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Reporting the 5th Gupha Forum at the University of Tokyo, November 2007

Gupha meet in Tokyo

The Gupha Forum 1 consisted of many speakers from all parts of the globe addressing both macro and micro forms of health care design from world health provision and massive hospitals in Malaysia to the new Community Facilities in Northern Ireland. Introducing the proceedings Professor George Mann of Texas A&M University 2 outline the main trends in facility design and described the challenge for the next generation would be the rise in population from a current 6.6 to 10 billion mostly in developing countries. He then proceeded to present the Gupha international student design awards for innovation. For his special lecture based on his considerable achievements and international experience, Professor Yasushi Nagasawa, described the lessons of the two Gs, – Global and Geography.

Including design for health in a global context is a complicated issue. The World Health Organisation is now attempting to update its knowledge base and capacity for guidance to meet 21st Century needs and patterns of care requirements. Enlightening the forum on WHO’s work on health care infrastructure, facilities and technology Dr Andrei Issakov made an appeal for assistance from Gupha delegates for current guidance. We appear to have arrived at a fragmented stage where central advice is no longer available and delegates found themselves unable to respond adequately to the invitation. In a culturally diverse world of such inequality in life expectation and access to health care, it is difficult to know where to begin, but the basic principles are straight forward. Consider first the subject, – the sufferer and all the individual citizen of this planet suffer at some time in their life. The aim is the well-being of the world’s population by aspiring to the public health objectives as defined in the WHO’s constitution. 3 Between the subject and the object are the means of delivery and availability, for instance the degree of inclusiveness and whether access is based on ability to pay and is affordable at the point of service. To establish a fair health infrastructure is a considerable undertaking with numerous stakeholders, politicians, clinical consultants, nursing carers, financial sponsors, drug companies, contractors and the service users. With an extraordinary commitment and investment each stakeholder believes they have a significant role to play in the health service delivery. At this stage the whole process becomes very muddled as each of the contributors compete for the territory and control over the programme and influence over the end product. In other words the means of the process begin to determine the outcome. The contractor for example believes the building is the subject and the object is to profit from their investment, when in fact it may not be appropriate or even necessary to build a permanent monument. Due to a lack of universal resources there is serious ethical imbalance where the privilege few have access to the specialist teaching hospitals and increasingly cosmetic surgery whilst elsewhere millions still don’t have access to clean water, the most common cause of disease and sickness. When it comes to achieving health care benefits across the whole population each independent country with variable ability to govern and regulate has different political, social and financial priorities. Overwhelmed with such dilemma all of this complexity compromises WHO’s effectiveness in delivering best practice guidance.

Considering the Geography 4

From the UK Architects for Health colleagues 5 and myself attended and although the majority of the delegates were from Asia, it was the Americans who were most vocal. Under the Chairmanship of Professor Kazuhiko Nishide, we were treated to two days of highly efficient communication support. The chair was assisted by the irrepressible Professor Nagasawa and his extraordinary capability to switch instantly between Japanese and English keeping everyone informed. Translation was simultaneous and even the Japanese volunteers were transforming spoken English directly into Japanese sign language. The only presentation throughout by a speaker from a disabled user’s viewpoint, Dr Toshinobu Obata from Honda Motors spoke on behalf of the deaf and appealed for their inclusion in environmental decision making. He informed the international gathering that sign language is by no means universal and that there were differences even between Tokyo and Osaka.

The conference provided a much needed platform and morale support for the various university departments who specialise in design for health care, and there were exchanges on the various educational structures. The conference however offered far more than approaches to curriculum, such as the Development of Guidelines for the Design and Construction of Health Care Facilities presented by Joe Sprague the Director of Health Facilities at HKS Inc.. On one hand there was the USA demand driven model with $43 billion pa worth of business and the mass care systems rapidly appearing in the Asia Tiger Economies. We were shown plans for a 3000 bed hospital in Malaysia by Professor Norwina M Nawawi and mega hospitals in China by architect Dr Huang Xi Qiu whose office has designed over a hundred such hospitals. In the mass orientated Asian countries there was little evidence of an individual patient focused service. (The sight of such mammoth hospitals being rolled out were beginning to make your reporter feel sick with despair, but of course huge swathes of users were likely to benefit from such enormous institutions, so it would be churlish to criticise such ambition!). Architects for Health Chairperson Dr Ann Noble presentation proved when it comes to health provision small is beautiful, and care in the communities of Belfast finished the day on a note of cautious optimism particularly in the aftermath of the troubles.

As a non-academy based delegate the Singapore and Single Room study were the most informative. Considering hospitals within the urban and cultural context we learnt about the phenomena of the edge and the importance of boundaries. In her presentation On the Edge Zone between Urban and Hospital Domain Dr Ruzica Bozovic Stamenovic presented a range of border conditions and how such segregation encourages stigma. Temporary Triage Tents systems erected on the perimeter during the recent SARS scare reinforced fear and did little to encourage confidence. Such separation of clinical services from the population was described as an anathema to the spirit of hospitals as healing environments.

Patient Room Prototypes

For a more specific scheme Professor David Allison presented the single room research, the joint Clemsom University and Carleton University Patient Room Prototype Project. a virtual interdisciplinary R&D collaboration with the Spartanburg Regional Health Care System. An elegant functional scheme offering essential nursing sight lines from the ward circulation the forum was able to get their teeth into the detail of this project. Your reporter questioned access to the wc, and it was suggested there were no mandate to provide double loaded disabled access. Although the twin mirrored single room arrangement did offer the disabled a choice, US regulations unfortunately seem to favour a single handed room orientation. Currently there is a mandate in the USA towards all single rooms in new facilities, but a Berlin based delegate pointed out that Germany was now moving away from single rooms. It appears single bed rooms are too expensive and there simply wasn’t a demand due to insurance companies reluctance to underwrite the tariffs on such services. Within the rooms it was noted the window elevations were least resolved, and it is unclear whether the outer walls were within the designer’s brief. This seemed a surprising omission as a permeable perimeter would connect the patient to the geography and natural phenomena which provides daylight and encourages the healing process.

Graham Cooper November 2007

Author Art and Nature: Healing


  1. Gupha is short for Global Universities Programmes in Healthcare Architecture.
  2. Texas A&M University is short hand for the Texas Agriculture and Mechanics University.
  3. WHO Definition: Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. The definition has not been amended since 1948.
  4. Geography is a reference to The Geography of the Hospital, (a planning principle identified by the late John Weeks).
  5. AfH Colleagues included Ann and Paul Noble, Junko Iwaya, Rosemary Glanville and Giovana Romero from MARU.

The 5th GUPHA Forum Schedule

  • Opening Remarks and Presentation Prof. George Mann, Texas A&M University
  • Clemson/Carleton Patient Room Prototype Projects Prof. David Allison, Clemson University
  • Can We Rely on Robots to Guide Users in Hospitals? Healthcare Facilities Wayfinding Studies Akikazu Kato, Mie University
  • Development of Guidelines for the Design and Construction of Health Care Facilities Mr. Joseph G. Sprague HKS, INC.
  • The Best Communicating Environment for Inclusive Education (to Get over the Handicap of Hearing.) Dr. Toshinobu Obata, Honda Motor Co., Ltd
  • Update on the WHO’s Work on Healthcare Infrastructure, Facilities and Technology Dr. Andrei Issakov, World Health Organization
  • Current Development of Healthcare Architecture in China Dr. Huang Xi Qiu, Institute of Project Planning and Research
  • A Master in Architecture Course with Specialization in Architecture for Health in the University of the Philippines Prof. Prosperidad C. Luis, Luis and Associates
  • Recent Development of Healthcare Architecture in Malaysia – Reflecting the 50th Year of Independence Prof. Norwina M Nawawi, International Islamic University Malaysia
  • National Development Program of Hospital Premises in Finland Prof. Kari Reijula, Finnish Institute of Occupational Health
  • On the Edge – Zone between Urban and Hospital Domain Prof. Ruzica Bozovic-Stamenovic, National University of Singapore
  • What Do Clients Mean When They Ask for: Flexibility, Sustainability And Whole Life Costings Dr. Ann Noble, Ann Noble Architects
  • Special Lecture Prof. Yasushi Nagasawa, Kogakuin University
  • Proposed Center for Health Facilities Design and Testing Prof. David Allison, Clemson University
  • A Holistic Approach to the Perception of Healthcare Environments Dr. Sanja Durmisevic, Delft University of Technology
  • Healthcare in Sri Lanka after the Tsunami Ms. Junko Iwaya, Nightingale Associates


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