HEALTHCARE ARCHITECTURE:

HISTORY, EVOLUTION AND NEW VISIONS

Elza Maria Alves Costeira

Architect M. Sc PROARQ / FAU / UFRJ;
Researcher in the Department of Cultural Heritage of FIOCRUZ;
Researcher at the Centre for Urban State of Rio de Janeiro-OUERJ / UERJ
* ecosteira@uol.com.br

In recent decades emerged new concepts for the design of hospitals seeking to
bring their spaces the values that make patients feelings like they are in their homes, that
is architectural should incorporate to the building’s design the patient's vision and their
everyday representations. These concepts also propose the integration of healthcare
environments with outer space and incorporate in the areas of diagnosis and treatment a
number of assumptions that are considered as promoters of healing. Current research on
length of stay and the quality of care-client point to the emphasis of the humanization of
these environments in order to alleviate the suffering and anguish during
hospitalization, adding family life practices and personalization to spaces, involving
teams professionals and families as care partners in offers therapies to achieve the
desired cure.

However we have to go back in time so that we can understand the importance

of Health Environments and Architecture of a trader - Healthcare Architecture - have
been established, becoming increasingly critical to the deployment of new centers of
excellence in the attention health arising in our country.

We can say that the aspect of contemporary hospital is formatted between the
seventeenth and eighteenth centuries in Europe. The event cited as crucial to the change
of the old hospital structure, with unsanitary facilities, housing hundreds of grouped
sick, was the great fire of Hotel-Dieu in Paris in 1772. As this was an institution where
many patients were held, it was urgent its reconstruction or replacement. A commission
was established to evaluate architectural designs appropriate to the case, conducting
studies and researches to find a definitive solution to the hospital. This committee was
composed of nine members and was named by the Royal Academy of Sciences, from
the efforts of the Baron de Breteuil, the Royal House of Louis XVI. On this occasion
had highlighted the works of Doctor Tenon, a French surgeon, which analyzed several
hospitals in Europe, not only in order to describe their architecture, but also with a
critical eye, functionalist. He published in 1788, five reports gathered in a work name
"Memoires sur les hôpitaux of Paris."

With the Tenon "project", triumphs pavilion organization, as horizontal hospital

space. With the adoption of pavilions thus allowing cross ventilation and an excellent
natural lighting, Tenon believed to have solved what was considered the largest
producer of unhealthiness in hospitals: the stagnant air and moisture. He also made a
series of volumetric studies to establish the relationship between the dimensions of each
pavilion and the number of beds in wards, to ensure optimal minimum volume of air
renovated to each patient. Tenon also studied the optimal number of floors for each
pavilion, establishing three the optimal number of floors.

The technological importance of elements in the consolidation of this profile in

the nineteenth century were the development of anesthesia, aseptic practices and the
spread of the nursing profession, secular, in this case. Throughout the nineteenth
century came also the concern with ventilation and natural lighting in the projects of
healthcare buildings, from the so-called "theory of miasma", where the spread of disease
was attributed to the effluvia of emanation of matter originating in decomposition.

The discovery of the transmission of germs, in 1860, revolutionized the design

of hospital projects, isolating the disease and patients in specific pavilions. The work of
Louis Pasteur demonstrated the need to combat infection and disease transmission, with
the separation of patients and sterilization of medical devices. These principles,
isolation of pathologies, lead to a true revolution in healthcare design. The arrangement
and the composition of the architecture in multiple pavilions facilitate the development
of buildings and integration with your installation space, enabling the creation of
hospitals with size of cities blocks, and deployments resembled the small garden cities.

At this time the surgery is definitely incorporated to hospitals and, alongside the
rise of scientific medicine, the pavilion model and the specific functions of division to
the environments of healthcare, we can say that the contemporary hospital profile was
born.

We highlight also the studies of Florence Nightingale, who, from her experience
in the Crimean War (1853-1856), established bases for the construction of Nursing with
concepts of ventilation and distribution of patients, lighting and hygiene, which are
adopted until today by some institutions. The study of the physical conformation of the
wards, called "Nightingale wards”, set a new space model for the healthcare design,
with the most striking examples of hospitals designed with this feature. Notes on
Matters Affecting published the Health, Efficiency and Hospital Administration of the
British Army (1858- Notes on health, efficiency and hospital administration in the
British Army). The wards "Nightingale" wards served as a model for the
implementation of hospitals for many years, as best healthcare reference, from then to
the first decades of the twentieth century, and are still used until the present day, for
some concepts and structures designed with horizontal placement.

Thereafter, until the twentieth century, the hospitals were greatly incorporating
technology into their spaces, requiring in its planning an ever more acute, with facilities,
sophisticated building infrastructure and the ever-growing concern in sectorial spaces to
separate patients with various diseases and establish tight control flow and circulation to
the development of medical activities.

The trend of vertical buildings appears as early as the second half of the
nineteenth century, with the emergence of "skyscrapers" in Chicago. At the same time,
we observed an increase in the cost of urban land, the shortage of labor nursing, desire
to reduce the existing routes in pavilion hospitals and also the issue of inadequacy of the
long corridors of movement to the hard climate of North America. The enhancement
technologies construction, such as the use of metal structures, is the basis for the
establishment of the new typology in healthcare building. The use of lifts, optimized
circulation, the use of mechanical ventilation systems and facilities in building
infrastructure deployment determine the development of the verticality of the buildings.
So the “monobloc” hospital as called rises that later turns into multiple blocks vertical
structures, setting the remarkable typology of the twentieth century.

Along with the advances in construction technology, we have seen a major

change in the health care system and the patient's profile housed in hospitals. These
include the continuity of the Lister surgeon (XIX century), subsequently deepened by
Ernst von Bergman, the bases for the sterilization of instruments used today. Hospital
Surgical Center highlight its importance, while hospitals are now mostly used in
patients who did not have resources for home care, used by people with more financial
resources.

In the period between the two world wars, the hospital was just a one-piece
stacking wards "Nightingale". Its typical anatomy designed the underground to the
support services, the ground floor for offices and imaging services, the first X-ray
services. On the first floor was the administration, the intermediate floors,
hospitalization and last floor, the so-called Operating Room.

The freestanding hospital model can be seen as a medical symbol of triumph, for
his energetic way refers to advances in medical research. This typology modeling
various hospital structures of the twentieth century and moves into blocks juxtaposed
conformation positioned over a larger base, composed of technical floors. The
freestanding hospital works its physical structure, with the rationalization of assistance
functions and the compartmentalization of services, disease and complexity of care,
implementation of its floors and buildings. During the course of the twentieth century,
hospitals reach mixed conformations in physical structures, with plans designed for
expansion and the incorporation of new services and users, following the huge
development of medical science and the increase in clientele, adding people who, until
then not could access to these institutions.

History of Public Health in Brazil begins, effectively, in the late nineteenth

century and early twentieth century. However we cannot fail to mention the Holy Mercy
Homes that are the most typical Brazilian healthcare institutions in the country's
establishment as a nation. The Hospitals arrived in Brazil with the coming of the
missionaries of the Company of Jesus - known as Jesuits, in the sixteenth century. The
first Santa Casa was founded in Santos, in 1543, by the settler Braz Cubas. These
hospitals have a major role in healthcare settings in Brazil and have great influence on
the care of populations, with its institutions, usually erected in very old buildings,
serving as an object of study and reflection for public health and healthcare
environments.

The development of the Brazilian hospitals to be confused with the

establishment of government healthcare actions throughout our history. We highlight
here the initiatives of sanitarist medical-doctor Oswaldo Cruz, seeking the eradication of
plague, yellow fever and smallpox, establishing the creation of mosquito coils and mass
vaccination of the population, culminating in the "Vaccine Revolt" in Century threshold
XX.

Actions to provide a network of appropriate assistance for their demand

continued after the hygienist reform of Mayor Pereira Passos and doctor Oswaldo Cruz,
with the "Reform Pedro Ernesto". In 1930, with the installation of the Provisional
Government, delineate the great transformation that his administration brought to the
public health services, in Federal District. Pedro Ernesto, M.D., Federal Intervenor at
the Federal District formed a team to study the health problems and undertook the
construction of several dispensaries and Ready Aid, promoting a major transformation
in health issues and medical assistance throughout the Rio de Janeiro.

In the field of social welfare, President Getulio Vargas government also

introduced important changes. Next to the Retirement and Pension Funds (who came
from the 1920s), Institutes of Retirement and Pensions were created, state-controlled
bodies responsible for extending social rights to national categories of workers. During
the 1930s, were created Retirement and Pension Institutes in various categories like
industrialists, commerce, banking, civil servants etc. After 1945, the Institutes of
Retirement and Pension expanded their areas, which now include services in the area of
food, housing and health.

From there begins a period of major public building construction and other
specimens with much more complex programs, featuring the so-called Brazilian modern
architecture. These architectural structures used the concepts of modernity and points
recommended by Le Corbusier, who was three times in Brazil and became a reference
for architects at that time, to the shaping of hospital designs. We can cite examples of
Brazilian modern hospitals as the Maternity University of São Paulo (1944) by Rino
Levi, Porto Alegre Clinical Hospital (1955) by Jorge Machado Moreira or South
America Hospital today Hospital da Lagoa (1952) by Oscar Niemeyer .

Since the transfer of the federal capital to Brasilia and the creation of the State of
Guanabara, began a new administrative stage, bringing a lot of buzz for the health of
network management of Rio de Janeiro. On December 28, 1962, is created SUSEME
(Superintendência de Serviços Médicos - Sanitary Services Superintendence) by Law
No. 279, in order to manage the hospitals of the State of Guanabara. Several hospital
works began and unfinished buildings were completed, such as the expansion of the
Miguel Couto Hospital, the completion of expansion works at the Hospital Salgado
Filho and the emergency room of the Hospital Souza Aguiar. The SUSEME sought
cover the problem of the physical structures of the health network, implementing
several health centers, which belong, currently the municipal assistance in various
locations of the city of |Rio de Janeiro.

From the military coup of 1964, we witnessed in our country, the closing of all
employee participation channels in decisions and discussions around the system
pension. Against this background, there is a fusion of IAPs- Institutes of Retirement and
Pension- (IPASE), through Decree No. 72 of November, 21, 1966 establishing the
INPS- National Social Security Institute. In 1968 the government developed the
National Plan of Health- PNS- proposing, in short, the free choice of doctor system, the
customer, and the medical fees paid by the client-part that exercised the right of choice-
and part by Welfare system. In 1974 it approved the action-PPA- Ready Action Plan-
that, among other things, provides for the bureaucracy and the universalization of visits
to clinics and surgical emergencies, through Ordinance No. MPAS 158 of February,18,
1974. The impact this plan in the physical structures of health units is obvious, with
institutions experiencing a large increase in demand for services of this nature.

The hospital network in Rio de Janeiro, bigger and more costly for their
managers, is configured as one of the largest offerings of beds in health facilities, in
terms of installed capacity. However, their disjointed physical structure, scrapped and
inefficient, comes up against the problems arising from the coexistence of the various
levels of government of the city hospitals: the Federal, with units of the security and the
Ministry of Health, the State and the City, not forgetting university hospitals,
philanthropic and units of the private system. The period between the years 1980 to
1983 was known as the social security crisis. Regardless of the different cyclical and
previous crises, resulting from the model of its financing, health could not extend their
coverage to rural populations and the criticism of the system and the development of
new projects, seeking alternatives.

The implementation and the consolidation of a unified health system depended

on the new Federal Constitution, adopted and promulgated in 1988. The completion of
the molds of the new system- the Unified Health System (SUS) - was established from
the so-called Organic Health Law , Law No. 8080 of September, 19, 1990. There are
points, irrefutably, the decentralization of healthcare services. Its strongest guidelines,
indication of municipalization of healthcare, are in Chapter III, when determining the
role of each of the spheres of government to action with the Unified Health System
(SUS).

The new recommended model has a big impact on the physical layout of
healthcare units, requiring a new approach to the architecture of these institutions. The
search for a methodology for design and construction of health facilities points to the
need for compatibility between medical technology and diagnostic support and therapy
present in these structures and the humanization of their environments, promoting the
integrity of healthcare to all population segments, as mentioned in the Organic Law of
Health.
 The much-touted humanization of healthcare environments requires a deep
reflection of the architects in the design of hospitals that can provide more than just
technological spaces, adding to the concepts of environmental sustainability and
comfort structures and employing systems and construction techniques that can provide
more readable and environments cozy users.

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Published at SUSTINERE at http://www.e-publicacoes.uerj.br/index.php/sustinere Jul/Dec

2014