What the future holds for our hospitals and long-term care homes

COVID-19 and Indigenous revitalization are changing the way we envision the architecture of health and elder care.

In April 2020, weeks after national sports leagues cleared their calendars, stadiums around the world transformed into makeshift hospitals as health officials scrambled to prepare beds for the growing number of patients hospitalized with COVID-19. The swift transformation from football fields to field hospitals hearken back to the floorplans of hospitals during the 1918 pandemic according to Professor Annmarie Adams, BA’81, architectural historian and Chair of the Department of Social Studies of Medicine at McGill University.

In times of health crises, hospitals and healthcare providers have been known to adapt. The stadiums-turned-hospitals look a lot like the open-concept “pavilion plan” associated with nursing pioneer Florence Nightingale and common through the 1918 flu pandemic. These pavilions had rows of beds spaced apart and were designed to minimize contagion by increasing air circulation through large windows. Elsewhere, “open-air” hospitals were camps that treated patients outside with sunlight and fresh air.

Hospitals built before World War I, such as the Royal Victoria Hospital in 1893, were imposing public institutions inspired by workhouses, convents and even prisons. With the war and flu pandemic came an unprecedented number of sick and wounded people, many of whom were also cared for in borrowed buildings.

After 1918, open wards were replaced with smaller rooms and corridors in the style of upscale hotels. St. Mary’s Hospital first took up residence in the old Shaughnessy House (now part of the Canadian Centre for Architecture). Following World War II, the modern hospitals were built like office towers (witness the Montreal General). The post-1980s superhospitals, such as the McGill University Health Centre Glen site, bring together the shopping-mall experience and specialized wards with single rooms that are still evocative of a hotel room.

Four walls are meant to isolate the sick and provide privacy and comfort. Today, the COVID-19 pandemic is changing the way we think about walls, which suddenly proved useless at preventing the spread of the disease. “PPE has become the new ‘wall’ that each staff member has around them,” Adams says of the protective equipment donned by healthcare workers to stop the spread of the virus.

Overnight, Canadian hospitals had to contend with predictions of mass hospitalization: modular units were assembled and field hospitals—such as a pandemic response unit in Burlington, Ontario—were hastily erected, proving that construction does not always require decades of planning and spending. The virus is a test for healthcare logistics, with superhospitals sharing resources. This is the case at the Glen, where the Montreal Children’s Hospital is now providing beds in its intensive care unit to adult patients.

In the 1970s, the world had its eyes on the McMaster University Health Sciences Centre, which was intended to be the hospital that could respond to unpredictable medicine. “The idea was that you could change it overnight. It was modular and infinitely extendable,” says Adams. “That kind of spirit will, I think, become important again.”

The pandemic has also shocked long-term care facilities, which were seized by rampant outbreaks. People living in these homes have been more likely to die of the disease and are reported to make up 75 per cent of the total death toll in Quebec.

“It’s destabilizing, because we like to think of the long-term care home as a safe place where older people are taken care of,” Adams says. “But the images have been nightmarish.”

She hopes the pandemic will be a wake-up call about the importance of design and architecture of these otherwise invisible facilities. This semester, long-term care design is the subject of a third-year studio class taught by Boris Morin-Defoy at McGill’s Peter Guo-hua Fu’s School of Architecture. Nursing home design is linked to the quality of life of seniors because it affects their social interaction and mobility. For example, accessibility and traffic in communal areas, or the number of windows and residents per room, can make a difference.

Infection control has always been a paramount concern for long-term care homes and hospitals, says doctoral student Christopher Clarke, who is Chief Architect of the Northwest Territories’ department of health. The proliferation of hand-hygiene sinks, sterile rooms and separate ventilation systems is part of a concerted effort to increase efficiency and safety in healthcare facilities.

“The infection control aspect of healthcare facilities is continually increasing,” Clarke says, and future improvements must be thoughtful and not a reaction to pandemic-induced panic. “In long-term care, we could separate the rooms more, like the isolation rooms now,” he says. “But you don’t want to live your last years in a facility that looks like a clinic.”

For long-term care facilities to embody the meaning of home, the solution may be to mimic multifamily residences and life in the community. A novel example of innovative long-term care design is the “dementia village,” a fictional town and controlled environment where people living with dementia can believe life is business as usual. The main streets are not real, the bus stops are fake. “Nobody has any money, but residents pretend they are shopping for dinner,” says Adams. “It’s a completely fake place, and I’m quite critical of it, because it uses architecture to fool people,” says Adams, “but as others point out, it’s the best thing we have, because it means people can go outside.” Quebec’s residential and long-term centres for elderly people (known as CHSLDs), meanwhile, resemble a cross between a hotel and hospital environment where people are isolated in their rooms except when grouped together under supervision for meals and activities.

In the Northwest Territories, nursing homes have rooms for out-of-town families to sleep in. Clarke proposes building camps for elders that recreate life on the land. Clarke, who is from the Treaty 8 Akaitcho Territory Łútsël K’é Dene First Nation, says patients living with dementia in the territory survived residential schools. Architects and policymakers need to be sensitive to the way facilities often resemble these schools. “If it looks like a residential school, somebody who has those memories with dementia—it could perpetuate their trauma,” he says. “Sometimes people who try to leave the facilities aren’t cognitively able to take care of themselves,” he says.

A camp for dementia patients, with teepees, cabins and smokehouse to dry meat and fish could create the experience of living off the land, while still being fenced in by raspberry bushes and monitored by healthcare workers. These sites can also be places of cultural knowledge sharing between older and younger generations. Clarke’s research to build these facilities, and other architecture that incorporates Indigenous medicines and healing practices, will continue through his PhD studies over the next four years. During this time, he hopes to work with elders and Indigenous doctors around the world to build new wellness centres in a post-pandemic world.

Adams is optimistic that COVID-19 is eye-opening for architects. “I’m hoping the architectural profession will become more caring, and I hope I can contribute to that.”


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