nature

The surgery’s waiting room does not offer any natural views or simulation of nature. In fact the waiting room has no windows except for the entrance door. And the predomi-nant sights in the waiting area are health information post-ers and notices. There are two electronic monitors, one for indicating to patients their appointment schedules and the other a television monitor which has the health channel (Life TV) on show.

The potted plant shown in the above image on the recep-tionist’s desk represents the only hint of nature that one could see within the vicinity of the waiting room.


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


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

Atmosphere

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


Fig. 1.42: The waiting room inside Goumont House Surgery

The sequence of spaces a typical patient has to navigate:

A: Main EntranceB: Secondary EntranceC: Reception areaD: ReceptionE: Waiting roomF: Treatment room

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

B

D

F

A

C

E



SummaryFuture health: sustainable places for health and well-being

1

Designed with care:Design and neighbourhood healthcare buildings

LIFTSurvey report

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

Design with care: Design and neighbour-hood healthcare buildings

Future Health: sustainable places for health and well-being. LIFT primary care buildings report

Using some key findings from three reports published by CABE regarding future health care facilities, comparisons are made to give an objective over-view of the state of health of Gaumont House Surgery.

All three reports share a similar theme, which are the emphasis on the importance of using passive ventilation or non-mechanically induced ventila-tion, the use of daylight for illumination, providing views of natural greenery and creating a positive sense of place.

The following are some of the main points extracted from the reports that emphasize the promotion of health and well-being in future medical facili-ties:

“Providing access to nature can reduce stress, improve mental well-being and relieve a sense of overcrowding in urban environments”1

“Use natural light and ventilation, and exploit views of greenery through well-placed windows, to help reduce stress, which is a barrier to healing.” 2

“Create places with strong identity and local character” 3

“Pleasant views make a positive contribution to the patient experience”4

“Natural light creates a calm and glare-free interior”5

“Offering glimpses of greenery can be as important as providing access to gardens” 6

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

1 2 3 4 5 6


[1.3] Diagnosis

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

2. Ibid. p. 15.

3. Ibid. p. 15.

4. LIFT primary care buildings report, CABE. 2008. p. 18. Accessed from : http://www.cabe.org.uk/publications/assessing-design-quality-in-lift

5. Design with care: Design and neighbourhood healthcare build-ings. CABE. 2006. p. 11. Accessed from: http://www.cabe.org.uk/files/designed-with-care.pdf

6. Ibid. p. 27.

Examination


1.Baker. C. F, “Sensory overload and noise in the ICU: Sources of environmental stress.” Crtitical Care Quarterly, Vol. 6. (1984) pp. 66-79.

2. Ulrich. R. S, “Health Benefits of Gardens in Hospitals.” Paper for Conference, Plants for People, Inter-national Exhibition Florida. (2002) p. 4. pp. 1-10,

3. Cooper-Marcus. C, Barnes. M. “Gardens in Health care facilities: Uses, therapeutic benefits, and de-sign recommendations.” Martinez, CA: The Center for Health Design. (1995)

4. Ulrich. R. S, “Effects of health facility interior design on wellness: Theory and scientific research.” Health Care Design. Vol. 3. (2002) pp. 97-109.

5. Nakamura. R, & Fujii. E, “A com-parative study of the characteristics of the electroencephalogram when observing a hedge and a concrete block fence.” Journal of the Japanese Institute of Landscape Architects, Vol. 55. (1992) pp. 139-144.

6. Ulrich. R. S, “Health Benefits of Gardens in Hospitals.” Paper for Conference, Plants for People, Inter-national Exhibition Florida. (2002) p. 4. pp. 1-10,

7. Kellert. S. R, and Wilson. E. O, The biophilia hypothesis. (Washing-ton DC: Island Press, 1993) p. 42.

8. Heerwagen. J. H, “Nature and healing.” in Kellert, S. R (ed.), The science, Theory and Promise of Biophilic Design. (2006). P.6. Accessed from: http://courses.be.washington.edu, on 28.03.2012

9. Ibid. p. 6.

10. Kellert. S. R, and Wilson, E. O, The biophilia hypothesis. (Washing-ton DC: Island Press, 1993) p. 61.

Physiological Components that Affect Health & Well-being

Chapter overview

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

ViewsViews that Heal

The experiment in Gaumont House surgery revealed that its patients’ waiting hall does not offer any views of nature. Instead, patients are bom-barded by healthcare posters. According to Baker, this could cause ‘sensory overload’,1 which can have a negative impact on patients’ stress and anxiety levels. Views of nature provide us with therapeutic energy for healing, even a brief sighting of greenery can provide us with a tremendous sense of comfort and relief, as Roger Ulrich pointed out, “visual exposure to plants and other nature lasting only a few minutes can foster considerable restoration or re-covery from stress.”2

To understand how views of nature affect our health, both qualitative and quantitative experiments were conducted. Some notable experiments in-clude those of Cooper-Marcus and Barnes, who interviewed patients about how they interact to nature and gardens in Californian Hospitals,3 and Roger Ulrich, who studied the recovery periods of patients who underwent gall bladder surgery who had window views of trees and nature (in comparison to ones who had a view of a brick wall), and had shorter stays and required few-er strong painkillers,4 and the investigation of Nakamura and Fujii, who meas-ured patients’ brain wave activity in response to looking at a plant hedge and a concrete wall that resembled it.5 Through the recorded electroencephalo-gram data, ‘they found that the green planted hedge elicited more relaxation while the concrete fake hedge created stressful conditions.’6

The ability of healing through views of nature can be explained from two different perspectives. Firstly, the biophilic relationship between natural sys-tems and human evolution. Researchers have argued ‘humans possess a basic need for contact with nature.’7 The relatively recent developments in “agriculture, technology, industry and the city are a small fraction compared to the much longer period of human biological evolution,”8 something our modern environment cannot, yet, replicate. Therefore we are still at a stage of dependency on nature and natural systems “for fitness and survival.”9 And whenever we are struck by illness, we have a tendency to affiliate back to nature,10 as a means of recovering the health and well-being which had de-rived from the process of biological evolution.

1 2 3 4 5 6 7 8 9 10

[2] Examination

[2.1] Views


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

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

3. ibid. p. 28.

4. ibid. p. 23.

5. ibid. p. 22.

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

7. ibid. p. 57.

8. Edwards. L, & Torcellini. P, “A Lit-erature Review of the Effects of Nat-ural Light on Building Occupants.” (National Renewable Energy Labo-ratory. 2002) p. 6.

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

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

LightingDay-light and its effects on health

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

1 2 3 4 5 6 7 8 9

[2.2] Lighting


Fig 2.2: Whereas man-made objects increases stress and anxiety levelsFig 2.1: Views of nature such as greenery and flowers can drasti-cally improve a patient’s recovery rate and relieve pain

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

Fig. 2.4: Diagram showing how natural light can affect our autonmic nervous system, which regulates our endocrine system and pineal gland. According to Liberman:

“Light enters the yes not only to serve vision, but to go directly to the body’s biological clock with the hypothalamus. the hypothalamus controls the nervous system and endocrine system, whose combined effects regulate all biological func-tions in humans. [...] hypothalamus controls most of the body’s regula-tory functions by monitoring light-related information and sending it to the pineal, which then uses this information to cue other organs about light conditions in the envi-ronment. In other words, the hypo-thalamus acts as a puppet master who, quietly and out of sight, con-trols most of the functions that keep the body in balance.”1

1. Liberman. J, Light Medicine for the future. (New Mexico: Bear & Company, 1991) p. 35.

1


The range of light that mechanical lighting do not contain, which areessential in initiating the biologicalreactions in the human body

The range of visible light and mechanicallighting o�ers

Health and Safety Executive

Movement of people, Lorry park, corridors, 20 5 machines and circulation routes

vehicles

Movement of people, Construction site

50 20 machines and vehicles clearance, excavation in hazardous areas; and soil work, loading rough work not bays, bottling and requiring any canning plant perception of detail

Work requiring limited Kitchens, factories 100 50

perception of detail assembling large components, potteries

Work requiring Offices, sheet metal 200 100 perception of detail work, bookbinding

Work requiring Drawing offices,

500 200 perception of fine

factories assembling

detailelectronic components, textile production

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

(b) The purpose is to avoid visual fatigue; the illuminances will be adequate for safety purposes (c) The purpose is to avoid visual fatigue; the illuminances will be adequate for safety purposes (d) The purpose is to avoid visual fatigue; the illuminances will be adequate for safety purposes

95 The exclusion zone criterion can be applied to individual luminaires (including local luminaires) and to regular or irregular arrays. Glare may also arise from lamps which are installed on walls or equipment if the exclusion principles outlined are not followed. It cannot be applied to glare from large sources, for example where the whole ceiling is used as a source of indirect lighting, because the whole of its surface may be too bright. To avoid glare in such circumstances the average illuminance on the ceiling of normal re�ectance should not exceed 2250 lx.

96 Severe glare may also be caused by direct sunlight coming in either through windows or roo�ights. Window glare can be prevented or reduced by using blinds or tinted glass, and roo�ight glare can be e�ectively reduced by using a white or colour wash. The disadvantage of these measures is that they reduce the amount of daylight in the interior.

Lighting at work Page 28 of 47

Activity Typical locations/ Average Minimum

types of work illuminance measured (lux) 1x illuminance

(lux) 1x

1. Edwards. L, & Torcellini. P, “A Lit-erature Review of the Effects of Nat-ural Light on Building Occupants.” (National Renewable Energy Labo-ratory. 2002) p. 7-8.

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

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

Day-light can also affect us down to microscopic levels. This can be illustrated in rickets, which is a disease caused by the deformation in the development of bones in young children due to lack of Vitamin D. One of the most impor-tant phototherapeutic discoveries in the late 19th Century was light can be used to cure rickets. Experiments have shown that the contact between skin and sunlight initiates a chemical reaction that leads to the production of Vi-tamin D; a crucial ingredient for the generation of calcium, a substance bone needs to grow.1 Therefore day-light also creates microscopic changes that our eyes could not detect, but the effects of which are visually evident. However, these microscopic chemical changes only occur in a specific range of light spectra, as Hathaway, et al. point out:

“The photobiologic action spectra of greatest importance to humans range from 290 to 770 nanometres. [...] vitamin D synthesis occur in the range of 290 to 315 nanometres. Reduction of dental… [cavities] occurs in response to band light from 280 to 400 nanometres [...] Bilirubin degradation occurs in response to light in the 400- to 500- nanometres range (blue light).”2

1 2


1. Godish. T, Sick Buildings: Defini-tion, Diagnosis and Mitigation, (Florida, CRC Press, 1995) p. 68.

2. Ibid. p. 173.

3. Ibid. p. 148.

4. Marinelli. J, & Bierman-Lytle. P. Little, Your natural home. (New York: Brown & company, 1995) p. 3. 5. Godish. T, Sick Buildings: Defini-tion, Diagnosis and Mitigation, (Florida, CRC Press, 1995) p. 145.

6. Ibid. p. 2.

7. Anderson. I, “Sick Buildings: Physical and psychosocial features, effects on humans and preventa-tive measures.” In: Berglund, B; Berglund, U. Lindvall, T. Sundell, J. (ed.) Indoor air: Proceedings of the Third International Conference on Indoor Air Quality and Climate, Vol. 6, evaluations and conclusions for health sciences and technology; (August 1986 Stockholm, Sweden) Swedish Council for Building Re-search. pp. 77-81 8. Godish. T, Sick Buildings: Defini-tion, Diagnosis and Mitigation, (Florida, CRC Press, 1995) p. 231.

9. Ibid. p. 140.

10. Ibid. p. 140

11. Ibid. p. 140.

12. Ibid. p. 140.

13. Ibid. p. 176.

14. Witherell. L. E, “Legionella in Cooling Towers.” Journal of Environ-mental Health, Vol. 49. (1986) pp. 134-139.

15. Godish. T, Sick Buildings: Defini-tion, Diagnosis and Mitigation, (Florida, CRC Press, 1995) p. 174.

[2.3] Ventilation

Passive VentilationThe Effects of Sick Building Syndrome

Gaumont House Surgery was found to rely on mechanical ventilation to regu-late thermal comfort in its waiting room. This, according to Godish, can cre-ate a potentially dangerous source of indoor air pollutants and harbinger of deadly disease.1,2

Indoor air pollutants can be categorized into two different types, gaseous and particulates. Both contain a wide variety of biological and chemical com-pounds, which are emitted from building materials, furnishings, mechanical ventilation systems and air intake from external sources. While most are ba-nal, some can be highly toxic and even pathogenic. These include formal-dehyde, a highly irritant particulate indoor pollutant resulting from the use of urea-formaldehyde foam insulation and urea-formaldehyde bonded wood products.3 Formaldehyde levels in outdoor ambient atmosphere ranges be-tween 0.0015-0.047 ppm, whilst indoors it can reach levels of 4ppm.4 Be-tween the range of 61-610 µg/m³ (0.05-0.50 ppm), it can cause Sick Building Syndrome (SBS),5 resulting in a myriad of symptoms from headaches to skin allergies and eye, nose and throat irritations.6 This is the result of the defence reaction of the body’s trigeminal nerve against the air pollutant’s penetration of the respiratory system.7

Example of dangerous gas vapour air pollutants include hydrogen chloride, nitrogen dioxide, carbon monoxide.8 But the most common gas vapour con-taminate is carbon dioxide (CO₂), a bioeffluent contaminate created by the human body.9 CO₂ in the ambient environment averages 355 ppm,10 but with-in a contained environment levels of CO₂ can reach in excess of 4500 ppm if the ventilation system is inadequate.11 In most cases, SBS as a result from CO₂ occurs between the concentration levels of 600-1000 ppm.12

Pathogenic air pollutants can exacerbate illness such as asthma and dermatitis,13 and in some cases, it can introduce new disease into the build environment, sometimes with fatal consequences. One such example is le-gionnaire’s diseases, a bacterium commonly found in rivers and lakes. Due to its tolerance to chlorine, it often ends up in HAVC systems, where warmth and moisture form an ideal incubating environment for the bacterium. Ac-cording to Witherell et al. L. pneumophila is commonly found in cooling wa-ter towers,14 and when “warm water is pumped to the top of the cooling tower where it is atomized. As water gives off heat, small droplets coalesce into larger droplets and collect in a sump at the base from which it is recircu-lated. Large volumes of air are moved through the tower by mechanical fans to maximize cooling. Some of the aerosolized water is lost as drift, which has the potential to carry infective L. pneumophila into the building.”15

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15


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

Table 1: Guideline values for community noise in specific environments.

Specificenvironment

Critical health effect(s)L Aeq

[dB(A)]

Timebase

[hours]

L Amaxfast[dB]

Outdoor living area Serious annoyance, daytime and eveningModerate annoyance, daytime and evening

5550

1616

--

Dwelling, indoors

Inside bedrooms

Speech intelligibility & moderate annoyance,daytime & eveningSleep disturbance, night-time

35

30

16

8 45Outside bedrooms Sleep disturbance, window open

(outdoor values)45 8 60

School class rooms& pre-schools,indoors

Speech intelligibility,disturbance of information extraction,message communication

35 duringclass

-

Pre-schoolbedrooms, indoor

Sleep disturbance 30 sleeping-time

45

School, playgroundoutdoor

Annoyance (external source) 55 duringplay

-

Hospital, wardrooms, indoors

Sleep disturbance, night-timeSleep disturbance, daytime and evenings

3030

816

40-

Hospitals, treatmentrooms, indoors

Interference with rest and recovery #1

Industrial,commercialshopping and trafficareas, indoors andoutdoors

Hearing impairment 70 24 110

Ceremonies, festivalsand entertainmentevents

Hearing impairment (patrons:<5 times/year) 100 4 110

Public addresses,indoors and outdoors

Hearing impairment 85 1 110

Music and othersounds throughheadphones/earphones

Hearing impairment (free-field value) 85 #4 1 110

Impulse sounds fromtoys, fireworks andfirearms

Hearing impairment (adults)

Hearing impairment (children)

-

-

-

-

140#2120#2

Outdoors in parklandand conservationsareas

Disruption of tranquillity #3

#1: As low as possible.

Contaminant Low Medium High Effects

Level of risk

Formaldehydemg/m3 <ppm

0.05 0.05-0.10 >0.10

Mucous membrane irritation, SBSSBS0.04 0.04-0.08 >0.08

VOCs, mg/m3 Ozone mg/m3 ppm

< 0.05 0.05-0.10 >0.10

Mucous membrane irritation < 0.03 0.03-0.05 >0.05

Hydrogen chloride mg/m3 ppm

< 1.4 1.4-4 >4

Mucous membrane irritation < 1 1-3 >3

Nitrogen dioxidemg/m3 ppm

< 0.2 0.2-0.5 >0.5

Mucous membrane irritationasthma < 0.1 0.1-0.3 >0.3

Carbon monoxidemg/m3 ppm

>10 Genreal symptoms

Carbon Dioxideppm

Stale air < 700 700-1000 >1000

Mineral fibersAir, f/m3 Surface, f/m2

< 200 200-1000 >1000

Mucous membrane and skinirritation < 10 10-30 >30

Bacteria in airCFU/m3

Allergy, SBS, respiratory complaints

Fungi in airCFU/m3


Tobacco smoke

none sometimes constant

Eye irritation, SBS

Dust (air)mg/m3

< 0.1 0.1-0.3 >0.3

Mucous membrane irritationSBS

Floor dust g/m2

< 0.2 0.2-0.5 >0.5

SBS

Bacteria in floor dust CFU/g

< 6x103 6-10x103 >10x103

SBS

Fungal spores in floor dust CFU/g

< 1000 1000-3000 >3000

SBS, allergy

Macromolecular organic dust mg MOD/g dust

< 1 1-3 >3

SBS

Dust mitesAllergen/g dustMites /g dust

< 100ng 100-2000ng >2000ng

Allergy, asthma< 5 5-100 >100

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

>9

Contaminant Low Medium High Effects

Level of risk

Formaldehydemg/m3 <ppm

0.05 0.05-0.10 >0.10

Mucous membrane irritation, SBSSBS0.04 0.04-0.08 >0.08

VOCs, mg/m3 Ozone mg/m3 ppm

< 0.05 0.05-0.10 >0.10

Mucous membrane irritation < 0.03 0.03-0.05 >0.05

Hydrogen chloride mg/m3 ppm

< 1.4 1.4-4 >4

Mucous membrane irritation < 1 1-3 >3

Nitrogen dioxidemg/m3 ppm

< 0.2 0.2-0.5 >0.5

Mucous membrane irritationasthma < 0.1 0.1-0.3 >0.3

Carbon monoxidemg/m3 ppm

>10 Genreal symptoms

Carbon Dioxideppm

Stale air < 700 700-1000 >1000

Mineral fibersAir, f/m3 Surface, f/m2

< 200 200-1000 >1000

Mucous membrane and skinirritation < 10 10-30 >30

Bacteria in airCFU/m3


Fungi in airCFU/m3


Tobacco smoke

none sometimes constant

Eye irritation, SBS

Dust (air)mg/m3

< 0.1 0.1-0.3 >0.3

Mucous membrane irritationSBS

Floor dust g/m2

< 0.2 0.2-0.5 >0.5

SBS

Bacteria in floor dust CFU/g

< 6x103 6-10x103 >10x103

SBS

Fungal spores in floor dust CFU/g

< 1000 1000-3000 >3000

SBS, allergy

Macromolecular organic dust mg MOD/g dust

< 1 1-3 >3

SBS

Dust mitesAllergen/g dustMites /g dust

< 100ng 100-2000ng >2000ng

Allergy, asthma< 5 5-100 >100

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

>9


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

Fig. 2.7: Chart indicating the rec-ommended ambient noise level set out by the WHO. Note that 30dB re-quirement recommended for hospi-tal wards, much lower than the find-ings from Gaumont House Surgery, which was at 48 dB.

35

1. Noise at work, guidance for employers on the control of Noise at work, Regulation 2005. p. 2. Accessed from: http://www.hse.gov.uk/noise/regulations.htm.

2. Devlin. A. S, & Arneill. A. B, “Healthcare Environment and Patient Outcomes: A Review of Literature.” Environemental and Behaviour. Vol. 35. (September 2003) p. 677. pp. 665-694.

3. Noise at work, guidance for employers on the control of Noise at work, Regulation 2005. p. 3. Accessed from: http://www.hse.gov.uk/noise/regulations.htm.

4. Goines. L, & Hagler. L, “Noise Pol-lution: A Modern Plague.” Southern Medical Journal. Vol.100. No. 3. (March, 2007) p. 290. pp. 287-294.

5. Ibid, p. 291.

6. Guzzetta. C. E, “Effects of relaxation and music therapy on patients with coronary care unit with presumptive acute myocardial infarction.” Heart & Lung, Vol. 18. (1989) p.610. pp. 609-616.

7. Devlin. A. S, & Arneill. A. B, “Healthcare Environment and Patient Outcomes: A Review of Literature.” Environemental and Behaviour. Vol. 35. (September 2003) p. 679. pp. 665-694.

8. Mengazzi. J. J, Paris. P, Kersteen. C, Flynn. B, Trautman. D. E, “A ran-domised controlled trail of the use of music during laceration repair.” Annals of Emergency Medicine, Vol. 20. (1991) pp. 348-350

9. Baker. C. F, “Sensory Overload and Noise in the ICU: Source of environmental stress.” Critical Care Quarterly. Vol. 6. (1984) p. 69. pp. 66-79.

10. Black. D, Healing with sounds. The Healing Currents Series. p.2. Accessed via: http://www.jlgnet.com/dean/Healing_with_Sound.pdf

[2.4] SoundSounds

The Negative and Positive Effects of Sound

The experiment yielded an average of 48.9dB ambient level of sound in Gaumont House Surgery. This is considered an acceptable level of noise in a work environment. Health and Safety Executive (HSE) stated a quiet office has an exposure between 40-50 dB level of noise.1 However, on the second and third day the measurement yielded a maximum level of exposure be-tween 82 to 87dB, which is considered hazardous, as exposure to noise level above 90 dB starts to cause hearing loss.2 HSE recommended employees should not be exposed to noise level over 87dB on average,3 and with the average measurement of nearly 80 dB experienced in Gaumont House Sur-gery, patients and particularly staff are susceptible to both psychological and physiological damage.

Physiologically excessive level of noise can ‘act as biological stressor elicit-ing reactions that prepare the body for a “fight or flight” response which triggers both endocrine and autonomic nervous system responses affecting the cardiovascular system,’4 causing elevated blood pressure and heart rate. This might help to explain some patients’ frustration to infants’ crying sound. Psychologically, excessive noise can act as a stressor causing the loss of con-centration levels. As Goines and Hagler further pointed out, “noise pollution impairs tasks performance at work, increases errors, and decreases motiva-tion. Reading attention, problem solving, and memory are most strongly af-fected by noise.”5

On the other end of the spectrum, there are certain sounds that active-ly contribute to our health. These include sounds of nature, and particular types of music. Guzzetta has found “music therapy effectively reduces anxi-ety, stress and the experience of pain.”6 This, according to Devlin and Arneill, is because our “emotional responses can be modified when music moves through the auditory cortex, it activates the limbic system, and in turn, af-fects emotional reactions,”7 Menegazzi et al. have conducted experiments that found patients exposed to music during a laceration operation reported less pain when listening to music.8 The disparity between noise and natural sounds and music can be explained by Baker, who defined noise as, “Non-periodic waveforms, random in fluctuation, not harmoniously related, that interfere with desired signals”9

Whereas natural sounds and music are composed, rhythmic and harmoni-ously interconnected vibrations that corresponds with our own internal bod-ily rhythms.10

1 2 3 4 5 6 7 8 9 10


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

2. Gesler. M. W, “Therapeutic landscapes: medical issues in light of the new cultural geography.” Soc. Sci. Med. Vol .34. No 7, (Great Britain, 1992) p. 736. pp. 735-746.

3. Gesler. M. W, & Kearns. A. R, Culture/Place/Health. (London and New York: Routledge, 2002) p. 121.


5. Ibid. p. 735.

6. Ibid. p. 736-38

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

8. Khachatourians. A, “Therapeutic Landscape: A Critical Analysis.” Simon Fraser University. (Summer, 2006). p. 20. Accessed from: summit.sfu.ca/system/files/ir-items1/3574/etd2429.pdf.

Psychological components that affect health and well-being

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

Traditional Therapeutic Landscapes

For millennia, human civilisation has always had a profound interconnection with the landscape. The landscape not only promoted a sense of health and well-being, but also has “enduring reputation for achieving physical, men-tal, and spiritual healing”.1 These therapeutic places can be found across a range of topographic and geographic entities, from natural landscapes, such as springs, forests and meadows, to healing landscapes, such as Stonehenge, the river Ganges and Bath. The therapeutic properties of these places can be attributed to many factors and materials, whether it’s the fresh air, water, or magnificent scenery,2 or its ability to alleviate us from the stress of everyday life.3 The healing abilities of landscapes have been well documented since the days of antiquity.

Yet, by simply describing places as therapeutic does not allow us to un-derstand why they are therapeutic or how they came to be thought of as therapeutic.4 It is only by de-constructing the makeup of the therapeu-tic qualities of a therapeutic landscape that we understand how it op-erates. Wilbert Gesler, a cultural geographer first introduced Health Geography into the academic scene in 1992. His article, ‘Therapeutic Landscapes: Medical issues in light of the new cultural geography’ proved to be a seminal work that initiated the research into therapeutic land-scapes. It draws ideas and interpretations from other fields of cultural and social studies that include anthropology, psychology, and sociology.5

Which helped to provide new concepts such as sense of place, authentic and unauthentic landscape and symbolic landscapes.6 With these, he was able to analyse and reveal the inner mechanics of a series of therapeutic landscapes. One such example is Epidaurus,7 an ancient healing landscape located on an Asclepian sanctuary developed in around 350AD. Its operation is based on the philosophies of Asclepius, the God of healing in ancient Greek religion.8

1 2 3 4 5 6 7 8

[2.5.1]Therapeutic Landscape

[2.5] Examination


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

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

[…] societies over time have moulded the physical landscape to suit their needs by practising various forms of agriculture, building cities, or constructing sacred sites. The emphasis is on the material aspects of culture, those objects that are visible in the landscape. From this �rst perspective, a site might be perceived to be healthy if there is a good source of ground water, this might be enhanced by the building of a well. The observer, in this case, is objective and an outsider looking at a scene.

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

[…] the recognition that landscape is as much in the head as in the yes and is ultimately a personal, mental construct. This emphasis on meaning recognizes that one is implicated in a cultural landscape through being an insider, and an active agent in inventing places. Thus, a hospital that may appear to be a neutral element in the urban fabric before an accident may well be reinvented as part of a landscape of fear after a stay that include surgery. To develop this aspect of meaning […] have to obtain insider’s perspective and to uncover the meanings which landscapes have for people, and which symbols are important for them.

Question: Can Therapeutic Landscape be found in the Everyday?

Fig 2.8: Stonehenge was an ancient therapeutic landscape

“Societies over time have moulded the physical land-scape to suit their needs by practising various forms of agriculture, building cities, or constructing sacred sites. The emphasis is on the material aspects of culture, those objects that are visible in the landscape. From this first perspective, a site might be perceived to be healthy if there is a good source of ground water, this might be enhanced by the building of a well. The observer, in this case, is objective and an outsider looking at a scene.”1

1


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

2. Ibid. p. 8.

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

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

3.Ibid. p. 20.

4.Ibid. p. 29.

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


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

Epidaurus is surrounded by natural beauty, nestling amongst hills and green-ery, criss-crossed by streams that provided clean water which was believed to have purification properties, which once sustained a great many bath houses around the site, also included temples, theatre and homes for priests and visi-tors to the sanctuary. Indeed its scenic location away from any daily stressors, greatly contributed to its healing property as a therapeutic landscape.1

However, besides the fact that the location of Epidaurus is tranquil and se-rene, there was a more fundamental element at work that makes Epidaurus a therapeutic landscape. It is the psychological belief that it contained super-natural healing powers.2 Long before Epidaurus was constructed, its location, on the site of an ancient Asclepian sanctuary, was already considered a sa-cred, ritualistic place.3 This can be illustrated by the description of the main treatment that was given to the visitors to Epidaurus, in which “‘day dream’ was performed on patients who would lie still and wait to be visited by the healing God Asclepius in a dream or ‘vision’. If they received a visit from As-clepius, he would diagnose and either treat or prescribe treatment for their illness.”4 Therefore both the physical setting and the psychological belief in the presence of a higher spiritual healer, combined to amplify and strengthen the therapeutic qualities of Epidaurus, as Gesler suggests:

“[…] the natural surroundings, the built environment, symbol complexes, beliefs and expectations, sense of place, social relations and relative equality, everyday activities, and territoriality all influenced physical, mental and spir-itual well-being.”5

It is only when both the physiological and psychological components in a landscape are working harmoniously, combining our senses, perceptions, and believes, can a therapeutic landscape materialise.

Sense of Place

Unravelling the make-up of a therapeutic landscape offered glimpses into the multi-faceted relationship between place and health; as well as a geo-graphical entity, it’s also ‘processes, setting, situations and locales, occupying both the physical and psychological realm.’6

Some health geographers have argued, all places can theoretically become therapeutic landscapes if they have the right set of circumstance that can cre-ate a positive sense of place.7 But what is this right set of circumstances? And what are the prerequisites of a positive sense of place?

1 2 3 4 5 6 7

[2.5.2] Sense of Place


+

+

+

Fig 2.10

Fig 2.11

Fig 2.12

Fig 2.13

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

Fig 2.14

=


A sense of place can be defined as “the identity, significance, meaning, inten-tion, and felt value that are given to places by individuals.”1 This can be either positive, places that are associated with intimacy, comfort and well-being. Or it can be negative, places that are associated with fear and a sense of threat. Therefore, a sense of place is rather subjective; it’s simply ‘what is out there’ for us to register with our senses.2 As Allison Williams further points out:

“It is through lived experience that moral, value, and aesthetics judgements are transferred to particular sites which, as a result, acquire a spirit or person-ality. It is this subjective knowledge that give such places significance, mean-ing and felt value for those experiencing them.”3

A sense of place requires ‘long-standing’ and ‘on-going’ relationship with certain places, which creates a strong level of ‘psychological rootedness’ that health geographers have argued is the quintessential component for the ma-terialization of a positive sense of place.4 Psychological rootedness is a valu-able source of identity and meaning, that mediates place and health. A typical place that entails a strong sense of psychological rootedness is our home.

The notion of home is so intrinsically attached to health that the spatial and emotional language of home has often been reconstructed as a therapeutic environment in medical facilities. Places such as care homes, sheltered hous-ing, and adapted hospital wards, they all mimic a homely environment. This is because home is often perceived as a place of ‘ontological security,’5 living at home is associated with independence, happiness and good health,6 qualities that we all associate with well-being. But what are the specific mechanisms that make a home happy and healthy? As the previous sections have explored, a therapeutic landscape is far more than what meets the eye. In the same way, a home is not just a dwelling, a location or geographical entity, it also consists of many personal and symbolic connotations. A home can be understood as a wider process that’s “created as much by the acts of those involved […] as by its immanent properties as a place.”7

To understand why home makes us feel rooted, we have to examine what a home provides us with. Besides being a shelter, home also provide us with security, memory and more importantly, freedom and control. Take a health clinic as an example; where we are confined to a bounded setting, we can only enter from a certain place, at a certain time. This renders us out of control, both spatially and physically. We have no control over what physicians do to us, and we cannot go into places where it’s off-limit to the patient. Do we have any choice in a health clinic? As Taylor has pointed out, a clinic “is one of the few places where an individual forfeits control over virtually every task he or she customarily performs.”8 But the notion of a home, is where we are in total control of our surroundings, over what we do, where we go, when to arrive, when to leave. In another sense, we have total freedom of a place.

1 2 3 4 5 6 7 8

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

2. Gesler. M. W, and Kearns A. R, Culture/Place/Health. (London and New York: Routledge, 2002) p. 120.

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

4. Ibid. p. 1198.

5. Gurney. C, & Means. R, “The meaning of home in later life,” in S. Arber & M. Evandrou (ed.) Aging, Independence and the Life Course. pp. 119-131. (London: Jessica Kingsley, 1993)

6. Martin. G. P, “Places like home? Physical, social and psychological aspects in the making of home and other environments in the healthcare of older people.” Doing, thinking, feeling home - 14/15, October, Delft, The Netherlands. p. 2. pp. 1-11.

7. Ibid. p. 2.

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


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

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

1


Recovery


Recovering Health and Well-being in Modern Health Clinics

Chapter Overview

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

A New therapeutic landscape

The changing landscape of healthcare across the country is revolutionising the way we access medical facilities. The rise of the primary-care clinics in the last decade has reduced hospitals to reserves for complex surgical procedures and emergencies. More and more, these smaller community health clinics are bearing the brunt of society’s healthcare responsibilities, from pre-natal care to palliative care. Yet this changing scale of medical spaces can be regarded at as a positive step towards creating clinical spaces that promote health and well-being. They emphasize more on healing and therapy, and requirefewer restrictive building regulations. One example, above all, that has cap-tured the public’s attention about just what health benefits can clinical spac-es offer are Maggie’s Centres.

Created as a consequence of Maggie Keswick’s experience as a cancer pa-tient in the early 1990s, Maggie’s Centres offer support and advice for suffer-ers and their families and friends. Unlike hospitals and GP surgeries, the cen-tre operates as a drop-in service, this ability of patients being able to access the clinic without making prior appointment, immediately created a much more accessible healthcare service, and it’s just one of the varieties of

[3] Recovery

[3.1]



2. Blakenham. M, “Maggie’s Centre, Marching on.” in Keswick, M. Jencks, C. (ed.) In A view from the front line, (London: 2007) p. 30.

3. Gurney. C, and Means. R, “The meaning of home in later life”, in S. Arber & M. Evandrou (ed.) Aging, Independence and the Life Course. pp. 119-131. (London: Jessica Kingsley, 1993)


5.Ibid. p. 38.

methods they used to emphasize its patient-focused strategy, which is based on creating an informal, un-institutional and homely environment where pa-tients would feel as though they are being given support and care in their own home. As Charles Jencks, co-founder of Maggie’s centre pointed out, “informal, like a home […] meant to be welcoming, domestic, warm, skittish, personal, small-scaled and centred around the kitchen or place to make coffee and tea.”1

This focus on domesticity in Maggie’s centres demonstrates the outcome of a positive sense of place where the previous chapter had explored. The creation of a psychologically rooted place that empowers the patients can facilitate a sense of control. This initiate a mentality of fight, rather than succumbing to the deadly effects of the disease, the sense of control metaphorically trans-lates into literally taking control over the disease and one’s own life.2 Further-more, spaces with a strong sense of place such as the domestic environment provide the patient with ‘ontological security’,3 so even though it may be the first time a patient encounters the centre, the feeling of homeliness, of deep psychological rootedness could be instantaneously established.

Maggie’s Centres employ several methods to create their focus on domestic-ity, and even though each of the centres has its own distinct characteristics, a familiar theme unites them, it is the integration of communal areas, where pa-tients and staff can participate in workshops and group activities, with smaller intimate spaces where patients can reflect and discuss with staff the psycho-logical trauma of coping with the disease. This is probably best illustrated by the Maggie’s Centre in Hammersmith. Its spatial layout recalls that of late 19th century domestic architecture,4 where semi-open plan living areas juxtaposed and intertwined with transitional spaces, with sliding doors to provide visual and acoustic privacy, the focal point is centred around the kitchen-dining area or a fireplace. This is reminiscent of Frank Lloyd Wright’s 1889 Oak House, with its large hearth occupying the centre of the house. The resulting space in Maggie’s Centre is personal and private, but also public and communal.5

The integration of semi-open and intimate spaces is also represented in many of my own proposed alternative health clinics. One example, the Ayur-veda clinic, which will be used in this section to calibrate with the Maggie’s Centres. The clinic is a part of a series of health centres that offer alternative treatments such as Ayurveda, Chinese and African Herbal Medicine across the London boroughs of Peckham. This proposal responds to the changing land-scape of health care that’s taking place across Britain, especially with the on-going threat of the privatisation of the NHS, it explores how we will access and interact with health care facilities in the future. It suggests future access to health care could become a part of everyday experience; Where going to the local supermarket could also mean a pit-stop at the dietician’s, or getting your hair cut in the local hairdresser’s mean a visit to the dermatologist to resolve scalp allergies.

1 2 3 4 5



Fig 3.1

Fig 3.2

Fig. 3.4: The plan of Maggie’s Centre in Hammersmith in West London. Fig. 3.5: The plan of Maggie’s in Hammersmith recalls 19th cen-tury domestic architecture such as the Oak House by Frank Lloyd Wright.

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


The privatisation of the NHS could see the commercialisation of health care facilities throughout our cities, where the sight of a clinic could become as ubiquitous as the local convenience store. This would create a much more dynamic and flexible health service. Just like the Maggie’s Centres, where pa-tients can ‘drop-in’ at any time, the patients using the proposed alternative clinics can visit the health service as a part of their daily routine; shopping, haircut, going to the gym and so on. This would make health care even more accessible than Maggie’s, where medical facilities are fully integrated with the everyday experiences of the local community, where health clinic is not a des-tination, but a part of the everyday process we take part in.

In this case the Ayurveda clinic becomes an extension of a salon, which it is attached to on Peckham Road. But instead of focusing around the kitchen and dining table as seen in Maggie’s, the Ayurveda clinic is focused around the hair dressing rituals, in particular, the hair washing facility, which is also doubled up as the waiting room of the health clinic.

The semi-open waiting area and hair washing facility offer close encounters with nature and greenery in the form of an ‘upside down garden’. (see fig 4.?)This concept came from analysing how hair dressers operate, especially when customers first get their hair washed before their hair cut. During this process, the customer usually lies down in a semi-flat position, visually fo-cused towards the ceiling. Interestingly, the ceiling is also one of the most institutionally symbolic aspects of health clinics, with its drab and bland tiling and florescent lighting, (as seen in Gaumont House Surgery), the stereotypi-cal suspended ceiling and its fluorescent lighting came to symbolise all that is wrong with health care facilities.

This inspired the proposal to offer a vertical view that is both calming and restorative, which resulted in a double skin ‘chimney’ (see fig 4.?) that offers a vertical view of a living green wall, an upside down garden.

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

1


Fig. 3.9: Maggie’s in Dundee also frames the spectacular scenery with its architecture

(A).

Fig 3.7 (top) and 3.8: Maggie’s in Gartnavel focuses on framing the natural landscape, both inside of a courtyard and outside the forest


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


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


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


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

This openness to the natural surroundings also enables the full use of natural light throughout the interior. Looking at the various Maggie’s Centres, each has a strong emphasis on utilising day-light. Gone are the dreaded white fluo-rescent ceiling lights, which drain the last breath of health from patients.

Each Maggie’s Centre harnesses the maximum amount of natural light through large windows and roof openings, but it never overpowers an interior. Instead through ‘complex compositions’ of layers of openings and partitions,1 sunlight is filtered, bounced, reflected and refracted into a soft, warm and sensual glow that illuminates communal spaces, and shades more intimate nooks and crannies. This idea of playing with natural light is most evident in Edinburgh, where a long narrow sky-light provides daylight into the offices on the mezzanine floor and communal spaces below, but a series of three-quarter height wall partitions hides a complex of personal seating spaces. The result re-emphasizes the language of domesticity.

In my proposal, the ‘chimneys’ also act as daylight catchers. Each ‘chimney’ is tilted at a slight angle towards the south to maximize the amount of natural light coming into the building. The planting and greenery on the ‘upside down’ garden become filters for the direct sunlight to reduce glare. The resulting natural light coming into the waiting area of the clinic is reminiscent of that of a forest, with the ‘upside down’ garden metaphorically acting as the canopy. This is to further enhance the sensation of being in a natural environment.

The ‘chimneys’ also serve another important function, which is to naturally ventilate the clinic. As we have seen in Gaumont House Surgery, too often medical facilities rely on mechanical ventilators for air exchange and regula-tion of thermal comfort. But these systems are also harbingers of disease such as Legionnaires, and further undermine our health. Maggie’s Centres serve as a catalyst for future health clinics to adapt passive methods of ventilation, not only to reduce the energy consumption of buildings, but also to avoid iatro-genic infections caused by the medical facility itself, such as sick building syn-dromes. Furthermore, as shown in Maggie’s in Gartnavel, passive ventilation is a natural consequence in providing sufficient day-light and access to nature, as the increase in porosity of the building increases the likelihood of passive ventilation, providing that the orientation of the building and openings cor-respond to prevailing wind directions.

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

1 2



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

Private/personal areasin the waiting room

Main public waiting areathat double up as the hair washing facility for the salon it’s attached to

Staircase upto treatment rooms

Pipes inside directs natural air down to the clinic spaces and the waiting room

Cool Air in

Warm Air out

Glaszing on the top of the central chimney allows day-light penetrateinto the waiting area

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

Furthermore, the planting on the living wall acts as filters for the air coming into the building, combining with the scents from the herbs grown inside the chimneys, to create naturally aromatic fresh air, one variable component this report did not explore but could potentially have significant impact on our well-being.

The various Maggie’s Centres illustrated in this final chapter and my own proposal have shown how clinical spaces don’t have to be institutional in feel to be efficient, hygienic and functional. Indeed, they have demonstrated how pleasant clinical spaces could be by putting in places the variable components, and drawing on ideas from our ancient healing practices which so many medi-cal clinics seem to have forgotten.

In the context, the Maggie’s Centre and my own proposal are not new ty-pologies of health care facilities; rather, they are contemporary reinterpreta-tions that aim to recover our ancient healing traditions that have been with us for millennia. A tradition that is fit for contemporary society and its cultural beliefs.



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

Conclusion


Conclusion

The thesis set out to assess the hypothesis that clinical spaces with variable components in place such as natural view, day-light, passive ventilation and positive acoustics can offer a better therapeutic environment than clinical spaces that are lacking in them. Clinical spaces lacking these components, the thesis has found, are the outcome of experiments of studies and systems, rather than answering the need of its occupants. The emphasis of hygiene and efficiency had triumphed over comfort and well-being. The result is the objectification of patients, no different to a surgical scalpel, or a life-support machine, a part of a bigger system that determines the design of a most ef-ficient and functional outcome.

These bland, cold and institutional clinical spaces pose a real threat to the health and well-being of their users. Soon after they appeared on our ur-ban fabric, their ill-effects started to be documented by scientists and re-searchers. But somehow, the thesis has found the adherence to efficiency and function still prevails despite its known ill consequences. And till this day, these clinical spaces can still be found in contemporary facilities. This is sup-ported by the evidence gathered in a local health clinic in Peckham, where the lack of natural light, view of nature and passive ventilation, created a highly institutional atmosphere, combined with the regular excessive noise experienced, the clinic offered a negative sense of place that increased the occupants’ stress and anxiety levels.

Each of the variable components measured in the health clinic has been ex-amined through the lens of medical science, which has successfully revealed how they promote a sense of health and well-being. Specifically, it has found that views of nature can significantly reduce stress levels and alleviate anxie-ty by re-establishing what researchers call the biophilic relationship, and pro-viding visual escape away from the confinement of clinics. Natural light has been identified to be critical in the initiation of important biological reactions in the human body, preventing fatal diseases like rickets, while the lack of it can lead to the alteration of our circadian cycle, disrupting our sleeping and eating patterns. Passive ventilation has shown to be useful in the prevention of Sick Building Syndromes, which can cause a multitude of ill-health from headaches and asthma, to fatal diseases like Legionnaires. Positive acoustics have been shown to be able to reduce stress and pain in patients due to its rhythmic composition that corresponds with our own cellular structures, while noise is associated with the disturbance of our ability to concentrate. More seriously noise can affect the cardiovascular system, causing elevated blood pressure and heart rate.

[4] Conclusion


These physical variable components have been found to be a part of a big-ger framework that contributes to the formation of a therapeutic landscape. As seen in Epidaurus, they combine with cultural and religious beliefs to form a positive sense of place that harbours ‘ontological security’. This help us to feel psychologically rooted. Similar to the domestic environment, it provide us with a sense of freedom and control, which in a clinical context, translates into relief from stress and anxiety, and promotion of health and well-being.

The goal of the examination is to propose methods of turning clinical spaces into a form of medical treatment in itself. Using reflections from Maggie’s Cen-tres and my proposal, this argument has been successfully demonstrated. It has shown how the variable components are applicable to contemporary clini-cal spaces which offer comfort, cosiness and warmth, and more importantly, they offer a sense of hope, an architectural equivalent of the placebo effect, which in itself, becomes a form of medical treatment.



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66

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1.4- http://www.liu.se/ikk/english/course-webpages/norman-s-pictures-for-the-examination/architecture-pictures?l=en

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1.8- By author

1.9- 1.17- By author

1.18- By author

1.19-1.25- By author



1.36- By author

1.37- 1.41- By author

1.42- By author


1.49- Design with care: Design and neighbourhood healthcare buildings. CABE. 2006. Accessed from: http://webarchive.nationalarchives.gov.uk/20110118095356/http:/www.cabe.org.uk/files/designed-with-care.pdf

1.50- Future Health: sustainable places for health and well-being. CABE. 2009. Ac-cessed from: http://webarchive.nationalarchives.gov.uk/20110118095356/http:/www.cabe.org.uk/files/future-health.pdf

1.51- LIFT primary care buildings report, CABE. 2008. Accessed from: http://we-barchive.nationalarchives.gov.uk/20110118095356/http://www.cabe.org.uk/publi-cations/assessing-design-quality-in-lift



References Image

Chapter 2

2.1- By author

2.2- By author

2.3- http://www.coachingworks.de/workinprogress/2010/04/07/let-the-sunlight-in/

2.4- Liberman, J. Light Medicine for the future. (New Mexico: Bear & Company, 1991) p. 35.

2.5- http://www.hse.gov.uk/pubns/priced/hsg38.pdf

2.6- Kukkonen, E. et al. 1993. Nordtest Report NT Tech. Rep. 204.

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

2.8- http://visit-stonehenge.blogspot.co.uk/2010/10/stonehenge-expert-awarded-obe.html

2.9- By author

2.10- http://upload.wikimedia.org/wikipedia/commons/e/e5/Pergamon_Museum_Asclepius_-_Berlin%2C_Germany_-_2009_%28cropped%29

2.11- http://greecefleece.blogspot.co.uk/009_02_01_archive

2.12- http://nobloodforhubris.files.wordpress.com/2011/03/cleopatras-pool

2.13- http-www.wacphila.org/travelblog/wp/content/uploads/2011/07/SAM_1619

2.14- flickr.com/photo/patrickmayon/2247783148/size/0/in/photostream

Chapter 3

3.1- P99. The architecture of hope: Maggie’s Cancer Caring Centres. Jencks, C. Heathcote, E. Frances Lincoln. London. 2010

3.2- http://www.dezeen.com/2011/01/04/maggies-centre-cheltenham-by-mjp-architects/


3.4- http://www.richardrogers.co.uk/work/all_projects/maggie_s_centre/com-pleted


References Images

3.5- http://jgonwright.com/ep01Geo.html

3.6- By Author, adpated from Bing maps: http://www.bing.com/maps/

3.7 -P187. The architecture of hope: Maggie’s Cancer Caring Centres. Jencks, C. Heathcote, E. Frances Lincoln. London. 2010



3.10- By Author

3.11- By Author

3.12- By Author

3.13- By Author

m.arch final thesis- spatial therapy

Documents

state of health

health geography

medical spaces

health wellbeing benv

clinical design

contemporary health

positive sense of place

healthcare spaces