Issue 11 / Care

August 31, 2020
Shadowy windows obscured by lace

Image by Celine Nguyen

The Tower and the Tent

Nitin Ahuja

Contemporary megahospitals present themselves as cutting-edge technologies. A physician reflects on what happens when they fail.

At the university-based outpatient practice where I work as a gastroenterologist, my office overlooks the construction site of a huge new hospital that is slated to open in the summer of 2021. Since taking this job three years ago, I’ve watched the project develop from its steel skeleton to its curving facade, a layer cake of plate glass and copper panels. The aesthetic matches the streamlined, futuristic style of academic megahospitals from Texas to Tokyo, casting the building as a technology that’s every bit as cutting-edge as the microsurgical robots and cancer immunotherapies it’s designed to house. At seventeen stories high and a price tag of $1.5 billion, it’s a tower among towers (including the one where my office sits on the seventh floor), adding to an already imposing skyline of healthcare buildings near the center of Philadelphia, just west of the Schuylkill River. 

The new hospital is also visible from two vinyl tents, each slightly smaller than a double-wide trailer, that were recently set up in front of my current hospital’s emergency room in the early phase of the COVID-19 pandemic. With a few dozen fellow doctors, nurses, and medical assistants, I was redeployed there for several weeks in April to test and triage patients walking in with flu-like symptoms—coughing, short of breath, but not quite sick enough to merit a hospital bed. As far as tents go, ours were pretty nice: we had Wi-Fi, some bleach-proof laptops, and sinks connected to hot water hoses that were slung like vines across the sidewalk. We also had carts that were implausibly well stocked with gloves, goggles, masks, and nasopharyngeal swabs. I was grateful for those carts, having heard terrible stories of healthcare workers dying for lack of basic supplies at the loftiest medical institutions of nearby New York City. So long as I was wrapped in the appropriate protective equipment, I was content to sit in a folding chair with rainwater pooling at the edges of our makeshift clinic.

But I was also struck by the juxtaposition between the looming megahospital, glinting in the sun like a freshly landed spaceship, and the humble tents below. It evoked an abiding paradox of modern medical care. Contemporary hospitals are like great machines: each discipline exists in its own silo, outfitted with its own technologies and specialized knowledge, often connected to other disciplines only by confusing networks of elevators, corridors, primary care physicians, and a vast, computerized bureaucracy. The proton-beam radiation equipment used to treat prostate cancer patients in the basement is far removed from the specially-trained neurology nurses working with brain-damaged patients on the floors above, but they meet in the electronic medical record, with its templated notes and billing codes. Critics have long pointed out that the enormity and complexity of this infrastructure, which is designed to literally and metaphorically convey biomedicine’s healing power, frequently leaves patients feeling lost, even spiritually deadened. 

The current pandemic adds another wrinkle to that longstanding contradiction. In the face of a widespread threat to our wellbeing, the megahospital hasn’t risen to the occasion. Past social upheavals, such as postwar modernism and the rise of mass production, helped to fuel major evolutions in hospital design. Looking out from my office window at the massive structure taking shape by the river, I wondered whether, after COVID-19 had laid bare the limitations of contemporary megahospitals, these buildings might be refashioned once again.

“It’s All in There”

More than a decade ago, as a medical student in Michigan, I began researching the origins of modern hospital design. As a soon-to-be doctor, I was interested in how my university hospital unsettled me. Months and even years into my studies there, I kept coming across new wards, offices, and laboratories. It often seemed to me at the time that miracles of healing and scientific discovery—organs transplanted, inflammatory pathways defined—must be happening around every bend. Some days, though, the hospital’s beige walls depressed me, the monotonous stretch of high-ceilinged corridors gave me vertigo, and the ambient smell of disinfectant turned my stomach. I wanted to understand how much of this disorientation came from navigating an unfamiliar space and how much was intrinsic to the building itself.

That megahospital, like the one in Philadelphia where I’ll soon work, had its formal origins at the turn of the twentieth century. Before that time, American hospitals were more modest buildings, staffed by familiar faces from the local community, decorated like middle-class homes, with sash windows and sloping roofs. But the growing acceptance of germ theory, in which common diseases were ascribed to the spread of pathogens, correlated with a shift in hospital design toward blank, unornamented surfaces made of visibly aseptic materials like linoleum and metal. 

At roughly the same time, industrial capitalism’s obsession with efficiency was exported from the factory floor to other domains, including medicine. Interest in scientific management led hospital designers to attempt to streamline patient movement in the way a factory was designed to streamline production processes. This move was reinforced by the rise of artistic modernism, which championed the now famous adage that form should follow function. 

The predecessor of the Michigan hospital where I started my training was one of the prime examples of medicine’s embrace of the ideals of industrial efficiency. It opened in Ann Arbor in 1925 and was designed by Albert Kahn, an architect better known for planning several of Henry Ford’s automobile factories in nearby Detroit. Kahn drew clear analogies between these two building types, once telling the American Hospital Association that “the same principles underlying the proper functioning of a manufacturing plant apply to the planning of a hospital building.”

Hospitals became emblems of progress and were celebrated for their rational forms. “The main purpose of the building is to function as a medical instrument,” said the Finnish architect Alvar Aalto with reference to his Paimio Sanatorium, a 1933 exemplar of modernist hospital design. But the flipside of the hospital’s increasing ability to anatomize patients was its capacity to dehumanize them. At the extreme, an analogy between hospitals and factories suggested an equivalence between sick people and disassembled parts.

Both the scientific power and the dehumanizing effects of the hospital have been amplified over the last several decades, as these buildings have increasingly been designed to accommodate new computing technologies. From wall-mounted monitors in every patient room to networked smartphones in the pockets of every white coat, digital interfaces have provided new avenues for clinicians to communicate with patients and each other, accelerating the pace of diagnosis and therapy. But these interfaces also risk further isolating patients, drawing clinicians’ eyes toward screens and away from the person in the bed. More than once, I’ve asked a patient to relate the story of their illness, only to have them point to the nearest computer and tell me wearily, “It’s all in there.”

An Emerging Labyrinth

I moved to a new state for each phase of my clinical training, spending a few years on one mammoth medical campus before graduating to the next. Though each had its spatial quirks, these tended to follow similar themes. Pavilions of various ages were connected by secret tunnels once used by hospital porters to transport equipment, now used by savvy employees to avoid walking outside in bad weather. Certain unmarked elevators skipped certain unmarked floors unless presented with a privileged ID badge. Wards were decorated with a hodgepodge of faded prints in dusty frames—geometric abstractions, a still life of flowers—apparently much easier to put up than to take down.

Irrationality emerges alongside obsolescence in hospitals, patchily, with various temporizing efforts made along the way to restore order and relevance. Inpatient units are retrofitted to new infection control guidelines requiring sinks in the hallway; radiology suites are widened to accommodate additional MRI machines. The hospital’s original floor plan is carved up, each territory stewarded by a different lineage of managers, each poised for its own idiosyncratic process of redesign: the secret tunnels’ access doors stay unlocked but have their signs removed; the enlarged radiology suite displaces the radiologists’ workroom to another wing, estranging them still further from the patients whose scans they read. It's maturation of a sort, but also a kind of decay; slowly, monuments to rationality become labyrinths. 

New hospitals are built when the obsolescence of old hospitals becomes difficult to ignore, but new hospitals can also become old hospitals rather quickly. In Medical Nemesis, his 1974 polemic against biomedicine, the social critic Ivan Illich describes hospitals as “concrete manifestations of those professional prejudices which were fashionable on the day their cornerstone was laid and which were often outdated when they came into use.” Those prejudices can be as nominal as the flooring selected for intensive care units (which, at the hospital where I completed my residency, were inexplicably carpeted) or as consequential as the total number of intensive care beds available in a given city for patients in simultaneous respiratory failure.

All of which is to say that there’s a limit to how nimble hospitals can be in their readiness for the future, despite what their exteriors seem to promise—a point that our collective experience with COVID-19 makes plain. According to its promotional video, my university’s new building was “designed to be ready for technologies decades down the road.” This breathless rhetoric corresponds to fairly basic practices, less anticipatory than agnostic (involving, for example, multipurpose rooms designed with a lot of electrical outlets). And however flexible it may purport to be, much of the new hospital will lie dormant so long as our clinical attention is preoccupied with one particular virus and the comparatively basic technologies—masks, swabs, ventilators—needed to manage it. 

Masks in Brown Paper Bags

Once the pandemic recedes, where will we cast blame and seek reform? Politicians, wet markets, global supply chains—but probably not the megahospital. Most messaging from the medical-industrial complex, from drug advertisements to corporate hospital slogans, reinforces a belief in scientific progress, the reversibility of physical distress, and the usefulness of technology in both regards. These pre-pandemic ideals of biomedicine seem likely to persist in the post-COVID era, as does our tendency to celebrate them through the usual tropes of megahospital design. But these buildings’ failure to prevent a great deal of death has tinged their formidable architecture with irony, and I wonder whether there are subtler ways in which our movement through these spaces might change.

Just before my stint in the emergency room tents, I finished a week-long rotation as a consultant gastroenterologist for patients admitted to the old hospital with various perennial complaints—trouble eating, painless jaundice, bloody stools. In order to keep protective equipment available for the clinical areas where they were needed most, including the tents and the ICU, respiratory masks were being carefully rationed from a central location—a control desk that oversees the building’s forty or so operating rooms. Rather than discarding our masks at the end of the day, we were asked to return them in brown paper bags, writing our names on the front, like schoolchildren, so that they could be disinfected for two hours with ultraviolet light and later reused. 

It was a long walk to the control desk from my office—past plaques bearing the names of erstwhile benefactors, past stairwells going up twelve flights, past rows of sleeping computers, past empty recovery bays, past unplugged fluoroscopic imaging machines stacked against the walls. Because my practice is focused on outpatients, my hospital-based rotations are rare, and on each one I have to make an effort to remember my way around. But it’s pleasant to get reacquainted with the vastness of the enterprise; the complexity of these spaces can beguile clinicians too. There’s plenty to marvel at along the way to preserving a two-dollar bit of air-filtering fabric—such a ridiculously simple thing, in the grand scheme, to be holding onto so tightly.

Nitin K. Ahuja is an Assistant Professor of Clinical Medicine in the Division of Gastroenterology and Hepatology at the University of Pennsylvania.

This piece appears in Logic's issue 11, "Care". To order the issue, head on over to our store. To receive future issues, subscribe.