Worth a read: “Beautifying hospitals: a tough sell,” posted yesterday to Canadian Medical Association Journal Online, discusses how our design knowledge is getting lost in translation when it comes to hospitals. More and more designers, health professionals, government representatives and other decision-makers are acknowledging design’s influence on health, but with a few exceptions, we aren’t designing hospitals any differently than we did before “evidence-based design” was a recognizable term. (Check out my post on evidence-based design here.)

Fascinating quote by one Dr. Alan Dilani: “The health care industry is typically looking for the cause of diseases, instead of focusing on the causes of health. We have 8000 diagnoses or causes of diseases. We might also find 8000 causes of health.”

Why the slowness to change? Evidence-based design isn’t some fuzzy postulate about “emotions” and other “soft,” unquantifiable variables – not anymore. It’s science – and no one questions that health and science go together.

What I think is the answer: existing hospitals get the job done, and sticking with traditional design allows us to avoid the scary unknown quantities, coughs and hiccups involved in trying anything new, even a new thing supported by scientific evidence. What’s more, we don’t yet know how to translate the theoretical into the practical in many design situations; just because we know design affects health doesn’t mean we’re always sure about how it does so. There’s a lot to learn.

But we shouldn’t hesitate to put into practice what we already know.

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The question of what and how much we should do to help those in other countires is a huge topic and a huge concern in the world of humanitarian work in general, not just in the world of humanitarian design. As a Global Health minor who hopes to do international humanitarian work one day, I consider it a personal concern, too. What right do we have to go into other countries and try to solve their problems? Do we have any right at all? Is it acceptable to do so if we make sure to involve locals and “allow” them, insofar as possible, to lead the way? To what extent can and should we rely on the guidance of locals and the utilization of local resources in addressing a community’s needs? Important questions that can make the well-intentioned privileged – myself included – highly uncomfortable. Uncomfortable about the question of whether what we are doing is ethical; of whether what we are doing is doing any good.

However, I do believe that on a fundamental level, there is nothing inherently wrong with Americans working in other countries to effect improvements in the lives of the underserved – as long as such work is done with sensitivity, respect, and open ears. I believe in asset-based community development; I believe in microfinance; I believe in the power for change already present in communities and in the efforts of humanitarians to harness that power. Humanitarian work can certainly take on imperialistic tones. And there is much to be said for the benefits of people working in their own backyards to effect change – but only because they are more likely to understand how to effect change, not because it is inherently imperialistic or imposing or colonialist for citizens of one country or state to work to help those of another. It’s all humans. Each of us needs different things and each of us can give different things; I think of humanitarian work as a part of a sort of global marketplace, with ideas for currency instead of money. Let’s not restrict the ideas market based on country borders out of fear of revisiting sour memories of imperialism past, but let’s do make sure that we’re engaging in this market with the utmost respect and sensitivity. That means continuing to ask uncomfortable questions, and thinking deeply about the answers.

Designer/writer/professor Bruce Nussbaum ignited a blogosphere firestorm with his recent post on fastcodesign.com, “Is Humanitarian Design the New Imperialism?” The title sets a provocative tone that the post continues. Nussbaum begins the post by a humanitarian design golden child, Emily Pilloton’s Project H Design, which describes itself as “a team of designers and builders engaging locally to improve the quality of life for the socially overlooked.” Nussbaum asserts that instead, some would describe it as an example of “new anthropologists or missionaries, come to poke into village life, ‘understand’ it and make it better – their ‘modern’ way.” He goes on to recommend that as we forge ahead with humanitarian design work, we pause “to ask whether or not American and European designers are collaborating with the right partners, learning from the best local people, and being as sensitive as they might to the colonial legacies of the countries they want to do good in.” And he concludes the article by asking, “why are we only doing humanitarian design in Asia and Africa and not Native American reservations or rural areas, where standards of education, water and health match the very worst overseas?”

Supporters of Pilloton, Project H Design, and humanitarian design in general came roaring back at Nussbaum with intriguingly intense resentment. Pilloton herself went far to the defensive, with a touch of petulance. In her response essay, “Are Humanitarian Designers Imperialists? Project H Responds”, Pilloton indignantly points out that of the 20 current Project H projects, “18 are based in the U.S., run by local designers invested in their own communities, in places they understand, with people who are fellow citizens (the remaining two projects are in Mexico City, but designed and executed by a team of talented Mexican designers).”

With his last question (“Why are we only doing humanitarian design in Asia and Africa?”), Nussbaum made a sweeping generalization that understandably offended a design leader working hard to improve quality of life for the rural underserved. But Nussbaum is making some great points that Pilloton and others brushed past in their hurry to express just how offended they were. And honestly, when the response to an essay is so heated, you have to think that there is some fear motivating the anger: fear that Nussbaum is making valid points that strike at the very core of what the humanitarian designers are doing. Metropolismag.com writer Susan S. Szenasy breathlessly frames the debate as the latest skirmish in “the age-old duel between the generations, the older one (Nussbaum) with preconceived notions of humanitarian design and cultural imperialism versus the new generation (Pilloton), which is bravely venturing forth to right the world their elders have wronged for so long.” Szenasy, I know this is no fun, but neither Nussbaum nor Pilloton “wins.” The debate is not a black-and-white, old-versus-young, “age-old duel.” Nussbaum makes generalizations, to be sure. But we do need to be thinking about the questions he poses – and it’s an important point that in “Is Humanitarian Design the New Imperialism?”, Nussbaum poses questions rather than making statements. The questions may be exaggerated, hyperbolic for the sake of grabbing attention and raising awareness, but the underlying concepts are deeply worthwhile. Pilloton is right to point out that there are plenty of American organizations, Project H included, working locally here in the U.S. But she sidesteps an essential question Nussbaum is getting at: should American designers be working abroad? In other words, is there anything inherently wrong with American humanitarians working in other countries?

Between 1980 and 2004, adult obesity in America doubled, and as a nation we now spend as much as $147 billion each year on health-care costs associated with obesity. This is a big problem. We know that Americans need to eat better and move more, but we need to look at why we aren’t eating well and moving enough in the first place. The moving-enough part? That has something to do with a little invention called the automobile. Which has a lot to do with how our communities are designed. Which both have to do with why we aren’t moving.

Thanks, Henry Ford

The rise of the automobile over the first half of the twentieth century encouraged suburban sprawl, or “conventional suburban development” (CSD) in urban-design speak. As access to cars increased, homes could be – and were – built farther and farther away schools, shops and other public-use facilities. Compact, mixed-use neighborhoods gave way to expansive suburban communities that could only be navigated and exited by car, and so we stopped walking. Dr. Richard Jackson, professor of environmental-health sciences at UCLA, summarizes the problem: “We have essentially engineered exercise and, to a degree, socialization out of American lives…We have spent decades building health-eroding communities in America…” He’s hopeful about the comeback of the healthy community, however: “…I think one of the big things we are going to see in the next ten years is a turnaround in that trajectory: we will build communities that are health-promoting.”

There's no escape...except by car

That’s a message of hope echoed by the Congress for New Urbanism (CNU), an organization that champions “walkable, mixed-use neighborhood development, sustainable communities and healthier living conditions.” The CNU advocates for streets arranged in compact and walkable blocks; diverse housing choices to accommodate people of different ages and financial means; schools, stores and other destinations accessible by foot, bicycle or public transit; and finally “an affirming, human-scaled public realm” with attractive, lively architecture.

Enter TOD and TND, here to right the wrongs committed by CSD. A transit-oriented development (TOD) is a mixed-use residential or commercial community designed to maximize access to public transport. Traditional neighborhood development (TND), meanwhile, refers to a community that features a center with public space and commercial enterprise; identifiable boundaries; a variety of available activities and building types; and open, interconnected streets, usually in a grid pattern. TODs and TNDs are designed to decrease automobile use, increase walking and use of public transit, and foster social activity – keeping people moving, interacting, and overall leading healthier and happier lives.

Take a walk in a TOD

Urban design deserves a bigger role in the debate over the growing problem of American obesity. We know that compact, walkable, mixed-use communities translate directly to smaller waistlines and healthier, happier people, so let’s reclaim our communities and design them for us – not for our cars.

Human-oriented design.

Does this term seem redundant? Of course design is human-oriented: humans design things for human use. But bear with me. Recently I stumbled across a rather stunning article on core77.com. The article, by designer-researcher-writer Ingrid Fetell, is titled “To Change Hearts and Minds…Change their Chair!”, a title that refers to a study in which participants, some sitting in soft seats, some in hard seats, were asked to negotiate with a car dealer. As Fetell describes, those in soft seats made far more generous second offers to the dealer than those in hard seats. Related studies have shown a link between temperature and social attitudes: in a recent study at Yale, researchers split 41 college students into two groups and casually asked those in the first group to hold a cup of hot coffee and those in the second group to hold iced coffee. All students were then asked to evaluate an imaginary person’s personality based on a packet of information about this person. Students who had held the hot coffee were far likelier to judge the imaginary character as warm and friendly than students who had held the iced coffee. Other studies have shown correlations between weight and perceived seriousness, between “clean” smells and moral behavior.

Soft->generous?

Warm->friendly?

It all seems too obvious to be true. As Fetell puts it, “There’s an almost comic lack of elegance in a mind [so] literal” that it associates generosity with softness, adversity with roughness or friendliness with warmth.” But it appears that this is just what our minds do, and the growing field of embodied cognition is proving it.

In 1954, the architect Richard Neutra predicted that “A workable understanding of how our psychosomatic organism ticks, information on sensory clues which wind its gorgeous clockwork or switch it this way or that, undoubtedly will someday belong in the designer’s mental tool chest,” he predicted. Three decades later, behavioral scientist Roger Ulrich published his revolutionary 1984 study showing that hospital patients whose windows looked out on greenery healed faster than those patients whose windows looked out on brick wall. Over the course of the study, Ulrich had examined the hospital records of forty-six gall bladder surgery patients, twenty-three of whom could see trees from their beds and twenty-three of whom could not. Patients who had looked out at greenery during recovery left the hospital nearly a full day sooner than patients who had not and also required significantly fewer doses of moderate and strong pain medication.

more of this...

...means less of this

Since the publication of this study, we understand the relationship between environment and well-being much better…but we have much more to understand. We know that our “built environments” influence our mental processes every moment of every day. And it seems that this influence is most critical in times of healing. It follows that hospital design should accommodate the humans – not just the technology – inside, because the well-being of patients and staff hinges on more than just the proper functioning of an MRI machine or CT scanner. As metropolismag.com stated in its January article, “What’s Next: Health Care,” “Thanks to a field known as evidence-based design, we now know that how a hospital looks and feels plays a big role in how well it treats patients.” Evidence-based design can detail “the environmental particulars of recovery down to the best floor pattern for Alzheimer’s patients.” Embodied cognition is showing us that the smallest details of our environments – from chair softness to floor patterns – influence our cognitive activity, which in turn dictates everything from how amenable we are to compromise to how fast we heal.

And that’s why health care facility designers aren’t just designing buildings, they’re designing “built environments;” they’re not just creating objects, they’re creating systems. Trending away from assuming humans will adapt to design and instead adapting design to humans reminds me of the artistic exercise of drawing upside down, which allows an artist to draw what she sees rather than relying on a preconceived characterization of her subject. Evidence-based design – which is truly human-oriented design – is about releasing preconceived notions of what a hospital, courthouse, student center, chair, etc. “should” look like and instead looking to the interconnected physiological and psychological needs of the human beings who use them. And that gives me a warm feeling inside – although that may just be from the cup of coffee in my hand.