“If it became automatic, would the hospital of the future be more human?” This is the last question posed in the video for The Hospital of the Future, an ongoing research programme led by OMA partner, Reinier de Graaf. Here he talks about the current problems of the healthcare system, and why architects should look at a hospital not so much as a design object but as a design strategy.

DAMN°: How did your research on healthcare and hospitals start?

Reinier de Graaf: In the beginning of 2019 we started working on two healthcare projects – a master plan for a health district in Qatar and a competition for a hospital in the north of Paris. We began our research simply because we didn’t know anything about healthcare design – the only healthcare-related project we had worked on was one of Charles Jencks’ Maggie’s cancer care centres back in 2010. But our lack of knowledge on healthcare was precisely the reason why we got to work on these two projects. Healthcare design has become the almost exclusive domain of specialized architecture firms, which have developed a routine of replicating the same ‘success’ formulas from one project to another. We were chosen because of our habit to challenge the status quo, our curiosity in looking for ways to do things differently.

The research continued in parallel with the design and at some point it acquired a critical mass that made it worth being published on its own. As an office, we have a long history of publishing books about the thoughts that precede or accompany our projects, but now we chose to work with another medium – video – which was again something we hadn’t really done before. Through video we could reach a wider audience and could do it faster than with a book. There was a certain urgency in addressing the topic, we felt. Some months later, the urgency took over the entire planet.

Hospital of the Future. Image courtesy OMA

DAMN°: Has Covid-19 changed your thinking or has it merely served to prove your thinking right?

RdG: A large part of our research focused on the underlying mechanisms behind the workings of the healthcare system in the 21st century. What you see is a system that, under the pressure of the market economy, abandoned its role as public duty and adopted the status of a service – a service that is to be deployed only in case of exception. The health of the population was no longer the responsibility of the state but of individuals alone. The scale of the public healthcare infrastructure was subsequently reduced under the impetus of efficiency, which was another way of saying profit. Hospitals were assessed like any other enterprise – are they profitable and what measures should be taken to cut losses? All these created a very fragile system and its vulnerability; we all see it now.

Covid-19 was indeed a confirmation of our observations, albeit a bitter one. But there is a good side to the current crisis and that is the fact that it happened now and not later. Asking ourselves questions such as how are medicines – or vaccines – being supplied worldwide, why aren’t there enough hospital beds, why do we have to turn other buildings into hospitals and why are other buildings more suitable to host patients than hospitals themselves, are a step towards acknowledging the problem of the current healthcare system.

Hospital of the Future. Image courtesy OMA

DAMN°: What changes are needed in hospitals?  What is the main problem?

RdG: The drive towards efficiency has resulted in a rat race between architects and scientists, where design tries to keep up with the latest developments in medical science. The problem is that the design and construction of a hospital can take up to twelve years, from project launch to building opening, while technology improves every three years. That makes the design of a hospital obsolete from the moment it starts functioning, which means that it will have to be redesigned, reconfigured and adjusted. In other words, a hospital is never complete; it is in a permanent state of transformation, similarly to an airport.

But there are so many hospitals that can no longer be upgraded and that have demolished. Contrary to what one would expect it is not old hospitals that end up irreconcilably dysfunctional but the ones built in the last 40 or 50 years. Bertrand Goldberg’s Prentice Women's Hospital, built in 1971, was vacated in 2011 and three years later it was torn down. The hospital was an iconic structure in Chicago – a curvilinear tower surmounting a rectangular base – one of the first computer-aided designed buildings in the world. But precisely its iconicity prevented it from being adapted to the changing needs of healthcare. The clearly defined tower, where patient rooms were located, was impossible to reconfigure according to new standards. On the other hand, hospitals built in the 19th century, when the current medical theory was in its infancy, have proved to be much more resilient and many function to this day. It is as if the naivety of the architects, who mainly adapted existing typologies of monasteries and palaces, left space for the unforeseen.

To function properly in the long run, hospitals have to be as flexible as possible. In that sense the architect should aim not so much towards a design object but towards a design strategy, in which space is equally taken into account as time is.

Hospital of the Future. Image courtesy OMA

DAMN°: Can a hospital ever truly be a self-sustaining environment, as you claim in the video?

RdG: Whether hospitals should, or could, be self-sustaining is a question that arises from the realization of how dependant hospitals are in terms of supplies. Of course, this dependency is not the same everywhere and it is for the hospitals that are the furthest away in the supply chain that the question is relevant the most. In a country like Qatar almost everything is imported: food, medicine, construction materials, even medical staff. In our project there, we explored how all these things can be produced locally. Qatar is by and large a patch of desert with no resources, except for oil. But it actually has more than oil; it has sun and it has water – seawater, that is. With the technology available today, sun equals energy, and seawater can easily be turned into water suitable for agriculture. These are two fundamental components in decreasing the country’s reliance on imports. In this scenario, one could imagine a hospital that would produce its own energy – the largest cost in hospitals is electricity! – and food, and even medicine. Ultimately, the question about the hospital’s self-sufficiency is about identifying, and making use of, the local resources and finding ways to shorten global supply chains, about making the system more polycentric.

DAMN°: Do we want digital hospitals?  People are scared of robots. Why shouldn’t they be?

RdG: I think people should be more scared by humans. When it comes to surgery, precision and endurance are crucial; wouldn’t robots be more suitable for that? Actually, the benefits of having robots in hospitals don’t have too much to do with the interaction with patients. There is a plethora of jobs in hospitals that make the medical act possible – from logistics and administration to interpreting tests – that could be transferred to artificial intelligence. A hospital populated with machines is not a dystopian science fiction; it is actually a place where humans can take better care of humans.

 Hospital of the Future. Image courtesy OMA

DAMN°: In the video the question of how new is new and how normal is normal is raised in relation to the new normal.  Can you elaborate on that?

RdG: Like major wars, pandemics have generated significant changes in the way people were used to living. After the Black Death, agriculture in Europe shifted from crops to animal husbandry since there was a shortage in labour to work the land. During the cholera outbreaks of the 19th century in London, the discovery of how the disease spread led to a two thousand-year-old medical theory being refuted. In the aftermath of the Spanish Flu the public healthcare institutions we have today were created. We can equally expect that after the coronavirus pandemic the world will not be the same. The digital revolution that started at the turn of the century is accelerating. But in the midst of things it’s hard to picture all the consequences. In any case, it’s hard to imagine we will return to our pre-corona lives like nothing happened.

DAMN°: Who will listen to this research and act on it?  What is your goal?  Who are the potential clients of this thinking?

RdG: Until corona came into the picture, there was hardly any interest among architects for healthcare, nor was there much interest in architects among doctors or policy makers. The last time a hospital was reimagined by an architect who hadn’t worked on healthcare projects was Le Corbusier in 1965 (he died before realizing it though). Before that, however, it was not uncommon that architects like Alvar Aalto, Henry van de Velde, Otto Wagner and Tony Garnier were commissioned to design hospitals or clinics. Now, there is again interest from architects for healthcare projects. It remains to be seen if those who decide the future of healthcare will reciprocate the interest.

Hospital of the Future. Image courtesy OMA

DAMN°: How can research change thinking in the general public?

RdG: For architects, research is a way to understand things and sometimes to justify the design. It is often the difference between a design gesture and a decision – a way to reinforce the position of the architect in the eyes of the client and the public. But research can also be a way to communicate ideas that cannot be expressed in built form. It then expands the role of the architect and his or her competences, since architects are capable of doing more than just buildings.

The Hospital of the Future was produced by OMA / Reinier de Graaf with the support of the Matadero Madrid Centre for Contemporary Creation and released as part of the centre’s Twelve Cautionary Tales exhibition.