Nr 21: April 2013 - the International Academy of Design and Health

April 2013 | WORLD HEALTH DESIGNARCHITECTURE | CULTURE | TECHNOLOGY APRIL 2013BREAKINGBOUNDARIESFrank Gehry’s new Maggie’s Cancer CaringCentre offers hope in Hong KongVolume 6 Issue 2ALSO:World Congress Brisbane 2013 previewDesign & Health Asia Pacific 2013 reviewProject report: Mental HealthMarket report: Australasiawww.worldhealthdesign.com

PRELIMINARY PROGRAMME& CALL FOR REGISTRATIONAlan Dilani,SwedenRay Pentecost,USAKate Copeland,AustraliaIan Frazer,AustraliaKen Yeang,UK & MalaysiaYeunsook Lee,South KoreaGunther deGraeve, AustraliaEve Edelstein,USARobert Rust,AustraliaJohn Mcguire,AustraliaAlice Liang,CanadaStephen Verderber,USAIan Forbes,AustraliaKatie Wood,AustraliaJames Grose,AustraliaRahim Mohamad,MalaysiaAnthony Capon,AustraliaDebajyoti Pati,USAPaul Barach,AustraliaClare CooperMarcus, USAJan Golembiewski,Australia

Photo: Brisbane MarketingAn international forum for continuous dialoguebetween researchers and practitionerswww.designandhealth.com info@designandhealth.comARCHITECTURE | CULTURE | TECHNOLOGY

ContributorsIan FrazerA greater focus on science,research and innovationin the built environment isneeded to meet the healthchallenges of lifestyle andchronic diseaseIan ForbesA shortage of postoccupancyevaluationsmeans that architects &planners do not haveaccurate findings on healthbuilding performanceElsie ChoyWhilst the costs ofhealth infrastructureprojects and proposals arestraightforward to quantify,the resulting benefits areharder to valueDavid KampA salutogenic approachto landscape design canhelp to make the bridgebetween creating sustainableenvironments and a healthycommunity resourceAnthony R MawsonRetro-fitting car-centric, rundown retail shopping mallsin the US by redesigningthem as mixed-use villagescan stengthen communitiesand improve wellbeingARCHITECTURE | CULTURE | TECHNOLOGYDoes size matter?Historically, the role of hospitals has never been justabout performing medical treatment and providing care.From Europe to the Middle East to Africa and Asia, fromdemocracy to dictatorship, the hospital is also one of themost powerful political statements a government canmake. Even in the USA, where the role of government inhealthcare provision is limited, the commercial statementto the market steps in to sing the loudest song. But isbig necessarily best? As world governments struggle tomake ends meet, and technology drives healthcare intothe community, the opportunities for more integratedhealthcare models that drive down cost, improveaccessibility and promote early diagnosis and morepreventive measures of care are changing the shape ofhealthcare and the infrastructure needed to support it.In our review of the recent Design & Health Asia Pacific2013 International Symposium in Singapore, we reflecton the success of two small countries, Northern Irelandand Singapore in redesigning their health infrastructure(pp17-19). In Hong Kong, the small but beautiful MaggiesCentres are now making an impact internationally (pp20-21). Whilst the USA looks into retro-fitting run downlarge shopping malls into mixed-use villages (pp64-69).What will the future of healthcare infrastructurelook like? Join us in Brisbane at the Design& Health World Congress to explore thesethemes and others (pp 8-13).Cover ImageThe Maggie’s Cancer CaringCentre in Hong Kong,designed by Frank Gehry.See pp20-21Marc SansomEditorial directorwww.worldhealthdesign.com WORLD HEALTH DESIGN | April 2013 05

ContentsEditorial DirectorMarc Sansom MBAT: +44 (0) 1277 634 176E: marc@designandhealth.comAssociate EditorEmily Brooks30PresidentRay Pentecost III, DrPH, FAIA, FACHAT: +1 757 961 7881E: pentecost@designandhealth.comDirector GeneralAlan Dilani PhDT: +46 70 453 90 70E: dilani@designandhealth.comEditorial Advisory Board:Dr John Zeisel PhD, USADr Ray Pentecost DrPH, AIA, USADr Alan Dilani PhD, SwedenProf Jacqueline Vischer PhD CanadaDr Innocent Okpanum PhD, South AfricaDato Dr Abd Rahim bin Mohamad, MalaysiaProf Anthony Capon PhD, AustraliaProf Ihab Elzeyadi PhD USAProf David Allison, USAProf Ian Forbes, AustraliaJohn Wells-Thorpe, UKMark Johnson, USAMike Nightingale, UKContributing writersVeronica SimpsonSubscriptions and advertisingT: +44 (0) 1277 634 176E: WHD@designandhealth.comPublished by:The International Academy for Design and HealthPO Box 7196, 103 88 Stockholm, SwedenT: +46 70 453 90 70F: +46 8 745 00 02E: academy@designandhealth.comwww.designandhealth.comInternational Academy for Design and Health UK8 Weir Wynd, BillericayEssex CM12 9QG UKT: +44 (0) 1277 634 176F: +44 (0) 1277 634 041E: WHD@designandhealth.comDesign and production:Graphic Evidence Ltdwww.graphic-evidence.co.ukVolume 6 Number 2ISSN 1654-9694Subscriptions:To receive regular copies of World Health Designplease telephone +44 (0) 1277 634176 to place yourorder, or email WHD@designandhealth.comYearly subscription rates:1 year £80; 2 years £130; Single Issue £30World Health Design is published four times a year bythe International Academy for Design and HealthNo part of WHD may be reproduced or stored ina retrieval or transmitted in any form, electronic,mechanical or photocopying without prior writtenpermission of the Editorial DirectorPrinted in the UK byThe Magazine Printing Companyusing only paper from FSC/PEFC supplierswww.magprint.co.ukBRIEFING05LEADER COLUMN Does sizematter? Delivering care in thecommunity where it matters needs a newapproach to health infrastructure08CALL FOR SCIENCE Ahead of the9th Design & Health World Congress& Exhibition in Brisbane, some of Australia’sscientists and policy makers have their say10A FESTIVAL OF HEALTH Add valueto your visit to Brisbane with one ofthe many fringe events at the 9th Design &Heath World Congress13RE-ENERGISING HEALTH A call forsubmissions for the Academy’s excitingnew publication, a survey of Australasianhealthcare projects completed in 2000-201513OPINION15SO WHAT? Clients won’t do the rightthing just because it sounds plausible,says Dr Ray Pentecost – which is why ourresearch needs to be genuinely meaningfulEVENTS & AWARDS17ASIA PACIFIC 2013 REVIEW TheDesign & Health Asia Pacific 2013International Symposium in Singapore exploredhow to deliver more integrated healthcarePROJECTS20PLACEMAKER Maggie’s breaks theboundaries with Frank Gehry’s HongKong centre, an Asian-influenced building thatenshrines the charity’s caring philosophyMARKET REPORTS22REDESIGNING REHABILITATIONFor short-term users of mental healthservices, design can help assist recovery andbreak down stigma, writes Veronica Simpson30THE LEADING EDGE Australasiahas taken the best global philosophiesand fed them into an acute-care building boom.How will it harness its experience?06 April 2013 | WORLD HEALTH DESIGN www.worldhealthdesign.com

DESIGN SOLUTIONS4422PROJECTS Schmidt Hammer Lassen’s plansto extend Helsingborg Hospital in Sweden,and a Victorian storehouse reinvented as a newprivate facility54PRODUCTS Hermetically sealed louvreblinds, a new hoist ceiling track system, andBritplas’s Rapidvent, a secure opening window thatlets in more fresh airSCIENTIFIC REVIEW50BENCHMARKING FOR EVALUATION TOOLSAn alternative to post-occupancy evaluation: ashort-form evaluation tool developed by Sydney’s Universityof Technology that uses existing benchmarking data58AN ECONOMIC ASSESSMENT OF HEALTHCARECAPITAL INVESTMENT How New South WalesHealth in Australia calculates ‘cost versus health benefits’ forits potential infrastructure investments64RETROFITTING THE BUILT ENVIRONMENTHow can the US turn run-down retail spaces intohealth-promoting environments? This study proposes turningthem into mixed-use ‘villages’ that strengthen communities70HUMANISM IN OUR DESIGNED ENVIRONMENTSA salutogenic approach to landscape design bridgesthe gap between creating sustainable environments, and makingcommunity resources that improve individual wellbeing4464ARTS & CULTURE76GENUS LOCI American artist Carl Andre’s first UKshow for more than a decade has an appropriatelyminimalist setting in David Chipperfield’s Turner Gallery in Margate78THE REDISCOVERY OF THE WILD The lure ofuntamed nature seems ever more potent in ourincreasingly urbanised lives. A new book explores this theme,from the mountains of Montana to city zoos and aquariumswww.worldhealthdesign.com WORLD HEALTH DESIGN | April 2013 07

World Congress Brisbane 2013A call for scienceAhead of the 9th Design & Health World Congress in Brisbane in July, a leading scientistand two policy-makers from the region offer their take on the event, while overleaf, findout how a dynamic fringe programme can help add value to your congress experienceResearch to innovate: The official Patron of the 9th Design & Health World Congress, Prof Ian Frazer, calls for afocus on scientific endeavour to address today’s health challenges by improving the quality of our built environmentAs global society comes to terms with today’s keynote challenges of climate change and human health, investment inscience, research and innovation is ever more critical if we are to build a future for the next generation and their children.In the 20th century, great advances were made in medical science, enabling societyto reduce – and in many cases eradicate – infectious diseases that had plaguedmankind for centuries, dramatically increasing life expectancy around the world.In the 21st century, as increased lifespans and modern consumption-led lifestylescombine, we are faced with a new challenge and a major shift in the disease profile.Debated for the first time at the 66th meeting of the General Assembly of theUnited Nations in 2011, the health challenge in the modern age is non-communicablediseases (NCDs) or lifestyle diseases, which are now the leading cause of death inthe world, representing 63% of all annual fatalities and killing more than 36 millionpeople each year.Medical science alone cannot provide the solution to this huge challenge. Asscientists, politicians and practitioners, we must seek to collaborate across disciplinesin an effort to use science and research to maintain people’s health and preventthe onset of chronic diseases. Together with climate change, it is the most importantProf Ian Frazer AC, FRA, FAACEO and director of research,Translational Research Institute,Australiascientific question of our lifetime. We can diagnose many causes of sickness, butwhat are main causes of health? How do we maintain our health, independence andquality of life far into old age? How do we reduce the burden of cost on healthcaresystems and economies globally through the prevention of chronic disease?08 April 2013 | WORLD HEALTH DESIGN www.worldhealthdesign.com

World Congress Brisbane 2013The built environment and the way we design our cities and communities provides a context for civil society andhas a huge influence on our lifestyles and our health. We need more scientific endeavour into this fast developingfield of work to support the adoption of innovation in the physical environment that will both directly impactpeople’s health and wellbeing and facilitate them to lead healthier lifestyles.As the world undergoes an economic and demographic shift to the east, Australasia is at the forefront of anopportunity to demonstrate its leadership in the creation and application of scientific research that will build afuture society that is healthy, harmonious and economically and culturally progressive.We look forward to seeing the international community in Brisbane – a city of science and progress that is at theforefront of international efforts to create a healthy global society – for the 9th Design & Health World Congress& Exhibition in July.Prof Ian Frazer AC, FRA, FAA is chief executive officer and director of research at the Translational ResearchInstitute in Australia. In 2012 he was named a Companion of the Order of Australia for “eminent service tomedical research, particularly through leadership roles in the discovery of the human papilloma virus vaccineand its role in preventing cervical cancer, to higher education and as a supporter of charitable organizations”The HonourableJann Stuckey MP,Queensland Ministerfor TourismSize doesn’t matter: In his opening message at the 9th Design & Health WorldCongress in Brisbane, Lawrence Springborg MP, Queensland Minister forHealth, will focus on the need for an efficient and effective health serviceAround the world, health systems are under ever-increasing cost pressures.Demand for healthcare is rising exponentially due to population ageing and theshift in the profile of diseases from infectious to chronic. In terms of life expectancy,Australia is considered to be one of the healthiest nations in the world. But weare spending an increasing percentage of our GDP on hospitalisation and acutecare, with diminishing returns in the overall health of our people.In Queensland, as in many state and national governments around the world,the health budget is dominant, with over a third of staffing resources committedto providing healthcare. International health systems can no longer sustain thislevel of investment.Australians need encouragement to maintain and improve their health andwellbeing. In our quest for better preventative health measures, we must respondto evidence of what works and what does not. Dependency on hospitalisationand healthcare services must be reduced, but a repeat of failed measures is not the key to improved social participationor economic productivity. Queenslanders do not judge our health system by its size, but by health services deliveredeffectively, efficiently, with care and on time.Public investment in our health system needs to be re-engineered to extend its capacity beyond its current focus.Ways must be found to leverage governmentexpenditure and to bring new sources of capital andWelcome to BrisbaneQueensland is proud to host delegates from interstateand across the globe to this worldwide forum for theexchange of research findings concerning the interactionbetween design, health, science and culture. The businessevents market is worth almost AUS$700m a year toQueensland’s economy, and international events like thishave an important role in raising the state’s profile. The 9thDesign and Health World Congress & Exhibition joins acalendar of events which, for Brisbane, includes the British& Irish Lions Tour, Brisbane Festival, the QPAC InternationalSeries featuring the Bolshoi Ballet, and more. We lookforward to welcoming you to Queensland’s capital.The Honourable Lawrence SpringborgMP, Queensland Minister for Healthinvestment to support our health system.Our goal must be the creation of a healthy society,with an appropriate level of government resourcesdirected towards an efficient and effective healthsystem. My vision is to develop new collaborativemethods and partnerships, to make our healthsystem economically efficient and to achieve betterhealth outcomes for all Queenslanders.I invite researchers and practitioners to the 9thDesign & Health World Congress to learn aboutour ideas for Queensland and Australia, and to maketheir contribution to the development of a globalhealthcare system less dependent on hospital careand medical treatment, and more focused on health.www.worldhealthdesign.com WORLD HEALTH DESIGN | April 2013 09

World Congress Brisbane 2013A festival of healthA series of new activities on the fringe of the 9thDesign & Health World Congress in Brisbane willadd a new and healthy dimension to the eventFirmly established as the world’s foremost event promotingthe exchange of knowledge and research findings through aleading-edge scientific programme that attracts internationalexperts from across the globe, this year’s World Congress inBrisbane will reach new heights with the development of anumber of fringe activities in a festival and a celebration of design Make the most of the congress in Brisbane with fringe events, includinga pre-congress symposium and a programme of sponsored debatesand health.Sponsored by Aecom and supported by the Health InformaticsSociety of Australia and the Australasian College of Health ServiceManagement, the pre-congress symposium on Wednesday 10 July this year will apply a new format. Entitled Future HealthLab, the event will provide an interdisciplinary workshop on the future of global health and healthcare provision.Starting at 10am, four keynote speakers will deliver scenario papers on the following challenges facing the global healthsystem: a) Climate change and human health; b) Economic and financial challenges; c) NCDs and chronic diseases; andd) Social and health inequities and changing demographics. This will be followed by an interdisciplinary panel session,including an international architect, clinician, technologist and healthcare CEO, tasked with presenting their perspectiveson a series of hypothetical future health scenarios before a workshop explores how to address the problems identified.For the early bird, three sponsored breakfast symposiums, from 7.30-8.30am each day of the conference, will providefurther opportunities for interactive debate in an informal setting close to the main halls and supplemented by a healthybreakfast before the main programme starts at 8.45am.On Thursday 11 July, a Siemens-sponsored symposium will feature three international speakers debating issues arounddisease management, managed equipment services and green hospitals. On Friday 12 July, Arup will be sponsoring a roundtableevent debating ‘Are we designing the right healthcare infrastructure for future generations?’ And on Saturday 13 July, therole of science, research and innovation in healthcare infrastructure will be debated in an Aurecon-sponsored panel debate.More information will be available on these events and the speakers in May at http://events.designandhealth.com/events/wcdhStudent poster competitionStudents are invited to submit ideas on howsalutogenic design can improve health statusThe International Academy for Design & Health, in partnership with the AustralianGovernment State Health Departments, Australian Institute of Architects and collaboratinguniversities, invites students to explore new ideas on the planning and design of buildingtypologies that support the development of healthy environments. Students are requiredto research current issues concerning the promotion of health within their communityin one or more of the following four categories: a) Buildings; b) Industrial Design; c)Landscape; d) Interior Design.The focus of submissions should be on how salutogenic design can improve healthstatus in any public or social spaces such as healthcare, education, the workplace or in anurban setting. Participants should prepare a poster that illustrates their thought processand shows how their design supports the creation of a healthy environment for thecommunity, and an appreciation of the determinants of health and health promotion.Entrants are required to submit a digital copy of the poster and 400 words explainingthe background to the poster idea, including the objectives, the methodology, results andconclusions to awards@designandhealth.com by 15 June. All prize winners will receivecomplimentary entry to the 9th Design & Health World Congress and Gala Dinner, awinning certificate and the opportunity to display their poster.Full details of the submission requirements and prizes are available on page 48 andonline at http://events.designandhealth.com/events/wcdh10 April 2013 | WORLD HEALTH DESIGN www.worldhealthdesign.com

Dates with historyThe newly restored Brisbane City Hall will provide the perfect backdrop for the WelcomeReception and Academy Awards Gala Dinner to launch and complete the proceedings ofthe 9th Design & Health World CongressBuilt between 1920 and 1930, the heritage-listed Brisbane City Hallis seen as the heart of Brisbane and has been the backdrop to manycultural, social and civic events. On 6 April, 2013, the building wasreopened to the people of Queensland following an historic AUS$215mthree-year restoration and repair project that not only saved thebuilding and increased space for community use, but also ensuredit met with modern-day standards of sustainability and accessibility.On the evening of Wednesday 10 July, this celebrated buildingwill help to launch the 9th Design & Health World Congress& Exhibition in Brisbane when it hosts the Welcome Drinks andCocktail Reception, accompanied by a string quartet, and theprestigious launch of a new publication, Australasian HealthcareDesign 2000-2015 (see p13) to coincide with the congress.Following four days of international debate and networking on therole of design and architecture in improving human health, wellbeingand quality of life, the City Hall will then again provide the closingmemories of the World Congress on the evening of Saturday 13 July,when it hosts the Design & Health International Academy Awards,Gala Dinner and Closing Ceremony.Established as the leading advocacy programme in the worldrecognising professional excellence in the research and practiceof designing healthy built environments, the Academy Awardshave a significant influence on the design and development ofhumanistic environments that support health, wellbeing and qualityof life around the world. The judging panel consists of a group ofindependent experts from all continents of the world, includingEurope, Asia, Africa, Oceania and the Americas.The spendidly restored Brisbane City Hall will host thecongress’s opening and closing eventsRecipients of the awards will be teams and individuals who through outstanding efforts, have contributed to theprogress of knowledge and demonstrated vision and leadership in exemplary initiativeswithin the field.This year, the programme comprises 12 categories across the key areas of internationalhealth delivery. The final awards will be presented at a prestigious ceremony at Brisbane CityHall, and will reflect important aspects of the exceptional work undertaken by researchersand practitioners at the forefront of the field.Saturday night’s Academy Awards willrecognise excellence across 12 categoriesAwards sponsorshipSponsorship of the Design & Health Academy Awards 2013 provides organisations withexceptional profile raising internationally and alignment with design excellence in the awardcategories of their choice. For more information on sponsorship packages, contact e-mailinfo@designandhealth.comBooking your placeTo book your place at the Design & Health Gala Academy Awards Dinner and ClosingCeremony, visit www.designandhealth.com to register online or download the registrationform on the rear of the Preliminary Programme. Individual tickets are priced at AUS$150,with tables of 10 people available at a discounted price of AUS$1,000. Attendance at theWelcome Drinks and Cocktail Reception is complimentary with a registration for the 9thDesign & Health World Congress & Exhibition.www.worldhealthdesign.com WORLD HEALTH DESIGN | April 2013 11

World Congress Brisbane 2013Re-energising healthThe International Academy for Design & Health (IADH) andits Australasian partners are inviting project submissions for anew and exciting publication to be launched at the 9th Design& Health World Congress in Brisbane, from 10-14 JulyAllen LauAustralasian Healthcare Design 2000-2015 will review past,current and future projects and trends in healthcare designin Australia and New Zealand, providing a unique referencepublication for researchers and practitioners in the field of design andhealth, both in the region and internationally.The new book will be published by the IADH and edited by KateCopeland, immediate past president of the Australasian College ofHealth Service Management (ACHSM) and senior director of clinicalinfrastructure at the Health Infrastructure Branch within QueenslandHealth. It is being produced in collaboration with GovernmentState Health Departments and the Australasian partners of the 9thDesign & Health World Congress, which will be held in Brisbane from10-14 July, 2013. These include the Australian Institute of Architects,the ACHSM and the Health Informatics Society of Australia.Gold Coast’s Robina Hosiptal expansion, by BVN Donovan HillAustralasian Healthcare Design 2000-2015 will feature a collectionof 20 essays from prominent Australasian academics and practitioners on topics ranging from the trends in acute care,mental health and children’s health to issues such as health policy and practice, medical research, health technologyand workplace design. The new book will also provide aSponsorship opportunitiesThe publication is being entirely funded through the generosityof its sponsors, including Billard Lease Partnership, Lend Lease,Aecom, Destravis Group, Lyons, BVN Donovan Hill, HamesSharley, Conrad Gargett and Woodhead. It will be distributedon a complimentary basis to all federal and state governmenthealth departments in Australasia, and to all participants atthe 9th Design & Health World Congress. Opportunities tosponsor the publication are open until 24 May. To support itscollaborative spirit, there is a flat sponsorship fee of AUS$5,000.For more information on how to sponsor this unique publicationcontact: info@designandhealth.comSilver Thomas Hanley’s Sunshine Hospital Radiation Therapy Centrecomprehensive catalogue of all major projects deliveredduring the most remarkable period of capital investment inhealth infrastructure ever seen in the region.The publication will be provided on a complimentary basisto all federal and state health departments in Australasia,as well as to all delegates at the 9th Design & Health WorldCongress in Brisbane. Copies will also be available for saleduring and post the event.Who should submit?The publication is open to any Australasian or internationalorganisations in both the private and public sectors involvedon the design and/or delivery of a healthcare building inAustralia or New Zealand during the period 2000-2015.All submissions of projects will be considered forpublication in the project directory, if completed during theperiod of 2000-2015. An editorial decision will be madeas to which projects feature in the project review section,which will include lengthier descriptions and multiple images.There is no fee for publication.To submit a project, the Call for Projects must becompleted in full and sent together with a 750-word projectdescription and a selection of high-resolution images towhd@designandhealth.com no later than the extendeddeadline of 17 May. To download the Call for Projects andProject Submission Form, visit www.designandhealth.comwww.worldhealthdesign.com WORLD HEALTH DESIGN | April 2013 13

StandpointAfew years ago I was introduced to a particularly valuableaphorism, one that has shaped my thinking in nearly everyaspect of my personal and professional life to a significantdegree ever since. Peter Bardwell, FAIA, FACHA, the noted USarchitect currently serving as the president of the American Collegeof Healthcare Architects, pointed out to me the distinction betweenthe “what” and the “so what?” The “what” is simply an item on record– little more than a “congratulations”, suitable for framing, a trophywhose place is for show but not necessarily for significance. The “sowhat?” is why that item matters – its true value.In recent years I have caught myself applying the “what/so what?”litmus test to some of what the research community is producing, andit is not always clear to me that this isa test that has been seriously appliedby researchers to their own work.Make no mistake: I am genuinelyimpressed with any research effortthat seeks to discover something, toprove something, or to otherwiseconfirm for us a point that seemedworthy of the time and effortdevoted to the investigation. Butall too often researchers can getcaught up in the great sense ofaccomplishment at having provedsomething, without paying adequateattention to why it matters.In architecture and design, it isfrankly old news that environments,both natural and built, influence human health. Granted, we are all very curious about the subtleties of that influence,and indeed there is some excellent research going on that is clarifying and exposing some of those influences inways that are extraordinarily interesting and useful. But after the impact, or the “what,” is identified in research, arewe effectively asking “so what?” Does the designed environment generate a positive health impact that justifies itscost, for example? If an environment improves human learning or intellectual performance, by how much could itimprove standardised testing of students, and what difference would that make in international competitivenessamong students in a job market? How much does a design feature improve the health of occupants, and to what end:a reduced demand on the medical infrastructure? Again, at what cost?And are the answers to these questions intuitive, or themselves the results of meaningful, substantive research?My sense is that we must diligently pursue a compelling reason for doing design differently so as to enhance health,because there are not enough building owners willing to simply “do the right thing” because it sounds plausible. Theywill insist that there be some accompanying “so what?” research to justify the decision to do the right thing – andwhere applicable, incur the additional expense.Research must celebrate its “whats” withThere are not enoughbuilding owners willingto do the right thingSo what?It is not enough for research to show how the environmentshapes our health. We must also understand what the resultsmean in the real world, and use them as a tool to justify tothe value of a new approach, writes Ray Pentecostgenuine appreciation for the successfulachievement of rigorous research in and of itself,and for the meaningful insights that it yields. But theresearch community, and those who look to it forintellectual leadership, must be vigilant to maintaina sharp focus on the “so what?” of research. Maywe never be satisfied to continue to fill our trophycases with investigative “whats” without payingadequate attention to finding the compelling “sowhat?” impacts of those trophies.Dr Ray Pentecost III, DrPH, FAIA, FACHA, isthe president of the International Academy forDesign & Healthwww.worldhealthdesign.com WORLD HEALTH DESIGN | April 2013 15

Asia Pacific 2013 ReviewSmall is beautifulThe city state of Singapore has long been recognised for possessing a healthcare systemcomparable with any other country in the world in terms of both the quality of careand its affordability. Marc Sansom reports from Design & Health Asia Pacific 2013In 2000, Singapore’s healthcare system was ranked by the World Health Organisation as the best in Asia, ahead ofHong Kong and Japan, and the sixth best in the world, despite spending just 4% of GDP on healthcare comparedwith 10-12% in Europe and 18-20% in the USA.It is a testament to the country’s administration that almost every type of medical treatment is available at a veryhigh quality and at an affordable price, providing an ideal backdrop to the inaugural Design & Health Asia Pacific 2013International Symposium & Exhibition. Yet, as the demographic benefit of a large and youthful workforce enjoyed by theemerging tiger economies of Asia subsides, ageing populations and declining fertility rates, combined with rising publicexpectations and changing patterns of disease, most notably a rise on the level of lifestyle or non-communicable disease(NCDs), such as diabetes and obesity, are presenting new challenges in Singapore and across Asia.The recent announcement by the SingaporeGovernment that it plans to grow its population,principally through immigration to 6.9m by 2030 fromits current size of 5.2m, is one mechanism it believesis necessary to maintain a strong and productiveworkforce to pay for its ageing population.At the level of health policy, another mechanism is toshift the emphasis to a more salutogenic perspectiveby focusing on maintaining the health, wellness andindependence of its population long into old age, thusreducing the burden of cost on its healthcare system.Introducing the symposium, group chief executiveofficer of the event hosts, Alexandra Health and the2011 double Academy award-winning Khoo TeckPuat Hospital (KTPH), Mr Liak Teng Lit recognisesthat whilst the core role of the hospital will always be“the repair shop of medical treatment”, it also has aprominent leadership role to play in health promotion.As a great believer in the duty of the health Ng Teng Fong General Hospital and Jurong Community Hospitalprofessions to “walk the talk”, by leading healthylifestyles and providing their patients with role models,Liak was the visionary behind the inspiring KTPH, recognised internationally and at home for its health-promotingqualities. As the first speaker, chief executive officer, Mrs Chew Kwee Tiang expressed how every aspect of theKTPH from its design and construction to its service delivery was driven by a vision to: “Help our people live along and healthy life and support them with thoughtful and dignified care to the end.”She added: “The three concepts we followed in the design of the building are: placemaking to create spaces thatpromote people’s health, happiness and wellbeing; health promotion to design an environment that nudges peopleinto action that keeps them healthy; and community ownership. We recognised in the design the link between theenvironment and four outcomes: patient stress; staff stress; safety; and quality. The KTPH offers a patient-centricenvironment, that is ‘high-touch’, energy-efficient, and supportive of the healing process with natural light, greenery,good ventilation and quiet corners for patients and their families.“As its population expands to meet the government’s growth plans, the pressure on the health system andhospitals like the KTPH will become ever greater. And despite Singapore’s wider philosophy to focus on its people’shealth, it remains necessarily committed to significant investment in its health infrastructure.Tasked with delivering all healthcare facilities in Singapore, the MoH Holdings Health Infrastructure ProjectsDivision (HIP) is central to implementation of Singapore’s national healthcare delivery plan, as a repository ofwww.worldhealthdesign.com WORLD HEALTH DESIGN | April 2013 17

Asia Pacific 2013 ReviewSingapore’s public healthcare facilities, guidelines and knowledgemanagement. Dr Norman Wu, director, MoH Holdings HIP explainedhow this would mean a “doubling of the healthcare budget fromS$4 billion to S$8 billion over the next five years, resulting in moreaccessible and affordable healthcare, including a 30% increase inpublic acute hospital beds; a 100% increase in community hospitalbeds; and a doubling of capacity for long-term services.”Singapore has adopted an integrated care model that is seeingthe implementation of a more structured approach to investmentTop left: Liak Teng Lit, in its healthcare infrastructure and the redevelopment of its publicgroup ceo, Alexandra healthcare facilities, including its acute hospitals, community hospitals,Health. Top right: Chew nursing homes and polyclinics across its six healthcare clusters.Kwee Tiang, ceo, Khoo Set to open in 2014, the most advanced of these developmentsTeck Puat Hospital. Left: is the 700-bed Ng Teng Fong General Hospital and 400-bed JurongJohn Cole (left), deputy Community Hospital, which is being led by chief executive officerpermanent secretary at of Jurong Health Services, Mr Foo Hee Jug. Designed by CPGthe Department of Health, Consultants, the new hospitals will not only provide medical treatmentSocial Services and Public but will serve the health and wellness needs of its population ofSafety, Northern Ireland 900,000 residents, of which 7% or 63,000 are over the age of 65.Mr Foo says: “We aim to provide an integrated and seamlesscare experience for the community by working closely with careproviders in the community, aswell as non-healthcare community partners such as grassroots organisations, employers,educational institutions and sports groups to help the community stay healthy.”With the new hospitals located in a dense urban environment at the centre of the Jurong Lake District Masterplan,integrating the fundamentals of patient focus, care in the community, seamless integration of service delivery, futureproofing, integrated ICT with smart and green technology and emergency preparedness into the design of the hospitalswas the priority, explained Mr Foo. “Every time we were faced with a challenge, we tried to turn it into a patient benefit.For example, the design enables every patient to have their own window in naturally ventilated wards, with the planningdesigned to provide a restful environment, despite the noise of the urban setting.“Greening the hospitals was also a priority in an urban setting, with the installation of an outdoor ‘sunrise’ garden forambulatory patients and visitors; a specialist outpatient clinic therapy garden; a sky garden at every floor; and a communitywellness garden as a large public space with a health and fitness theme for hospital staff and the extended community.”As global health systems struggle with rising costs and expectations, few have been able to build a clear vision forhow to create a new and more efficient model that can deliver high quality healthcare at an affordable price. One healthsystem that has been able to make significant progress is Northern Ireland, which over the past two decades, has beenled by John Cole, deputy permanent secretary at the Department of Health, Social Services and Public Safety.With a population of 1.8m, Northern Ireland has the advantage of its health and social services being under the controlof a single government department, enabling better integration around the needs of patients and users. Faced with itsown funding challenges, the health system in Northern Ireland needs to make savings of 3.5% each year to break even.“Integration of services therefore”, explains Cole, “and a focus on preventing illness and improving health and wellbeingthrough a total system design approach became enshrined in a new Departmental policy document, called TransformingYour Care, in order to bridge the funding gap at the same time as improving the quality of care.“Central to the delivery of the plan” explained Cole, “isthe location of services in a mix of local health centres,community health centres, local hospitals, acute hospitalsand regional centres, with the movement of out-patientdiagnostics and treatments from acute to the community andof complex specialties to Centres of Excellence. The key issueis moving chronic disease management to the community andpreventing unnecessary hospitalisation.”As the USA and larger European countries struggle to meetthe financial and quality of care challenges posed in the 21stcentury, the examples of Northern Ireland and Singapore,are, on a smaller scale, providing vision and leadership in thereform of their health systems for future generations.Marc Sansom is editorial director of World Health DesignHealth leaders from Singapore, Malaysia, Qatar, Australia, South Africawww.worldhealthdesign.com WORLD HEALTH DESIGN | April 2013 19

PlacemakerBreaking theboundariesCancer charity Maggie’s has opened its first centre outside the UK – andthe success of Frank Gehry’s building in Hong Kong proves that the needfor a supportive, stress-free space for patients and carers is a universal one20 April 2013 | WORLD HEALTH DESIGN www.worldhealthdesign.com

Cancer care charity Maggie’s has for the first time opened one of its feted facilities outside of the UK.Maggie’s Hong Kong, which opened in March, continues the organisation’s use of world-renownedarchitects to design its centres, with Frank Gehry taking the reins for his second Maggie’s building (thefirst was in Dundee, completed a decade ago).Taking the form of a series of pavilions with steeply pitched roofs, set around an intimate garden, the building isrecognisably Asian in its appearance, and yet the core ideas that define every Maggie’s – the homely ‘kitchen table’around which people can gather, for example, or the strong connections made with nature – have been carriedthrough. “The building has feelings which I hope engender community activity, and that it’s comfortable for thepatients to be there,” said Gehry. “It’s respectful of Chinese architecture and motifs. I hope it’s not copying anythingChinese or architectural, but I hope it’s very respectful of them.”Maggie’s has in fact had a presence in Hong Kong since 2008, when an interim facility was set up in a temporarybuilding at Tuen Mun Hospital. The fact that more than 10,000 people with cancer, and 2,000 carers, visitedthe facility in 2011, demonstrates that the need for an emotionally supportive, practical and non-institutionalenvironment for patients is a universal one, irrespective of geographical boundaries.Gehry, meanwhile, had a particularly poignant message about his design: “I was going through the loss of adaughter while I was designing the Centre. I think you sort of suck it up and hope to make something that issoothing and respectful and hopeful. There’s always hope, it’s not a dead end.”David Millingtonwww.worldhealthdesign.com WORLD HEALTH DESIGN | April 2013 21

Market Report: Mental HealthRedesigningRehabilitationFor short-term users of mental health services, design can play a dramaticrole in breaking down stigma and assisting recovery. Veronica Simpson reportsThe power of architecture to both contain and sustain the long-term populations of mental health facilitieshas been amply demonstrated in recent years. There are now exemplary schemes around the world thatplace accommodation and treatment spaces around landscaped gardens or courtyards, providing ampledaylight, inspiring views, passive supervision and accessible outdoor spaces, all within an inherently secure setting.Just as challenging – and possibly more complex – is the design of short-term or occasional spaces for peoplein states of emotional crisis. Is it possible to create a sense of welcome, security and safety in a facility that isvisited for a day, an afternoon or just an hour? What more must a building do to communicate its intentions whenthose seeking help are doing so voluntarily? How can the design of these buildings attract those in greatest needof treatment or counselling, and facilitate their recovery while they are there?Emerging typologiesIn the last few years, a handful of new building typologies have emerged that attempt to address the wholespectrum of emotional needs of people at their most frightened and vulnerable. One of the most inspiring isthe South Essex Rape and Incest Crisis Centre (SERICC), based in the east London suburb of Thurrock. SERICCis one of the UK’s oldest charities for abused women, and when Sarah Featherstone, of Featherstone YoungThe South Essex Rape and Incest Crisis Centre (SERICC): Featherstone Young Architects’ shingle-clad ‘pods’ help soften the building’s external appearance22 April 2013 | WORLD HEALTH DESIGN www.worldhealthdesign.com

HELIX Forensic Psychiatry complex, Flemingsberg, SwedenArchitect: BSK ArkitekterClient: LocumCost: US$117mSize: 17,000sqmCompletion: 2012Landscape architecture Jonas Berglund, Nivå LandskapStructural engineer: ClaesHenrik Claesson, ELUConstruction: NCCThis new building for all of Stockholm’s regional psychiatric requirements– from healthcare to forensic psychiatry for sentenced violent offenders –marries optimum security with a calm, uplifting environment that takes fulladvantage of its hilltop forest setting. Rocky outcrops with pine trees betweenthe wards obscure the scale of the complex, while the hilltop position alsominimises the visual impact of the six-metre-high perimeter walls. The mainbuilding is arranged as two X-shapes, to optimise natural daylight and internalsightlines. The complex is organised with a focus on the communicationarteries (dedicated to either personnel, patients or visitors) thereby reducingthe number of secure passages and doors required. The healthcare spacesare substantially daylit, with generous ceiling heights and the use of highquality natural materials. Decorative textures and elements include a printedwindow pattern that acts as a screen, and a rippled concrete wall finish thatcontrasts beautifully with natural wood and coloured wall panels. The fourpatient wards per block are built around a ‘caretaker plaza’ where personnelcan meet and share knowledge. In this central space, patients are providedwith a variety of flexible activity and relaxation settings, with ample seating,window nooks, and forest views from every window.Max PlungerArchitects, was asked in 2005 to refurbish and extend the shabby, church-hall base from which SERICC operated, she wasstruck by the fact that there are “little or no historical precedents for buildings or environments [that] respond to this need”.In order to identify the appropriate spatial requirements, Featherstone and her colleagues conducted lengthy interviewswith SERICC staff and their clients – women aged 13 and over who have experienced sexual violence – to understand thenature of the charity’s work and how women feel when they visit the centre. The consultations resulted in an ‘emotionaldiagram’, which informed the design. “The first-time visitor has a very different experience than someone who’s been therefive or six times,” says Featherstone. “Initially, you don’t want to feel that there are lots of people watching you. You want tofeel quite cocooned.” But, as the visits continue and the client beginsto make progress, they become more open to forging links with othervisitors, and interacting with the wider environment: as Featherstoneputs it, “they come to feel a part of the family.”The design solution involved the building of a new first floor into theexisting, double-height hall. This floor is divided into two distinct butconnected areas, separated diagonally by a movable timber-clad ‘ribbonwall’, which acts as a bookshelf and further acoustic buffer betweenoffice and counselling rooms (the previous arrangement had twocounselling rooms leading directly off the office space, with almost noacoustic separation). On the office side, the atmosphere is light, brightand open, with flexible meeting and working spaces. The counsellingrooms have a quite different character, typified by oddly angled walls,strongly coloured upholstery and cosy nooks: quirky, shingle-cladwindow pods have been bolted on to the building, adding a fairytalequality to the exterior, and helping to break down the daunting aspectof the building’s approach – through the church graveyard. These podsalso make the counselling rooms feel cosy and contained.The clarity and charm with which this little building communicates SERICC’s cocooning counselling roomswww.worldhealthdesign.com WORLD HEALTH DESIGN | April 2013 23

its mission has won widespread support (as well as an RIBA award), but more importantly, it hasdramatically improved the circumstances of the women and children who visit, as well as thosewho work there. “When it opened, people responded immediately to it,” says SERICC director,Sheila Coates MBE. “Most of the women who come here have never seen anything like this – ithas no straight walls, and the pods are unique.They said it makes them feel special… Comingto a space like this makes them feel valued. I seethe effect it has on them when they enter ourspace. There is a feeling of safety and calmness– and a huge part of that [comes from] beingsomewhere that doesn’t look in any way like aninstitution.”Designing for the dispossessedFrom that groundbreaking beginning in2006, it appears that healthcare authoritieseverywhere are waking up to the power ofunorthodox designs in dealing with specificpatient groups. In Australia, New SouthWales (NSW) is undergoing something ofa revolution in its sub-acute mental healthprovision for Aboriginal or indigenous Australiandrug and alcohol addiction – a problem that apparently afflicts three times as many indigenousas non-indigenous Australians. The NSW Health executive believes that creating culturallyappropriate environments for Aboriginal service-users has the power to substantially enhance the effects of rehabilitationand therapy. A few new, dramatically different typologies have emerged to date, including the Bunjilwarra Koori YouthAlcohol and Drug Healing Service, by the Melbourne-based Vincent Chrisp Architects together with the New SouthWales Government Architects Office’s IndigenousDesign Unit. The 16-bed residential facility (patientsare expected to stay for between three and sixmonths) is all about unorthodox spaces.Set in bushland, the modern-looking buildingsare fragmented, typified by diagonal outlines ofcorrugated cladding. They reference the shape oficonic bush shelters, and are arranged around acentral fire-pit. The layout is inspired by traditionalindigenous community villages and enables residentsto weave multiple paths through and between thebuildings, developing their own relationships to thesurrounding landscape. Opportunities for informalgathering abound – in and around the shelters,in a covered decking area and also in the central‘cultural building’, which offers a unique, sacredspiritual healing space for up to 20 people.This ethnically and demographically specific,spiritually focused approach is also being explored– albeit for a far more privileged population – inStantec’s luxurious clinic aimed at treating the drugand alcohol addictions of Qatar’s affluent young(see case study). Stantec’s lead interior architect onthe project, Velimira Drummer, and her team werewell aware that only an environment that matchedthe opulence of wealthy young Qatari’s homescould even start to break down the stigma and fearBunjilwarra Koori Youth Alcohol and Drug Healing Service, a culturally appropriate mentalhealthfacility for the indigenous Australian population in New South WalesIs it possible to createa sense of welcome,security and safety ina facility that is visitedfor a day, an afternoonor just an hour?that rehabilitation may spark in these youngsters.But, more to the point, the centre – funded bythe state and intended as an exemplar project for24 April 2013 | WORLD HEALTH DESIGN www.worldhealthdesign.com

Market Report: Mental HealthRos KavanaghCherry Orchard Child and Adolescent Facility,Dublin, Republic of IrelandArchitect: Reddy Architecture + UrbanismClient: Health Service Executive Dublin Mid-LeinsterCost: €6.3m (£5.4m)Size: 3,500sqmCompletion: 2012Structural/civil engineer: O’Connor Sutton CroninQuantity Surveyor: O’Reilly Hyland Tierney + AssociatesMain Contractor: John G Burns LimitedThe new Linn Dara Child and Adolescent MentalHealth Facility at Cherry Orchard Hospital is one ofthe first physical manifestations of the Irish HealthService’s new Vision for Change mental healthprogramme, aimed at transforming both its buildingsand its care delivery into world class, user-centredand recovery-oriented facilities. Reddy Architecture+ Urbanism’s design, intended as an exemplar for thecountry’s mental health services, amalgamates severalexisting satellite departments into one site, providingservices for young people aged two to 18 years. Setin the parkland of South Dublin County, the building’sdesign was inspired by organic and plant forms, withthree storeys at varying heights to minimise bulkand massing. Two child and family community teams,an adolescent community team, an adolescent dayhospital, staff training department and administrationsupport services are accommodated in differentwings while providing staff interconnectivity througha shared, common and secure foyer.Key aspects include natural light and ventilation, highquality interior design and art installations, and visualand physical links with the outside – via green roofterraces, integrated winter gardens and courtyards,which provide safe havens or decompression zonesfor patients and staff. Each ‘wing’ has a discreet,dedicated entrance and individualised colour schemeinspired by specific plants.www.worldhealthdesign.com WORLD HEALTH DESIGN | April 2013 25

Market Report: Mental HealthLow Secure Unit, Northgate Hospital, Morpeth, UKClient: Laing O’Rourke/Northumberland, Tyne and Wear NHS TrustArchitect/lead consultant/landscape architect: Medical ArchitectureSize: 1,400sqmCost: £8mCompletion: 2013This new centre is for the long-term continuing care, treatmentand rehabilitation for men with learning disabilities, and those withdevelopmental issues that can pose a threat to public safety. Thebrief was to provide first-class accommodation comprising: single,en-suite bedrooms; increased therapy and activity spaces; andbetter external space for service users and better facilities for staff.Following consultations with all stakeholders, the NHS Trust felt thatsmaller accommodation clusters would improve care and treatmentfor the service users, many of whom have impaired social skills andstruggle to cope on larger wards. The new building comprises twoaccommodation wings with a central element linking them. Eachwing is made up of four six-bedroomed flats in two identical squareblocks, with a central shared patient space (in addition to the flat’sown communal space) combined with entrance and staff facilities.Connected to the ward wings via glazed links, the central elementtakes the form of a substantially glazed pavilion, providing viewson to the external landscaping. Timber elements wrap around thebuilding, with vertical timber posts screening external staircases toprovide privacy and permeability of views, as well as enhancing thenon-institutional exterior presentation of the building.Jill Tate+ Urbanism’s Cherry Orchard Child and AdolescentFacility (see case study) is one of the first facilities toexemplify a new direction.Located just outside Dublin, the facility is notat all what its visitors or clients would expect.There is barely a straight line in the building, whichis inspired by organic forms and vivid colours thatecho the tree-filled parkland around it. Says Healy:“We were inspired by the idea of the Teddy Bear’sPicnic – you know the song lyrics: ‘If you go downto the woods today, you’re sure of a big surprise.’This is a pleasant surprise for everyone who comeshere. For the children, they see this and think: ‘Thislooks interesting.’” But it’s not just children who enjoythese unusual spaces. “The lead psychiatric consultanthas said that everybody is intrigued by the building,particularly how soft it is. There are no sharp corners.People are constantly being drawn into it.” Healy saysthat the positive response to this building has been“far greater than we expected”.In making large institutions feel non-institutional,form, finishes and detailing can do much to breakdown the clinical atmosphere, but so can strategicseparations of pathways – for staff, patients andvisitors – by facilitating as much openness andcollaborative exchange as possible. Swedish practiceBSK Arkitekter has come up with a fascinating newmodel in designing the HELIX Forensic Psychiatrycomplex just outside Stockholm (see case study).While security is a priority, key details ensure that isisn’t intimidating. With a large, glazed public entrance,visitors enter through a standard – not high-security– glazed doorway with the receptionist visible fromacross the paved approach; security doorwaysare placed beyond reception. Staff have their owncopper doorway, leading to a bright, welcomingatrium entrance that provides ample daylight andviews in to the adjacent administration block, while acafeteria, conference rooms and gym enhance socialnetworking and cross-disciplinary co-operation.For anyone still questioning the value of carefullyconsidered, emotionally intelligent design for mentalhealth service users, workers or facilitators, SERICC’sSheila Coates now has six years’ worth of observationto add to the cause. The calming, non-institutionalspace “enables the counselling to proceed in avery positive way,” she says. And the quality of theirbuilding has also benefitted their relationship withpartner agencies: “It enables them to take us moreseriously. They see us as a proper organisation. So ithas had a definite impact on promoting what we do.”In a field still hampered by stigma and taboo, suchbenefits are priceless.Veronica Simpson is an architectural writerwww.worldhealthdesign.com WORLD HEALTH DESIGN | April 2013 29

Market Report: AustralasiaThe leading EdgeWith its remarkable period of capital investment startingto slow, Australasia is assessing the progressive healthcarefacilities it has created, and working out how to build onexcellence for the years ahead, writes Emily BrooksAustralia delivered a world first in preventative healthcare last December when itswitched to ‘plain packs’ of cigarettes. In fact they are far from plain, their uniformolive-green boxes framing a selection of grim warning and gruesome images –this is design as a blunt instrument.The World Health Organization praised this audacious stab at the improvement ofpublic health; Australia seemed to have reached the next level of the game. New Zealandannounced in February that it plans to follow suit (it already has some of the strictesttobacco controls in the world, and has pledged to be completely tobacco-free by 2025).This sort of pioneering thinking around health is mirrored is Australia’s recenthealthcare building spree, the result of increased demand coupled with the need torefresh worn-out facilities, many of which were built during the post second world warpopulation boom. As a result of this generational renewal of health assets, some internationally recognised facilities are at ornearing completion, including the Royal Children’s Hospital in Melbourne, Western Australia’s Fiona Stanley Hospital, GoldCoast University Hospital and Queensland Children’s Hospital (see case study).Despite – or perhaps because of – the region’s relative remoteness from the rest of the world, Australasia seems tohave been able to cherry-pick the best of healthcare design ideas. “Australians are quite good at learning from the world,”says Ron Billard, director of Billard Leece Parnership (BLP). He says of the firm’s research for the Royal Children’s Hospital,designed in conjunction with Bates Smart Architects, “we did a tour five or six years ago of all the hospitals at the time, andwe’ve done a few since. And we were surprised to find that people in America hadn’t been across to see what Europe wasdoing, and surprised to see that people in Europe hadn’t been across to see what America was doing.”30 April 2013 | WORLD HEALTH DESIGN www.worldhealthdesign.com

Architects: Jackson ArchitectureClient: Austin HealthCost: AUS$195m (£134m)Size: 25,000sqmProject completion date:June 2012 (stages 1 and 2a); mid-2013 (stage 2b)Main contractor: Leighton Contractors Pty LtdOlivia Newton-John Cancer & Wellness Centre,Heidelberg, Victoria, AustraliaThe Austin Hospital has a long history of cancer treatment,and was by 1935 the largest cancer hospital in Australia.Today, following a fundraising campaign spearheaded bymuch-loved actress (and breast-cancer survivor) OliviaNewton John, Austin Health can offer one of the mostinnovative cancer centres in the country. The brief was fora ‘feelgood’ experience for patients, with natural light andopen spaces, typified by alternative treatment areas suchas the oncology day room, with its a huge bay windowsoverlooking a magnificent mature tree.The emphasis on ‘wellness’ was a key part of the brief,with emotional, social and spiritual support seen as vitalfunctions alongside clinical treatment. The 1917 Zeltner Hall– originally a recital hall for patients – is now a dedicatedwellness centre, a domestic-looking education and socialspace with a verandah overlooking a landscaped courtyard.The facility is being completed in three stages to coincidewith funding availability, with the radiation oncology structure(four bunkers), ambulatory oncology unit and wellnessareas among the spaces already completed. The final stage,due to open mid 2013, will see the opening of shell-stageresearch areas and the addition of 92 inpatient ward beds(64 acute oncology beds and 28 palliative care beds), plusadministration and clinical trials areas. Layout and wayfindinghave been devised not only to be intuitive for patients, butwith a translational remit, for better connectivity betweenresearch and clinical spaces. As Jackson Architecturedescribes it, the aim was for “an overall impression ofopenness to encourage staff to enlighten each other, soavoiding the desperate ‘territoriality’ of departmentsgenerally apparent in most large Australian hospitals.”www.worldhealthdesign.com WORLD HEALTH DESIGN | April 2013 31

Gunther De Graeve, managing director of strategic consultants Destravis, says that “in the last roundof major hospital development in the late 1990s and early 2000s, Australia did start to look outside, but Ithink it missed a lot of new trends. This time, they’re really being understood.” He thinks that Australia haspicked up on “two very identifiable trends”, firstly, the evidence-based design largely coming out of northAmerica – “natural light and greenery are the obvious ones, but we’realso starting to look at evidence relating to certain flow optimisations,and on sound and acoustics” – and the more experimental approachPeople comefrom manycountries, andthey all bringsomethingwith themcoming from northern Europe, in particular Scandinavia and theNetherlands. “The Dutch hospitals are based on simplicity and greatfunctionality combined,” he continues. “And the Scandinavians havepulled that off as well – but what we also learned from them is howthey integrate their health with their communities; how they make itpart of the existing texture of the cities.”A sense of placeThis distillation of ideas has as much to do with the talent flowing into Australasia as a willingness to look outside. “Our [building] wave hascome a bit after the European and American wave. Key personnel are now moving across and bringing theirknowledge with them,” says BLP’s director Mark Mitchell, adding that this doesn’t just include the design side,but construction giants such as Skanska. Woods Bagot’s project director Douglas Roxburgh likens the talentpool to “a crucible”. He says that “some new models of care – for example, the combination of services withindepartments, like when a patient receives a scan and operation sequentially, in the same room – have beenquick to develop, partly because of the international population that is modern Australia, both on the medicaland design side. People come from many countries, and they bring something with them.”So, if Australasia is writing a new language of healthcare design, what exactly defines it? Many architectspoint to facilities’ unique sense of place – not just echoing the generic geography of a region but a building’sexact surroundings. This particularly refers to the way they reflect and respond to nature; Australia is blessedwith a good climate and abundant natural beauty, so it is not hard to see why this has come about.At Mackay Base Hospital in Queensland, Woods Bagot and BLP’s redevelopment scheme (see case study)sees the orientation redirected towards the adjacent Pioneer River. “There’s a culture and history specific to thisarea, and it’s different to the culture that might exist in Brisbane, or in Cairns – every small centre is incrediblyproud of its heritage of the last 150 years,” says Roxburgh. “Communities feel a need that the building shouldJon Linkins32 April 2013 | WORLD HEALTH DESIGN www.worldhealthdesign.com

Market Report: Australasiaexpress their particular environment,and we went out of our way in theearly design stages to try and bring inthe colours and contrasts that we tookfrom the area.”Gunther De Graeve says Australasianarchitects are also particularly adeptat following through with the qualityof their buildings, inside and out.“Ten years ago, internal planning wasone thing, and the architecture ofthe building was another, but we’vebecome aware that the two need toblend in so strongly with each other.Architects have started to show aninterest in the clinical rooms, and tryingTony MillerBillard Leece Partnership’s just-completed AUS$55mRegional Integrated Cancer Centre in Ballarat, Victoriato lift up the design of those” – he cites BVN’s Robina Hospital in Queensland, where the operating theatresfeature wall-to-wall landscape photography – “but it’s not just those things, it’s the patient spaces, the staffspaces. Before, it might have had a shiny facade, but on the inside in was just a dull hospital, very institutional.”Making hospitals feel less institutional is at the heart of many projects, together with a desire to createbuildings that sit at the heart of the communities they serve. “We are seeing hospitals starting to reclaimtheir role as important symbolic and civic touchstones within our communities,” says Corbett Lyon, LyonsArchitecture’s global director, health projects. “We are also seeing hospitals playing a more direct role insupporting health and many new hospital designs are ‘opening out’ to re-engage with the communities theyserve. Hospital design is again being looked at in the same way that we think about libraries, courthouses,town halls and other public buildings that give our communities a sense of place and meaning.”Knitting in to the urban fabricAt Ballarat in Victoria, BLP has just completed a AUS$55m integrated cancer centre, part of a widermasterplan for the city’s regional hospital. “We’ve tried to make a very approachable and caring environmentfor people who have cancer, and their carers,” says Ron Billard. Striking as it is – a five-storey glazed towerrising up next to a red-brick 1920s hospital building – the fact that it sits at the heart of the urban fabricCentral Queensland University Health Clinic, Rockhampton, Queensland, AustraliaSome 400 miles north of Brisbane, Rockhampton is the home of Central Queensland University’slargest campus; this new clinic, opened in 2012, is the campus’s first public building, a space intendedto welcome patients as well as provide an education and training hub for students. Its facilities includeboth specialist and generic consultation rooms for disciplines such as podiatry, occupational therapyand speech pathology; several gyms, for exercise physiology; an orthotic lab; and an activities of dailyliving (ADL) space where patients recovering from strokes, for example, use a kitchen and bathroomspace to relearn everyday activities.The building rests beautifully within its bushland setting. Architect Emma Healy of Reddog Architectsexplains that it “sits between two landscapes; to the south-east a protected landscape of wild eucalyptusand marshlands, to the north-west a sister landscape of curated angophoras on a lawn. The clinic takesadvantage of the former enshrined green outlook by locating significant clinical functions on thisedge so that patients benefit most from the context.” A facade of gold and yellow undulating verticalelements echoes the shape of the trees but is bright enough to act as a beacon for patients, while awall of cream, white and yellow brickwork makes reference to “the mottled eucalyptus bark and thedappled shadows cast by their canopy”.The healing potential of gardens and landscapes became a key part of Reddog’s approach to thelayout, with the best views being given over to the clinicalareas; open-ended corridors keep a constant connectionto the outside world, and there are skylights and clerestorywindows to let in even more light. Healy says that thebuilding was “conceived from the inside out”.Architect: Reddog ArchitectsClient: Central Queensland University/Queensland HealthCost: AUS$6m (£4.1m)Completion: 2012www.worldhealthdesign.com WORLD HEALTH DESIGN | April 2013 33

Market Report: AustralasiaBuilt in 1917, Zeltner Hall now acts as a non-clinical wellness centre for the Olivia Newton-John Cancer Centre, VictoriaMany newhospital designsare ‘opening out’to re-engage withthe communitiesthey serveis important, its central location somehow helping to soften any feelings of anxiety in a way thatdriving up to a large out-of-town facility could never do. The red-brick building, once the outpatientbuilding, is now a drop-in cancer advice and wellness centre, with its own separate entrance, “whereyou can can walk off the main street, almost like disappearing into a shop,” but linked to the lightfilledcentral atrium of the new building at the rear.Jackson Architecture’s Olivia Newton-John Cancer Centre in the Melbourne suburb of Heidelberg(the final phase of which is approaching completion) also features the conversion of an historicbuilding into a non-clinical wellness centre, separate but linked to the main hospital. In this instancethe historic building is the 1917 Zeltner Hall, originally a recital hall for patients. The analogieswith the UK’s Maggie’s Centres are obvious, in its domesticity – there is a kitchen, and a kitchentable for gathering, plus sofas and armchairs – and its contact with nature outside, in this case alarge courtyard garden. The emphasis is on whole-body ‘wellness’, not just disease treatment, withthe provision of complementary therapies to work in tandem with clinicaltreatment. The clinical building also wraps around the restorative courtyardspace, and inside the layout and interiors work hard to create a welcomingnon-insitutional feel, with domestic touches such as pendant lighting, bambooand carpeted flooring, and timber panelling.Brisbane’s Reddog Architects cite Maggie’s as an influence (specifically,OMA’s Gartnavel centre in Scotland) on the design of its first healthcarebuilding. It’s not a cancer centre, however, but a clinic on the campus of CentralQueensland University (CQU), a building for local patients and a trainingground for students of occupational therapy, physiology, podiatry, nutritionand more. As the first-time designer of a healthcare building, architect EmmaHealy says that “the most significant challenge was overcoming the restrictionsimposed by the medical and institutional standards to generate a building thatfelt welcoming and relaxed. With a fairly restricted internal palette of resilientfloor finishes, smooth white walls and ceiling tiles, careful colour selection andthe strategic placement of openings was our primary tactic.”Looking for talentBy attracting students to its state-of-the-art new clinic, CQU and Queensland Health hope that students will be morelikely to stay in the area for the rest of the working lives. Creating appealing settings for staff is a recurring theme,especially in Queensland, whose population is set to rise and whose northern reaches are some of the remotestparts of the country. Mackay Base Hospital for example, is creating a “staff retreat” as part of its redevelopment,comparable with a business-class airport lounge, with food and beverage stations, a gym, overnight accommodationand a large barbecue-equipped deck with river and mountain views.www.worldhealthdesign.com WORLD HEALTH DESIGN | April 2013 35

Market Report: AustralasiaRon Billard says that the federal decision to direct funding into regional hospitals has as much to dowith keeping those smaller urban centres economically viable as it has with creating a convenient localbase for patients. “In towns like Ballarat or Wagga Wagga, with populations of around 50-80,000 people,the biggest employer tends to be the hospital, and they are at risk of losing employment opportunities ifall the medical stuff gets centred in the capital cities. So there has been a trend, just in the last five yearsor so, of reinvesting in town hospitals to make them centres of employment and attract professionalsand specialists. I think it’s a really important initiative.”GP Super Clinics are also concerned with creating fulfilling employment opportunities away frommajor city hospitals. An AUS$650m federal initiative, they are intended to strengthen primary careand keep patients out of hospital, bringing together GPs, practice nurses, allied health professionalsand other healthcare providers (which could be public or private, such as dentists) to deliver servicesat a local level. The model of continuous care, and the sense of being at the heart of a community, isalso an attractive option for staff; as Ron Billard says, “It’s trying to say to doctors, you don’t have to goto a big hospital to have a good career.” BLP has designed a numberof these clinics; its 1,500sqm Kardinia Health Super Clinic in Geelong,Victoria, belies its size with courtyards and broken-up waiting areas,demonstrating that even in smaller healthcare buildings the desire isthere to make things ‘human scale’.In New Zealand, the equivalent is the Integrated Family HealthCentre (IFHC), which have the same integrated, multi-disciplinaryapproach. “It’s primarily about private investment in public health,” saysDarryl Carey, director at Chow:Hill and chair of the New ZealandHealth Design Council. “The Ministry of Health is encouraging localbusinesses and health providers to invest in primary and communityservices, helping that to happen by providing some seed money, and byfunding expertise and consultancy work to get them off the ground. Sowe’re part of a consortia that a local group can call upon to provideadvice and scoping, to get a project up and running.”One such project is Te Whareora O Tikipunga IFHC in Whangerei,opened at the beginning of April. The facility is culturally supportive toBallarat Regional Integrated Cancer Centre,Ballarat, Victoria, AustraliaThis cancer centre follows a trend for remodelling Australia’s regionalhospitals, to attract staff where there would otherwise be feweropportunities, as well as cope with increased demand for services.The new centre consists of a refurbished red-brick 1920s buildingabutting a sharply contrasting glazed five-storey structure.The four radiotherapy bunkers (two for use straight away, theother two for when demand increases) have been placed on theground floor of the new building, balanced by a light-filled atrium atthe entrance, with lots of timber used in the bunkers to soften thespace. “Due to their technical nature, cancer centres often requirelarge blank walls, whereas other areas need big sweeping views, soit was about trying to balance those in the urban grain,” says BLP’sdirector Mark Mitchell. The hospital is on a hill, and the oncology unit,one level up, enjoys views across Victorian Ballarat.The 1920s building, formerly the outpatients, is now a drop-inwellness centre for patients and their families. It has its own entranceoff the street, but it links to the main atrium at its rear.Tony MillerArchitect: Billard Leece PartnershipClient: Department of Health/Ballarat HealthCost: AUS$55m (£38m)Size: 8,500sqmCompleted: 2013www.worldhealthdesign.com WORLD HEALTH DESIGN | April 2013 37

Market Report: Australasialocal Maori and Pacific families, with a large room atthe front of the building for whanau (extended family),who can be present during the consultation. It istypical of a more enlightened approach to healthcarefor indigenous populations. Life expectancy is 16-17years less for indigenous Australians, and closing thisgap is a federal priority. Healthcare settings whereindigenous people feel better understood are playingtheir part. At Mackay Base Hospital, says DouglasRoxburgh, “it was important to ensure that the localindigenous population was considered equally withall other local populations. This is particularly evidentin the mortuary, which has an external courtyardgarden, to allow for the usual processes of death tobe observed by all members of the community.” (InAboriginal culture, the deceased are laid out in theopen, rather than placed in an enclosed space.)Striving for world-classAustralasian healthcare design is characterised by astrong innovative streak. At Queensland Children’sHospital, there will be a new “no wait” triage system inthe emergency department with patients immediatelysplit in to four groups depending on need; also new isan interlinked ‘pod’ concept for the ICU that CorbettLyon describes as “enclosed ‘roomicles’ rather thanthe traditional open-bay cubicle. This gives betterMackay Base Hospital Redevelopment,Mackay, Queensland, AustraliaMackay Base Hospital is nearing the end of a threestageprogramme of upgrading that will see themajor consolidation and expansion of its campus,with the number of beds rising from 120 to 320.The five years it will have taken to complete theworks reflects the complex logistics involved whena hospital needs to remain operationally activethroughout.The remodelling has made many hospital buildingsmuch more visually engaged with the adjacentPioneer River, with inpatient wards shifted so thatthey enjoy river views. The sub-tropical climate –high temperatures, and high levels of rainfall – hashad a “pivotal impact on the look of the building,Architects: Woods Bagot andBillard Leece PartnershipClient: Queensland HealthCost: AUD$407m (£280m)Size: 40,000sqmCompletion: Late 2013and the specification of roofs, facades and structure,” according to Woods Bagot’s Douglas Roxburgh.“There are also lots of external spaces to provide shading, both for staff and patients, and to reduceheat loads on the windows.” Earthquake-proofing and the need for a core part of the hospital to stillbe operational in the face of a natural disaster such as a cyclone further complicated the brief.Regional Queensland’s population is expected to grow in the next 25-50 years, so a capability forexpansion was critical. “We made provision for something like 30% over and above the current floorarea and parking capacity. It means that the structure is designed so that it can be built on top of,or extended to the side, or that it can be refitted or reorganised entirely,” says Roxburgh; some ofthese expansion plans have in fact already been implemented. Providing an environment to attractand retain staff in this remote part of the country is a priority for Queensland Health; accordingly,the hospital’s “staff retreat” is a high-quality space with dedicated food and beverage areas, relaxationspaces, overnight accommodation, a gym, and external balconies with river views.www.worldhealthdesign.com WORLD HEALTH DESIGN | April 2013 39

Australia nowhas somethingtangible to offer interms of the globaldebate abouthealthcare designprivacy for patients and families but also allows the walls to be folded backto provide a single contiguous treatment area.” There will also be a ‘long daylounge’, a breakout space that caters to families who have appointmentsthat unavoidably spread across the day.In New Zealand, the rebuilding of Christchurch’s two hospitals following2011’s eathquake is highly anticipated. Chow:Hill has been involved in thepreparation of the business case, approved by government in February,and is now in the process of finalising conceptual design work while theprocurement of the project teams occurs for both projects. “The DHB[district health board] is very determined to achieve an innovative solution,not just a standard solution,” says Darryl Carey. “For about six months it hashad clinical and design teams working on what it’s calling a ‘design lab’ – effectively a great big warehouse, withcardboard walls that we can move around to simulate different environments. We’re working with users to workout optimal options for inpatient design, and trying some really innovative ward design.”Corbett Lyon says that the culture of innovation in Australia has much to do with having enlightened clients.“Hospitals have traditionally been an architectural type that has been very resistant to change – so this confluenceof clients looking for innovation and architects and designers who are able to bring informed creative thinking to theprocess has been a unique feature of this period.” There are concerns, however, that the rise of PPP as a procurementmethod may dampen this spirit, because of the way it minimises any level of risk. De Graeve distinguishes betweenattitudes before and after the financial crisis: “Before, PPPs were very much focused on the comparative designbeing the basic deliverables, and then people were competing on anything over and above that – value added – butnow the attention has shifted towards value for money, and it becomes a price offering solely.” He feels that as aresult, truly landmark projects like the Royal Children’s Hospital could not happen again. Queensland’s SunshineCoast University Hospital is the currently the most high-profile PPP in Australia, a AUS$1.98bn tertiary teachinghospital that will be built on a greenfield site north of Brisbane. Architectus Brisbane and Rice Daubney Architectshave partnered with Lend Lease to deliver the hospital in late 2016, with a masterplan by Conrad Gargett Riddel.What next?The Australian building boom – at least when it comes to acute facilities – is winding down, and it is time to lookahead. Architects have a decade of experience and expertise to draw on, and there are hints that that expertisecould be ripe for export. The UK’s NHS recently looked to Flinders Medical Centre, a public teaching hospital inAdelaide, when it wanted to learn lessons about Lean thinking to improve quality, safety and throughput. BLP is40 April 2013 | WORLD HEALTH DESIGN www.worldhealthdesign.com

Market Report: Australasiabidding for a job in Hong Kong and sees a future inpartnering with architects in Asia to design hospitalsthere.“We have made an enormous capital investmenthere over the last five to 10 years, evidenced bynew hospitals designed using these new approachesand new thinking; putting patients at the centre,and designing environments to support health andwellness,” says Corbett Lyon. “Many of these newfacilities are already being looked at by serviceproviders, clinicians and researchers from othercountries. There is no doubt that Australia now hassomething tangible to offer in terms of the currentglobal conversation about healthcare design.” July’s9th Design & Health World Congress, to be held inBrisbane, will offer a perfect platform.Sunshine Coast University Hospital – Australasia’s biggest PPP health projectFinance is, as ever, the biggest challenge, in NewZealand even more so than Australia. “The challengefor us is to provide buildings that can support the delivery of the growing expectations of health services against increasinglyconstrained budgets – providing for appropriate levels of care that relate to need,” says Conrad Gargett Riddel’s Bruce Wolfe.Recent reform means that internal funding for health is now awarded based on efficiency, rather than number of beds, whichhas quickly shifted the focus on to how to design facilities with better throughput.The debate will move from acute to sub-acute facilities (“We’ve done absolutely nothing about it; it’s the elephant in theroom,” says De Graeve), and even away from hospitals altogether. With such a scattered population and scarce resources,the region must look to more home-based services, and strengthen its focus on health promotion.“We have the hospitals incontrol; the bit that’s out of control is everything else,” says De Graeve. “Australia has a beautiful, open, natural environment,but in our planning we are not embracing that. Our cities are not walkable. We could be the healthiest nation on the planetbecause of our climate, but we have turned our back on that opportunity. Our planning and health departments need to talkto each other, and once that happens, and that energy is created, thesolution will start appearing. Things will start to happen.”Emily Brooks is an architectural writerBrisbane’s new children’s hospital will be one of the city’s moststriking landmarks. Its central concept is that of a “living tree”, withtwo atria as the trunks, and projecting lateral spaces as the branches.Purple and green sunshade blades adorn the facade, derived fromthe colour of the bougainvillea in the adjacent parkland. “Colourhasn’t been introduced for colour’s sake,” says Corbett Lyon, globaldirector, health projects at Lyons. “We saw it as a way of directlyrelating the building to its context – its a very Australian/Brisbanebuilding – to give it a strong local meaning.”Extensive research has fed in to the design, from internationalbest practice to the study of patient and staff movements in the twoexisting Brisbane children’s hospitals. Innovative new service-deliverymodels include a “no wait” triage system in the ED, where patientsare immediately assessed and filtered into four treatment areas.Surgical and medical admissions have also been split up, with eachhaving a separate lounge-like lobby on the building’s upper floors.The hospital offers up a patient-centric approach. “The centralbrief was very wise: it centres on the sick child and their family,” saysConrad Gargett’s Bruce Wolfe. “A child in the care of at least oneparent often has an entourage of siblings and other family members. Asa consequence, bedrooms are able to accommodate family members,and entrances are located where there is a peaceful atmosphere. It alsomeans that the service will come to the patient wherever practical.”Queensland Children’s Hospital,Brisbane, Queensland, AustraliaArchitects: Lyons Architecture / Conrad Gargett RiddelClient: Queensland HealthCost: AUS$1.5bn (£1.03bn)Size: 71,000sqmCompletion: Late 2014www.worldhealthdesign.com WORLD HEALTH DESIGN | April 2013 41

Two hearts beatingWHR Architects has completed two specialist heart hospitals, both inTexas. Located on the campus of Trinity Mother Frances Hospital, TheLouis and Peaches Owen Heart Hospital (pictured opposite, top) isnamed for its benefactors, who donated US$18m to build the 14,000sqmfacility. WHR’s Tasha Gupta, who led on the design, says that the brief wasto build “a world-class facility that would combine the latest technologyand equipment with a welcoming, timeless design in order to deliver thehighest quality of cardiac care”. Special features include rooms that flexto meet the needs of patients as their healing progresses so they don’thave to move, an oval-shaped chapel, and meditative gardens.Meanwhile, at the Texas Heart Institute in Houston, the emphasis wason research and development as WHR were charged with designing newlaboratories for regenerative medicine specialist Doris A Taylor, PhD.The labs (pictured opposite, bottom) feature a customised bench thatspecifically supports her team’s work in ‘whole organ decellularisation’ –removing existing cells from hearts of lab animals, leaving a framework tobuild new human hearts. A procedure room, conference area and stemcellbiorepository make up the remainder of the newly designed space.Mental healthupgrade for LiverpoolMedical Architecture and Arup have teamed up to delivera £28m mental health facility for Liverpool’s MerseyCare NHS Trust. Located on the site of the city’s formerWalton Hospital, it will serve adults and older peoplewith acute mental health needs and dementia. Its patientactivity rooms and 85 single inpatient rooms will becomplemented by some major new art commissions, theresult of a collaboration with Tate Liverpool. Bob Wills,project director at Medical Architecture, said “It is greatto be delivering a scheme for such a forward-lookingclient, where staff and service users can get on with thebusiness of healing in safe and uplifting surroundings.”Surrey vet school won by DevereuxDevereux Architects has won a competition to delivera veterinary medicine school for the University of Surrey.Comprising three complementary buildings – an academicbuilding, a veterinary clinical skills centre and a veterinarypathology unit – the 9,000sqm facility will sit on theuniversity’s 150-hectare campus just outside Guildford.The academic building will provide world-class teachingand research laboratories, lecture theatres and flexiblebreakout spaces organised around a common shared atrium;naturally ventilated office and teaching spaces will sit to oneside of the atrium, and research spaces and lecture halls alongthe other. Sustainability features include a heat-recoverysystem that will recycle the heat from the rising hot air inthe atrium. The building will be completed in 2015.www.worldhealthdesign.com WORLD HEALTH DESIGN | April 2013 45

ARCHITECTURE | CULTURE | TECHNOLOGYReporting globally on developments in healthcare’s built environment,WORLD HEALTH DESIGN is the only journal to bridge the gap betweenresearch and practice. Uniting opinion in architecture, design and clinicaldisciplines, each quarterly issue provides essential knowledge and insight for:• Leading architects and designers• National and local government officials• Health planners and capital project consultants• Public and private healthcare providers• Senior estates and facilities managers• Building construction and healthcare industries• Universities and academic researchers“The one magazine that I can’t waitto get as soon as it is available!Kurt Wege, Architect, CanadaSave£40off the cover pricewhen you subscribe““Absolutely fabulous! The articles are all of highsubstance, the projects are interesting and welldesigned,the art direction and layout is superband there are lots of colour photos.Jain Malkin, Jain Malkin Co, USA“World Health Design has been warmly receivedby all my colleagues. Keeping health plannersand architects happy with the same publication– you must be doing a lot right!Craig Dixon, Tribal Consulting, UK“WHD is the missing platform for all who sharethe same vision for healthcare design.Dr Ruzica Bozovic-Stamenovic, School ofDesign and Environment, National Universityof Singapore, Singapore8 Weir Wynd, Billericay, Essex CM12 9QG“““Four times a year there’s nothing likeWORLD HEALTH DESIGN with..• The latest scientific research• Incisive comment and analysis• Thought leadership interviews• Health policy briefings• Architectural project reviews• International market reports• Global technology updates• Arts and culture reviewsDon’t miss out!SUBSCRIBE TODAYand SAVE £40off the cover price!12 month subscription – JUST £80.00(single copy price: £30.00 per issue)Subscribe online atwww.worldhealthdesign.comor call: +44 (0) 1277 634176Subscription rates: Cover price: £30; Annual Individual: £80; Annual Team (5 copies): £260; Two Years Individual: £130; Two Years Team (5 copies): £435

Design & HealthStudent Ideas Poster Competition 2013PrizesAll prize winners will receive an awardpackage that includes:·• Complimentary registration to the 9th Design &Health World Congress & Exhibition, 10-14 July,2013 at the Brisbane Convention & ExhibitionCentre, Brisbane, Queensland, Australia• A winning certificate• Attendance at the Gala Awards dinner on13th July to collect their prize• Copy of the Design & Health World CongressFinal Programme and Book of Abstracts• Poster will be exhibited in the BrisbaneConvention & Exhibition Centre during theWorld Congress.Prize CategoriesCategory Building• First Prize• Second Prize• Third PrizeCategory Landscape• First Prize• Second Prize• Third PrizeCategory (IndustrialDesign) Product• First Prize• Second Prize• Third PrizeCategory Interior Design• First Prize• Second Prize• Third PrizeThe competition is open for entry from 1 April,2013 until 15 June, 2013, when all completedsubmissions must be received. There is no feefor entering. Register and submit at awards@designandhealth.comPhoto: Royal Children’s Hospital Melbourne, designed byBillard Leece Partnership and Bates Smart with HKSStudent-inspired Futures –Healthy Communities by DesignIntroductionA ‘salutogenic approach’ to health and urbanplanning developed as a preventative healthstrategy changes the focus to a more holisticunderstanding of healthy environments. TheInternational Academy for Design & Health inpartnership with the Australian GovernmentState Health Departments, Australian Instituteof Architects and collaborating universitiesis delighted to invite students to explorenew ideas and perspectives on the planningand design of different building typologiesthat supports the development of healthyenvironments. For literary references, visitwww.designandhealth.comConditions of EntryStudents are required to research currentissues concerning the promotion of healthwithin their community in one or more of thefollowing four categories:a) Buildingsb) Industrial Designc) Landscaped) Interior DesignThe focus of submissions should be onhow salutogenic desjgn can improve healthstatus in any public or social spaces such ashealthcare, education, the workplace or inan urban setting. Participating individuals orteams should prepare a poster presentationthat illustrates their thought process anddemonstrates how the design solutionsupports the creation of a healthy environmentfor the community, or clearly shows anappreciation of the determinants of healthand health promotion. The participants shouldNote: Printing costs of the poster will be borne by individuals/institution. Pleasecollect your poster at the end of the 9th Design & Health World Congress.focus on designing a healthy environmentutilising the salutogenic approach asdescribed in the following paper, which can bedownloaded at www.worldhealthdesign.com/Psychosocially-Supportive-Design.aspx. Thiscompetition is open to all built environmentdesign students in Australasia and around theworld at any level in their college or universitycareers. Upper level and graduate studentsare encouraged to compete.Submission requirementsEntries must reflect the criteria of thecompetition and comprise the following items:i) Full contact details, including name,university, department and degreeprogramme, address, telephone, e-mailand the categories being entered.ii) A digital copy in JPEG and PDF format(minimum 300 dpi high resolution). Amaximum of four posters per person isallowed. One poster per category only.Shortlisted entrants will be invited to displaya hard copy of their poster presentation atthe 9th Design & Health World Congress.Each poster should be 1800 (H) x950mm (W) size in Portrait format. Allsubmissions will be posted online at www.designandhealth.com after the competitionwinners have been announced.iii) A word document, including a maximumof 400 words explaining the backgroundto the poster idea; the objectives; themethodology; the results & the conclusion.Candidates should send their submissiondigitally to awards@designandhealth.com by15th June 2013.

Design&HealthInternational Academy for Design and HealthDesign & Health Scientific ReviewFrom Knowhow to NowhereDr John Zeisel is chair of theinternational advisory boardof the International Academyfor Design & Health andpresident of HearthstoneAlzheimer CareAs far back as I can remember planners, architects, andlandscape architects have talked about the value ofadaptability – creating environments in the present thatcan be changed in the future to respond to new needs, newrequirements, new users. As far back as I can remember, therewas always a missing ingredient – a sense of what future to planfor, to remain open to, to build in adaptability for. One futureto plan for is greater and greater complexity – the result of“improvements” in technology, transportation, and communication. Another future might be characterisedby shifts in societal power – differing political, economic, and social priorities. Still another future might bea return to a simpler past.We know that being alive means change – but in what direction? MIT historian of science Elting Morrisonin his classic book From Knowhow to Nowhere refers back to thetime of old English villages, the time of crafts persons, the timeof major discoveries that did not shake society’s fundamentalstructure. He observes that at that time people had a commoncultural knowhow that was incrementally improved withminimum destruction and disruption, while today our great“advances” in the sciences and technology lead ... nowhere!This question remains salient today for planners anddesigners – where are we going? Underlying much discussionof urban, suburban, building, and systems “improvement” isa quest for an earlier time, when the ecological, social, andtechnological dimensions of society were naturally aligned. Thiswished-for future lies not in increased complexity but in thecohesion and coherence of the past – or at least the imaginedand ideal past we carry in our minds.So perhaps in order to figure out where we are going orat least where we hope to be in the future we need to turnaround and look behind us. Whether we are planning urbanneighbourhoods in New York and Northeast England, shoppingmall renovations, or using post-occupancy evaluations toidentify fit-for-purpose objectives – we need to identify wherewe are headed. Perhaps we are headed in the wrong direction.Architect, planner and creative thinker Buckminster “Bucky”Fuller pointed out in a public lecture I attended years ago thatour sense of direction reflects a flat world, although we knowbetter – up and down, he explained, ought to be replaced with“out” and “in” as in “outstairs” instead of upstairs and “instairs”instead of downstairs.Perhaps it is time to reexamine what we mean by planningfor the future – perhaps time is a Mobius strip where the pastand future eventually come together.50-57Post-occupancy Evaluation:Benchmarking for Health Facility Evaluation ToolsIan Forbes58-63An Economic Assessment of HealthcareCapital InvestmentElsie Choy64-69Retro-fitting the Shopping Mall toSupport Healthier CommunitiesAnthony R Mawson MA, DrPH,Thomas M Kersen PhD, Jassen Callender MFA70-75The Future of Healthy Communities:Humanism in our Designed EnvironmentDavid Kamp FASLA, LF, NAwww.worldhealthdesign.com WORLD HEALTH DESIGN | April 2013 49

Design & Health Scientific ReviewFrom POE to design-in-use:Benchmarking for health facility evaluation toolsA shortage of post-occupancy evaluations means that planners and architects do nothave access to accurate findings regarding healthcare buildings’ performance. This paperproposes an alternative evaluation method that is robust, informed and easily sharedAdjunct Professor Ian Forbes, University ofTechnology, SydneyWhen people talk about thehealth and social care systemin any country, it is usuallywith an understanding that this is the mostcomplex and rapidly changing organisationalenvironment one can imagine. Builtenvironments that provide for these servicesare equally complex. It is also acknowledgedthat this complexity is enhanced by themultitude of stakeholders who exercisepower and preferences over it, not onlyconcerning how and whom shall deliverservices, but what allocation of resources willenable that to happen. 1,2 One of the mostexpensive and therefore problematic aspectsof the delivery system is the issue aroundcapital investment in buildings, equipmentand health facilities of many kinds.It is well recognised that design decisions,when translated into physical facilitiesthat accommodate health services andpatient care environments, will need to beevaluated in order to determine if they arefit for purpose. 3 It is well accepted that toavoid making repeated design mistakes andeven alignment with strategic business intentthrough Building Performance Evaluation 4some form of systematic evaluation isrequired. Further, as funding for the majorpublic hospitals in developed countries andalmost all developing countries comes fromgovernment sources it means the longtermresponsibility for maintenance andfunctioning of the assets falls to them. Thisconcern for longer-term issues has resultedin the development of guidelines oftento achieve regulatory controls but usingevaluation processes to feedback findingsto those who prepare the guides withrefreshed knowledge.There is considerable research andmaterial written about the conducting ofhealth facility evaluations and specificallythe methods used for Post OccupancyEvaluation (POE). 5 It is not my intentionhere to go over the details of history ormethods although it has been recognised 6that in the early evaluation studiesundertaken for health facilities, theywere of academic interest and initiallyconducted by academic researchers whoinvestigated select issues in institutionalsettings (eg examination of different warddesign, operating theatre systems, logistichandling approaches, etc).What was achieved by theseapproaches?Through the 1970s and 1980s this evaluativeresearch was developed as a systematicmethodological process giving betterscope and rigor to facility studies. Initiallyderived from architectural concerns withsocial and behavioural issues as opposedto aesthetic ones. 7 POE has now becomean internationally accepted approachto learning from building experiences.Variables such as task performance, privacy,communication, safety and thermal comfortwould all be considered. Evaluations wereconducted by an individual or teams on site.They followed a specified format, whichcould range from a simple to complexinvestigation. Performance was typicallymeasured on three dimensions: technical,functional and behavioural. 8Significantly the concern was withtechnical issues 3 relating to the capabilityof the building and its engineering servicessystems as well as functional aspects suchas the ability to achieve operational andclinical tasks efficiently and effectively.However it was the behavioural aspectsthat drew continued attention. 5 This wasthe psychological and social aspects of usersatisfaction and concerns related to betterunderstanding the general wellbeing ofbuilding inhabitants that had not previouslybeen considered in the more typical areasof evaluation. 8The POE process itselfToday, POE is a well-developed field ofscholarship and the process is taken forgranted as the generally accepted approachto finding evidence about what should orshould not be repeated in building solutions.This fits within the current wisdomsurrounding evidence-based design usingthe quasi-scientific POEs to establish amore valid base for evidence-based designdecisions. 1 The learning aspects of POE alsofit within the current context of ContinuousQuality Improvement. 9However, literature reviews show thereis no industry standard or standardisedmethodology for building evaluation. 5 TheUK Higher Education Funding Councilfor England has identified six acceptedmethods for conducting POEs in its Guideto Post Occupancy Evaluation. 10Unfortunately the POE has beenidentified as having several major shortfalls.These include an unwillingness to participateby design teams and owners because POEsmight discover a failure, which could leadto litigation. Essentially they are not beingundertaken in sufficient quantity due tothe large cost associated with undertakingthem. 3 Early POEs were done as individualresearch activities and were funded as such.In recent years, although many governmentshave put POE as an essential aspect tobe conducted as part of the process ofplanning new facilities, they don’t actuallyfund it sufficiently.In addition it has been found there wereseveral problems with Scotland’s POEs. 11 Itwas difficult to obtain sufficient responsesdue to the time and participant effortinvolved in carrying them out, and there wasa lack of comparability between old and new50 April 2013 | WORLD HEALTH DESIGN www.worldhealthdesign.com

Post-occupancy Evaluationfacilities as most patients and many staff hadnot experienced both. It was also hard toavoid distortion of the results by low-levelconcerns – such as parking and availabilityof magazines – not being distinguished frommore significant environmental concerns.Frequently the standardised questionnairesgenerated responses that were not usablein establishing how, or if, improvements hadbeen made. The survey team was oftenhampered as the questionnaire format leftlittle opportunity to capture comments,particularly if these did not refer to aspecific question or issue.Other barriers to sustained POE activitynoted in the study conducted by theAmerican Federal Facilities Council (FFC)of the National Research Council 12 are thefear by organisations and professionals ofcostly changes as a result of doing POEsand the lack of expertise in organisations tocarry them out. Interestingly, architects havenot taken ownership in pushing fundingfor or doing POEs and making sure theirbuildings are evaluated for effectiveness orsatisfaction of the users.Zimring et al 13 suggests that historically,large organisations such as the US CourtSystem, Disney, US General Services andother government bodies in the US andinternationally have all carried out extensivePOE programmes. However his researchshows that organisational learning, definedas the ability to constantly improve routineactivities, especially the inputs to operationalprocesses, was not achieved. Members ofproject teams, project managers and clientswere unaware of these POEs unless aspecial evaluation had been conducted toaddress a specific problem they were facing.The implication of these concerns,whether right or wrong, are that evaluationsare not being done and as a consequencechanges that should be taken in futuredesigns are not included. Too often anecdotalideas and poorly assessed information areused to determine what should be includedin future design solutions.Decisions are based on the so-calledexpertise of senior planners or clinical staff.We might call this eminence-based design,not evidence-based design.Understanding the evaluationmethodology requiredThere are several objectives that have beendescribed as driving the need for POEsFigure 1: Stantec’s Tunbridge Wells Hospital. The National Nursing Research Unit at King’s College London iscurrently conducting a study focusing on how its 100% single inpatient rooms impact upon staff and patientexperiences, costs, and staffing. Such studies are critically important – but all-too rare, for a number of reasonsin health facilities. Importantly the mainconcern is whether a building fulfils its designrequirements. 3,6 Perhaps what is missing inall the rigorous evaluation methodologiesand processes developed for POE is theneed for continuing discussion around whythings have happened. These evaluationscan provide a rich picture generated frommany cases reviewed. Dialogue amongparticipants involved in the review isperhaps the most important aspect ofthe evaluation. Seeking to find simplisticmethodologies that will answer all aspectsof health facility design is not possible.The question that we need to address iswhether there is an alternative evaluationmethod that will move design decisionsforward and be more informed, yet robust,so that the findings can be implementedquickly and most importantly shared with anetwork of designers and clients.Benchmarking as a method fordesign-in-usePreiser, Rabinowitz and White 8 suggestedthat we need to have a variety of suchevaluation approaches reflecting thedegree of effort involved. The types ofwww.worldhealthdesign.com WORLD HEALTH DESIGN | April 2013 51

Design & Health Scientific Reviewevaluation they described are indicative,investigative and diagnostic, in which eachhas a different objective:Indicative: is a very general short-timeevaluation in which the presence, frequencyand location of factors that supportor impede activities are identified andcompared to the expert’s knowledge. Thisis intended to provide an indication as towhether further work is then required.Investigative: is a longer and largerevaluation with greater surveying andinterviews and includes a literaturereview and comparisons with similarfacilities to achieve a more comprehensiveunderstanding of what has occurred andwhat can be adjusted.Diagnostic: is a large research activitywith multi-phasic studies over longerperiods of time. They require a large teamof investigators who employ triangulationor multi-levelled strategies for gatheringdata on numerous variables; they use basicscientific research designs; and they employrepresentative samples, which allow theresults to be generalised to similar buildingsand situations. In essence they are intendedto develop new ideas.In the review of evaluations undertakenat the University of Technology, Sydney(UTS) we believed that it would be possibleto develop a more responsive evaluationmethod to overcome the time and costissues of the full POE. Several POEs hadbeen commissioned by the NSW HealthDepartment over many years and as aconsequence of their reluctance to releasefindings, none of these were able to providelearning to the wider health facility designcommunity. However, they may haveinfluenced changes in the AustralasianHealth Facility Guidelines (AHFG) issued bythe Australian State Health Departmentsand generally used for both public andprivate acute hospitals across Australia.There was, however, no feedback into thegeneral design knowledge base that wouldbenefit the many private firms engagedin public health facility design. If the onlynew knowledge is to be within the AHFGthen this is very problematic. A debate hasalready occurred about how useful theguidelines are beyond being a regulatorycontrol, essentially for cost control, andas a useful introduction to inexperienceddesigners and user groups. There aresome serious concerns about their rigidFigure 2: The EAT tool evaluates elements specific to dementia design, including familiarity and the reductionof unhelpful stimuliimposition, thereby limiting the possibilityfor change and innovation in functional andphysical solutions.In order to provide faster feedback andsome indication of factors to improveaspects of spatial design, a combination ofthe indicative and investigative evaluationapproaches seemed possible while leavingdiagnostic to more specific research. Thisapproach required the setting to be the focalpoint and not a generalised evaluation tool.An examination of the various evaluationmethods all assume a project-by-projectanalysis in which the questioning processesbecomes broad enough to be used for anykind of health facility or department.Good examples of current tools createdto do evaluations in this vein are the BritishAEDET Evolution (Achieving ExcellenceDesign Evaluation Toolkit) 14 and ASPECT (AStaff and Patient Environment CalibrationToolkit). 15 The AEDET Toolkit will enablethe user to evaluate a design by posing aseries of clear, non-technical statements,encompassing the three key areas of Impact,Build Quality and Functionality. ASPECT is atool used either in an individual evaluationor in conjunction with AEDET. It is usedfor evaluating the quality of design for staffand patient environments in healthcarebuildings. It delivers a profile that indicatesthe strengths and weaknesses of a design oran existing building.These tools cover two very importantelements of evaluation. They are simple touse, although it is recommended to haveexperienced users as well and they lead to adiscussion of what is found in the evaluation,especially around the scores that arederived from them. In this way scores give ameasurable value for what would otherwisebe arguable and subjective interpretations.However they attempt to cover a verygeneric set of health facility situations andalthough many elements are of value, theydon’t address the many specific concerns ofeach department.Consistent with the desire to focus onthese concerns as requested by specialistnursing staff, the research team fromthe Faculty of Health and the Faculty ofDesign, Architecture and Building at UTSdeveloped a series of evaluation tools. Theywere based on the following principles:1. To focus on the design-in-use of aspecific department, rather than use ageneric tool2. To identify whether the importantelements of the space considered to beessential to the operational philosophywhere present3. To identify from literature reviewsa benchmarked solution that wouldaddress the operational concerns of themembers of staff and other users of thespecific location52 April 2013 | WORLD HEALTH DESIGN www.worldhealthdesign.com

Post-occupancy EvaluationFigure 3: The EAT tool was used to evaluate the effectiveness of minormodifications to dementia-specific aged care facilitiesFigure 4: 500 people living with dementia, across 40 residential agedcarefacilities, were involved in the PerCen evaluation4. To create a simple tool that comparedthe benchmarked solution with what wasthere to identify any deficits or benefitsobserved in the space5. That the tool could be used by nonexpertsfor self-assessment6. That the tool would have a high levelof inter-rater reliability after a shorttraining time7. The use of a scoring system that identifiedoverall scores and sub-scores to enablediscussion as to what might be changedor which aspect could be avoided infuture design solutions.In addition, the results could be sharedas case studies for further research and thefindings would stand as a hypothesis forothers to test or challenge.The dementia EAT toolThe first tool to be developed wasfor dementia-specific aged care designsolutions. The opportunity to explorethis arose from a request by the NSWHealth Department for an assessment andsolution to problems in small rural acutehospitals where the facility designed foracute patients at times had 80% of patientspresent with dementia co-morbidity andbehavioural issues. Richard Fleming and IanForbes 15 undertook the study and – basedon an international literature review aswell as the findings from the pilot studyon three rural facilities – they prepared adraft tool.The elements included were specific todementia facility design and inclusions inthe tool were:1. Be safe and secure2. Be small3. Be simple with good visual access4. Have unnecessary stimulation reduced5. Have helpful stimuli highlighted6. Provide for planned wandering7. Be familiar8. Provide opportunities for a range ofprivate to communal social interactions9. Encourage links with the community10. Be domestic in nature, providingopportunities for engagement in theordinary tasks of daily living.An opportunity to further develop thetool occurred when it was needed for amajor research project undertaken by thecombined teams from UTS, University ofNew South Wales (UNSW), University ofWollongong (UW) and Sydney University(USyd). The study, called PerCen, deliberatelyseparated built environmental changes fromstaff training in Person Centred Care (PCC)to determine the separate effects fromthese interventions. Psychometric testswere used to determine before and afterchanges in the quality of life and qualityof care. This included 500 people livingwith dementia in 40 residential aged-carefacilities that were randomly assigned togroups of 10, being: care as usual; personcentredchanges only; physical changes only;and both changes.The tool was then examined againstother tools historically used internationallyfor evaluating dementia specific and agedcare facilities. The tool was found to bevalid and reliable. 16 The tool was labelledEAT (Evaluation Audit Tool) and specificallycompared to a similar tool developed atStirling University in Scotland. Both toolswere used and compared favourably inevaluating the 40 facilities in the pre-testround of this study. EAT was used in thepost-test and final rounds. Further useof the tool continued in other studieswith dementia-specific units and minormodifications were made.Findings in the PerCen study showedthe EAT tool was effective in evaluating therelationships between operations and spacein terms of effectiveness when compared toideal residential care. The scores were usedin determining the required changes to meetpatient-centred environmental principles atthe different sites. Using the EAT scores,discussions were held with managers andcare staff at each site to determine theirdysfunction as identified by the tool andwww.worldhealthdesign.com WORLD HEALTH DESIGN | April 2013 53

Design & Health Scientific ReviewPost-occupancy Evaluationenvironment – heat, light and especiallywho came into the room• Women did not want to change roomsto give birth or to use a birth pool• Women birthing in hospital were lesslikely to have helpful facilities than thosebirthing at home or in midwife-ledbirthing centres• Women with good facilities were morelikely to have a natural birth• The objective was to remove themedicalisation of birthing.Figure 5: The BUDSET tool was developed to evaluate how birthing environments compare with the idealgaining agreement to the interventionalchanges planned. Due to limited funds inthe grant, only minor modifications to theenvironment at each of the 20 interventionsites were possible.In regard to the objectives of theevaluation tool, it has proved to be easyto use, with only a few hours of trainingby a variety of researchers and with highreliability in the scores. The results providedan overall score for comparison to otherfacilities and a series of sub-scores thathighlight areas of concern in order to makechanges at individual sites.The birthing unit BUDSET toolWhile the EAT tool was being tested,the researchers in the UTS Centre forMidwifery, Child and Family Health inthe Faculty of Health, believed that thework with environments in dementiacare would have similar results to thosefor birthing spaces. Their objective was toestablish a birthing environment that wassupportive but that was also unconsciouslyunobtrusive. The cues given to birthingoccupants by the configuration of thespaces were either frightening or notcomfortable. The objective was to developa specific evaluation tool that would takethe philosophy of ideal birthing spacesinto account. This tool would determinewhether the hospital birthing units inNSW were currently achieving spatialbenchmarks for such facilities, or to seewhat could achieve them.The conceptual framework thatapplied to this was the theory of “birthterritory”, which was co-developed by UTSProfessor Maralyn Foureur. 18 Birth territoryrecognises the physical territory of the birthspace over which jurisdiction or poweris claimed for the woman involved, andbuilds on work of philosophers includingFoucault. Birth territories affect howwomen feel and respond as embodiedbeings; safe and loved, or unsafe, fearful andself-protective. 19The resulting Birthing Tool, calledBUDSET (Birthing Unit Design SpatialEvaluation Tool), was developed to respondto these specific issues and to see whataspects of birthing spaces were needed insupport of the women and carers involved.A considerable literature was reviewedand the benchmarked elements frombirthing design were included from thisreview. 20 Some of the findings showed thatkey elements of spatial design were lackingand needed to be considered specificallyfor Birthing Units. 21 These were:• Many women did not have access tofacilities they felt were essential• Women wanted control of theirThe above key principles underpinnedthe BUDSET and included provision forthose elements.A pilot study was undertaken to test thetool with seven facilities in one Area HealthService of Sydney that covered new andold, large and small units. The early resultsshowed that some of the elements werenot strong on inter-rater reliability whenmidwives’ views did not match architects’views of adequacy. Changes were made tothe tool for clarification of questions, anda PhD student carried out another studyusing the new tool, which had a moresuccessful result.In regard to achieving the principlesfor the evaluation tools, it was found thatthe BUDSET was easy to use, requiredlittle training for people not familiar withbuilding design and gave a clear indicationof where design-in-use was not matchingbenchmarks. It produced scores that wereable to be discussed in recommendingchanges to physical space. The operationalphilosophy derived from the literaturereviews was able to be accommodated. 22Additional research from a furtherstudy has now been completed, usingvideos of seven births that show howthe spaces are actually being used. Theseobservations show the use is consistentwith expectations of the benchmarkedobjectives covered in the tool.Further developmentsThe next set of evaluation tools arebeing developed for Mental Health andEmergency Departments. Collaborationbetween members of the Faculty of Design,Architecture and Building at UTS, PsychiatricNursing in the Faculty of Health at UTS anda PhD student from the Australian Instituteof Health Innovation (AIHI) at UNSWare currently undertaking a researchwww.worldhealthdesign.com WORLD HEALTH DESIGN | April 2013 55

Australian excellence in regional andaccessible healthcare.Mackay Base Hospital RedevelopmentWOODSBAGOT.COM

Design & Health Scientific ReviewPost-occupancy Evaluationproject that will develop a Mental HealthEvaluation Tool. The aim of this researchis to investigate the relationship betweenthe mental healthcare built environmentand safety, thereby furthering anunderstanding of how the physical habitatmay support or hinder therapeuticobjectives and the building of interpersonaltrust in clinical settings.The main unit of analysis is a 10-year-old,50-bed mental-health unit, which is currentlybeing refurbished (the intervention) toimprove the physical, social and symbolicenvironments of care. The embeddedunit of analysis is the staff, and the aim isto understand how the built environmentaffects their perceived safety climate andpropensity to trust patients.The physical environment in the unitis recognised as deficient in terms ofhigh social density, poor noise control,minimal acoustic privacy, institutionalaesthetics, little access to nature, andpoor functionality. These stress-inducingconditions are probably implicated inthe intractably high seclusion rate in theunit’s 20-bed observation ward. Both thenumber of patients secluded more thanonce during an admission, and the lengthof time that people are secluded (morethan four hours) have been above averages.From this work the underlying philosophythat a benchmarked health facility requiredwill lead to an evaluation tool that complieswith the principles for design-in-useevaluations in mental health.An emergency department (ED) projecttaking the opportunity to develop afurther tool followed a workshop on thedesign implications for emergency facilitiesfollowing the introduction in NSW of thefour-hour turnover rule. In the case ofEDs, designers look for factors that affectthe processing and movement of patients.From a facility perspective, the planningshould seek to identify the essential physicalresources, particularly treatment spaces anda variety of waiting areas.Reviews of literature show that,regardless of the specific geographiclocation with their various external demandpatterns, there were some key elementsinvolved in benchmarked EDs. Theseinvolve the various patient flow modelsand how patients are moved in peak hoursto holding, waiting and treatment. Accesspoints and triaging are considered critical.There are also the implications forinformation gathering and for continuousaccess to avoid repeated patient datacollection using digital Informationtechnology. This aspect is now a major partof the contemporary EDs.Through further work in this area, a newtool will be useful for quickly assessing thecurrent situation in NSW and the areaswhere simple or larger changes to spaceswill be necessary.ConclusionAlthough POE has been used for over50 years and is accepted as the goldstandard we believe that POEs are notbeing used enough or effectively. A shortformevaluation tool developed at UTScan achieve a great deal of what is foundwith POE results by examining designin-useassessments when compared tobenchmarked information.It would normally be shunned as atime consuming process to examiningeach department and then developinginformation required to benchmark allhealth units. However we have foundliterature reviews abound, and theunderlying philosophy needed to establishbest practice for these benchmarks hasusually been developed for the Briefsof Requirements. Various methods ofevaluation are needed to achieve a varietyof measured outcomes. We offer this asanother one in the range.AuthorProfessor Ian Forbes is managing directorof Forbes Associates International HealthFacility Planning Consultants, and an adjunctprofessor at the University of Technology,Sydney, New South Wales.References1. Ulrich, RS, Zimring, CM, Zhu, X, Dubose, J, Seo, HB,Choi, YS, Quan, X, Joseph, A. A review of the researchliterature on evidence based healthcare design, WhitePaper Series 5/5, Evidence-Based Design Resources forHealthcare Executives, The Center for Health Design;2008.2. Ulrich, RS, and Zimring, C. The role of the physicalenvironment in the hospital of the 21st century: A once in alifetime opportunity. Concord, CA: The Center for HealthDesign; 2004.3. Preiser, W, and Vischer, J. Assessing BuildingPerformance. Burlington, MA: Elsevier; 2005.4. Steinke, C, Webster, L and Fontaine, M. EvaluatingBuilding Performance in Healthcare Facilities: AnOrganisational Perspective. Health Environments Research& Design Journal, Vol. 3, No. 2; 20105. Zeisel, J. Towards a POE paradigm. In W Preiser(Ed.). Building Evaluation, pp167-180. New York: Plenum;1989.6. Zimring, C. Post-occupancy evaluation andimplicit theory: An overview. In W.Preiser (Ed.). BuildingEvaluation, pp.113-125. New York: Plenum; 1989.7. Wener, R. Advances in evaluation of the builtenvironment. In E. Zube and G. Moore (Eds.). Advances inEnvironment, Behavior and Design. Vol. 2. pp287-313. NewYork: Plenum; 1989.8. Preiser, W, Rabinowitz, H, White, E. Post-OccupancyEvaluation. John Wiley & Sons, Incorporated; 1988.9. Sollecito, WA, and Johnson, JK (Eds). McLaughlin andKaluzny’s Continuous Quality Improvement in Health Care(4th Ed) Jones and Bartlett Learning, Burlington; 2013.10. Barlex, MJ, Blyth, A, Gilby, A. Guide to Post OccupancyEvaluation. London; 2006. Accessed at www.aude.ac.uk/info-centre/goodpractice/AUDE_POE_guide11. Nicholson, K. Exploring Post Occupancy Evaluationin Health care. Architecture and Design Scotland, (A+DS),Government of Scotland, Edinburgh; 2011.12. Learning from Our Buildings: A State-of-the-PracticeSummary of Post-Occupancy Evaluation. Federal FacilitiesCouncil Technical Report No. 145. National AcademyPress Washington, DC; 2001.13. Zimring, C, Rashid, M, Kampschroer, K, FacilityPerformance Evaluation (FPE), paper for Whole BuildingDesign Guide, National Institute of Building Science,Washington USA; 200514. National Health Service. (2007). AEDET evolution:Design evaluation toolkit. Retrieved March 20 2013, fromwww.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_08208915. National Health Service. (2007). ASPECT:Staff and patient environment calibration toolkit.Retrieved March 20 2013, from www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_08208716. Fleming, R, Forbes, I, and Bennett, K. Adaptingthe Ward for People with Dementia. Sydney, NSWDepartment of Health; 2003.17. Forbes, I, Fleming, R. Dementia Care: Determiningan environmental audit tool for dementia-specificresearch, Design & Health Scientific Review. World HealthDesign, London; 2009.18. Fahy, K, Foureur, M, Hastie, C. Birth Territory andMidwifery Guardianship: Theory for Practice, Education andResearch. Oxford, Elsevier; 2008.19. Foureur, M. Creating birth space to enableundisturbed birth. In Fahy, K, Foureur, M, Hastie, C. BirthTerritory and Midwifery Guardianship: Theory for Practice,Education and Research. Oxford, Elsevier: 57-77; 2008.20. Lepori, B, Foureur, M, Hastie, C. MindbodyspiritArchitecture: Creating Birth Space. In Fahy, K, Foureur,M, Hastie, C. Birth Territory and Midwifery Guardianship:Theory for Practice, Education and Research. Oxford,Elsevier: 95-112; 2008.21. Forbes, I, Homer, CSE, Foureur, M, Leap, N. BirthingUnit Design: Researching New Principles. Design &Health Scientific Review 1, 47–53. World Health Design,London; 2008.22. Foureur, M, et al. The Relationship Between BirthUnit Design and Safe, Satisfying Birth: Developing aHypothetical Model. Midwifery, Elsevier, London; 2010.www.worldhealthdesign.com WORLD HEALTH DESIGN | April 2013 57

Design & Health Scientific ReviewPublic funding:An economic assessment of healthcarecapital investmentWhile the costs of health infrastructure investment proposals are relatively straightforward toquantify, the resulting health benefits are much harder to value. This paper describes New SouthWales Health’s experience and the assessment method it uses to assess cost versus outcomeElsie Choy, Health Infrastructure, NewSouth WalesHealth infrastructure is important ininfluencing the outcomes, qualityand efficiency of the healthcaresystem. Decisions about public funding ofhealth infrastructure require considerationof relative costs and benefits of options. InNew South Wales (NSW), considerableefforts have been placed on benefitsassessment in the economic appraisal ofcapital projects. This involves qualitativeassessment of the extent to which optionsimprove patient access to health servicesand economic efficiency, and quantitativeassessment of the value of health benefits tothe greatest practicable extent.This paper describes the NSWexperience and approach to valuing healthbenefits in major capital projects. Since2009, NSW Health has applied quantitativevaluation (monetisation) of benefits forinvestment in single-purpose health facilitiessuch as radiotherapy treatment facilities.This is done by comparing the number ofadditional patients receiving service andbenefits, accounting for changes in patientdisability burdens as a result of treatmentand applying survival rate assumptionsbased on findings from research literature.Assessing and quantifying benefitsassociated with investment in infrastructureinvolving a range of health facilities andservices is much more difficult, given thecomplexity in identifying the cause andeffects in health outcome improvementsfor a wide range of medical conditions. Themethod for single-purpose facilities wasexpanded to consider a range of clinicaltreatments in general hospital environments.Method of valuationThe method is based on the causalrelationship that there would be reductionOne of the NSW Government’s key goals is to drive economic growth in regional as well as metropolitan areas.The Manilla Multi-Purpose Service Project delivers flexible, integrated health and aged care to the rural areain pain and suffering and aversion ofmortality for seriously ill patients whowould otherwise not be treated withoutthe hospital development because theexisting hospital is at capacity.Patients who access treatment at apublic hospital are expected to experiencea reduction in their disability (includingpain and suffering) caused by the healthcondition for which they seek treatment.The degree of disability that a medicalcondition or disease inflicts on the suffereris measured by its disability weight.The assessment therefore involvesestimation of average of time for whichthe disability burden of a patient is reducedas a result of treatment at a hospital. Thereduction in pain and suffering is estimatedby multiplying the number of such patientsby the average reduction in disability foreach patient, their years of remaining lifeand the Value of a Statistical Life Year (VSLY).The formula used for this calculation is:Change in number of clinical separations xdisability weight (pre-treatment) x reduction inburden of disability (years) x VSLYThe steps are:i. Identify a representative medicalcondition or disease from each of thehospital’s Service Related Groups (SRGs)and the estimated average period of timefor which the disability burden is reduced asa result of treatment at a hospital.ii. Apply disability weights for eachcondition/disease that has been publishedby the Australian Institute of Health andWelfare and estimate the reduction indisability burden as a result of treatment.iii. Estimate the average age at whichthe patient is treated at the hospital byexamining the prevalence of each condition/disease in the Australian population.iv. Estimate the percentage distribution ofprevalence of conditions by service groupand by age.v. Using the formula from step (iv) andassuming the average life expectancy,estimate the mean age at which a patientis likely to present at the hospital fortreatment, as well as the duration overwhich they will experience a reduction intheir disability.58 April 2013 | WORLD HEALTH DESIGN www.worldhealthdesign.com

Capital Investmentvi. Calculate the increase in the activitylevels for each SRG by comparing thecurrent levels and the projected activity infuture years.vii. Estimate the patient heath gain bymultiplying (v), (vi) and the VSLY.The quantification exercise considersalternative scenarios regarding themagnitude of reduction in disability burdenacross all health conditions and diseases.AssumptionsChange in number of clinical separations:The change in the number of clinicalseparations is obtained by comparing thecurrent and the projected level of activityin future years of each SRG provided in thepublic hospital.The SRG is a classification systemfor grouping hospital inpatient recordsinto categories corresponding to clinicaldivisions of hospital activity. The majorpurpose of the classification is to assist withthe planning of health services.This disease classification is thentranslated into an Australian medical codingsystem, ie Australian Refined DiagnosisRelated Groups (AR-DRG) as outlinedin the Australian Institute of Health AndWelfare (AIHW) report, The Burden ofDisease and Injury in Australia 2003. 1 Mostclassifications used in the AIHW study areconsistent with the classifications used byWorld Health Organization ie InternationalClassification of Disease (ICD) system. 2Disability weights: The disability weightsare sourced from the AIHW, which collatesinformation mainly from the GlobalBurden of Disease (GBD) study 3 and theNetherlands study. 4 for some diseases,there is no equivalent in either the GBDor Netherlands set of weights. In theseinstances, the weights are specifically derivedfrom earlier Australian studies. The disabilityburden weights are measured as a numberon a scale of 0-1, where 0 is assigned to astate comparable to perfect health and 1 isassigned to death.Reduction in burden of disability:Currently, there is insufficient data from themedical literature to precisely determinethe treatment-enabled reduction in disabilityburden across the wide spectrum of servicegroups. Consequently, the quantificationexercise considers alternative scenarios ofa 10%, 20% and 30% reduction in disabilityburden across all health conditions andThe redeveloped Narrabri Hospital, an AUS$40m project, finished in 2012. Since 2010/11, NSW Health has alsocommenced AUS$850m-worth of regional hospital redevelopment and a number of regional cancer centresdiseases (with 20% being the central case).The computation of the reduction inburden of disability (years) requires makinga number of assumptions, which aredescribed in Table 1.Value of Statistical Life Year (VSLY):The value of statistical life (VSL) is sourcedfrom an Australian Office of Best PracticeRegulation’s Guidance Note. The VSL is anestimate of the financial value society placeson reducing the average number of deathsby one. The VSL is most appropriatelymeasured by estimating how much societyis willing to pay to reduce the risk ofdeath. A number of empirical studies havederived estimates for the VSL. In reviewingTable 1: Reduction in burden of disability assumptionsthe studies relevant to Australia, Abelson(2007) 6 argues that the most credibleestimate is AUS$3.5m for the VSL andAUS$151,000 for the VSLY (in 2007 dollars).These estimates represent an average andare based on a healthy person living foranother 40 years. The VSLY in 2011/12dollars is assumed to be AUS$168,000.Application to capital investmentin regional hospitalsThe Australian and state jurisdictionsare committed to making long-termimprovements in the health systems for thecommunity. Capital investment is needed tomeet increased demand in health servicesAssumptionDescriptionPrevalence of diseases The severity-weighted disability occurrencemeasured as a percentage of the population of thatage and service group, sourced from AIHW.Average life expectancy The methodology assumes the average lifeexpectancy to be 82 years (no gender differences). Itis noted that the Australian Bureau of Statistics citesthe average life expectancy for males as 79.3 yearsand 83.9 for females. 5Age group The age groups are: 0-14, 15-24, 25-64, 65-74, 75+Mean ageThe estimate of the mean age at which a patient islikely to present at the hospital for treatment, basedon the prevalence by age data.Reduction in disability burdendue to treatmentSize of the reduction in disability burden for thosepatients (with less serious illnesses) after receivingtreatment at the hospital in question – 10% to 20%as the central estimate (case by case assessment)with sensitivity analysis.www.worldhealthdesign.com WORLD HEALTH DESIGN | April 2013 59

Design & Health Scientific Reviewas a result of the ageing population and toaddress the rising burden of chronic disease.One of the investment priority areas isregional health infrastructure.The Australian Government hascommitted to a total of AUS$1.8 billionfunding to improve and develop regionalhealth infrastructure. Funding allocation isdecided through a process of applicationand assessment by an independent advisoryboard. The priority regional hospital fundingprogramme will improve access to essentialhealth services to as many Australiansas possible living in rural, regional andremote areas through investments in healthinfrastructure. The objective is to provideTable 2: Reduction in disability burden as a result of treatment at hospital.Source: AIHW (1999 7 & 2003 1 )Service Related Group(SRG)Notional disability weight(pre-treatment)Cardiology 0.323 17.87Interventional cardiology 0.395 17.87Dermatology 0.070 38.21Endocrinology 0.214 22.34Gastroenterology 0.463 27.06Haematology 0.090 36.74Immunology & infections 0.613 36.81Neurology 0.480 18.92Renal medicine 0.104 32.58Respiratory medicine 0.230 31.29Rheumatology 0.370 24.57Pain management 0.190 23.13Colorectal surgery 0.224 27.06Upper GIT surgery 0.420 36.81Head & neck surgery 0.231 49.74Dentistry 0.005 35.54Ear nose & throat 0.110 52.56Orthopaedics 0.201 33.02Ophthalmology 0.170 18.92Urology 0.157 32.58Vascular surgery 0.600 17.87Extensive burns 0.255 33.02Gynaecology 0.180 32.58Obstetrics 0.011 41.81Qualified neonate 0.110 46.50Drug & alcohol 0.330 40.13Psychiatry – acute 0.584 40.13equitable access to, and affordable servicesfor, patients in rural, regional and remoteAustralia, and the needs of IndigenousAustralians and people experiencing socioeconomicdisadvantage. This will help closethe gap in health outcomes between majormetropolitan and regional areas of Australia.NSW is the largest state in Australia with apopulation of 7.3 million. It is estimated that4.6 million people (63%) live in the Sydneymetropolitan area and 2.7 million people(37%) live in regional NSW in 2010. Thepopulation is projected to reach 7.9 millionin 2021. One of the NSW Government’skey goals is to drive economic growth inregional NSW. This is underpinned byPeriod of reduceddisability burden (years)the need to balance population growthbetween regional and metropolitan areasso all people have access to good economicand lifestyle opportunities.Since 2010/11, NSW Health hascommenced a number of regional hospitalredevelopment projects including PortMacquarie Hospital, Wagga Wagga Hospital,Dubbo Hospital Project, Tamworth Hospitaland Bega Valley Hospital at a total capitalcost of AUS$850m, jointly funded bythe NSW and Australian Governments.This is in addition to the AUS$40mNarrabri Hospital redevelopment whichwas completed in 2012 and a number ofregional cancer centres at a total capitalcost of AUS$149m at Coffs Harbour,Lismore, Port Macquarie, Gosford, Illawarra,Shoalhaven and Tamworth.In the project planning and developmentphase, NSW Health applies cost benefitanalysis, including the health benefitquantification method described here,to demonstrate the net benefits of eachproject. The analysis forms a key componentof the economic appraisal of the project.Table 2 shows the disability weightsassociated with the medical condition ordisease from each of the hospital’s SRGs,as well as the estimated average periodof time for which the disability burden isreduced as a result of hospital treatment.A simplifying assumption is made thattreatment results in a permanent reductionin disability. As treatment will only result ina temporary remission for some chronichealth conditions or diseases, a modestaverage reduction in disability as a result oftreatment at the regional hospital is assumed.For the purpose of the assessment method,a notional disability weight is nominatedbased on the range of disability weights forvarious diseases within each SRG.Prevalence of diseases and healthconditionsThe estimated average period of time forwhich the disability burden of a patient isreduced as a result of treatment at theregional hospital is dependent on theaverage age at which the patient is treated atthe hospital. This is estimated by examiningthe prevalence of each disease or conditionin the Australian population, and assumingthat a patient who is successfully treatedwill live on until the current average lifeexpectancy in Australia.60 April 2013 | WORLD HEALTH DESIGN www.worldhealthdesign.com

Capital InvestmentLiverpool Hospital, Sydney. Projected patient demand is based on projections from each Local Health DistrictTable 4 shows the distribution across agegroups of conditions by Service RelatedGroup. This distribution is calculated fromthe prevalence numbers in Table 3. Usingthe information in Table 4 and assumingthe average life expectancy to be 82 years,the mean age at which a patient is likely topresent at the hospital for treatment, aswell as the duration over which they willexperience a reduction in disability, can becalculated as shown in Table 5.Projected activity levelsThe projected patient demand at eachhospital by SRG is based on the LocalHealth District’s clinical service planningdata over a five year and ten year projectionperiod. The activities are separated into dayonly and overnight.In the economic appraisal, it is assumedthat the base case (keep safe and operating)will only enable hospitals to meet the actualcombined activity level or increase to thelevels using existing capacity. It is thenassumed that hospital redevelopment andexpansion will enable them to meet activityprojections to a 10-year planning horizon.Magnitude of potential reductionin disability burdenThere is currently insufficient data fromthe medical empirical literature to preciselydetermine the treatment-enabled reductionin disability burden such as years of life lostTable 3:Prevalence of conditions by age and Service Related Group (‘000).Source: AIHW (2003) 1Service Related Group Prevalence (‘000)All 0-14 15-24 25-64 65-74 75+Infectious and parasitic diseases 21.4 1.5 1.1 15.3 1.9 1.5Acute respiratory infections 12.1 4.6 1.7 4.7 0.6 0.6Maternal conditions 2.1 0.0 0.3 1.8 0.0 0.0Neonatal causes 38.5 8.6 5.5 20.4 2.3 1.6Nutritional deficiencies 5.6 0.8 0.7 3.3 0.4 0.4Malignant neoplasms 89.1 0.8 0.8 40.0 23.1 24.3Other neoplasms 3.3 0.1 0.0 2.1 0.4 0.6Diabetes mellitus 93.5 0.4 0.9 43.9 20.8 27.5Endocrine and metabolic diseases 16.4 3.0 1.6 6.4 2.0 3.5Mental disorders 394.5 18.5 47.8 297.5 21.9 8.9Nervous system and sense organdisorders263.9 8.6 8.3 74.7 47.3 125.0Cardiovascular disease 119.8 0.9 1.5 38.8 27.7 50.9Chronic respiratory disease 150.4 15.6 12.0 62.8 25.1 35.0Diseases of the digestive system 37.3 0.8 1.0 20.8 6.5 8.3Genitourinary diseases 43.8 0.3 4.2 28.3 4.7 6.3Skin diseases 18.5 1.8 3.8 8.1 2.0 2.9Musculoskeletal diseases 94.8 0.9 2.0 48.4 19.0 24.6Congenital abnormalities 38.5 11.8 5.1 18.1 2.0 1.5Oral health 23.3 2.1 2.0 13.3 2.8 3.1Unintentional injuries 77.8 3.0 5.4 49.5 8.9 11.0Intentional injuries 5.8 0.0 0.3 4.4 0.6 0.4Ill-defined conditions 8.9 0.0 0.3 8.2 0.3 0.1www.worldhealthdesign.com WORLD HEALTH DESIGN | April 2013 61

Design & Health Scientific ReviewTable 4: Prevalence of conditions by Service Related Group Distributionacross age groups. Source: AIHW (2003) 1Service Related GroupPrevalence (proportion)0-14 15-24 25-64 65-74 75+Infectious and parasitic diseases 7.2% 5.0% 71.8% 8.8% 7.2%Acute respiratory infections 38.3% 13.7% 38.8% 4.6% 4.6%Maternal conditions - 12.9% 84.6% - -Neonatal causes 22.3% 14.4% 53.0% 6.0% 4.3%Nutritional deficiencies 14.1% 13.0% 58.5% 7.5% 6.9%Malignant neoplasms 0.9% 0.9% 44.9% 25.9% 27.3%Other neoplasms 2.3% 1.4% 65.8% 12.6% 17.9%Diabetes mellitus 0.4% 0.9% 47.0% 22.3% 29.4%Endocrine and metabolic diseases 18.4% 9.9% 38.8% 11.9% 21.0%Mental disorders 4.7% 12.1% 75.4% 5.5% 2.3%Nervous system and sense organdisorders3.3% 3.1% 28.3% 17.9% 47.4%Cardiovascular disease 0.8% 1.2% 32.4% 23.2% 42.5%Chronic respiratory disease 10.4% 7.9% 41.7% 16.7% 23.3%Diseases of the digestive system 2.0% 2.8% 55.7% 17.4% 22.1%Genitourinary diseases 0.6% 9.7% 64.6% 10.8% 14.3%Skin diseases 9.6% 20.4% 43.5% 10.9% 15.6%Musculoskeletal diseases 0.9% 2.1% 51.1% 20.0% 25.9%Congenital abnormalities 30.7% 13.3% 46.9% 5.2% 3.9%Oral health 8.9% 8.6% 57.4% 11.8% 13.2%Unintentional injuries 3.9% 6.9% 63.6% 11.4% 14.1%Intentional injuries 0.8% 6.0% 76.1% 10.9% 6.2%Ill-defined conditions - 3.3% 92.5% 3.7% -(YLL) and years lost due to disability (YLD)averted across the wide spectrum of healthconditions and diseases shown in Tables 3,4 and 5. Instead, the assumptions shown inTable 6 are used in estimating the healthbenefits to patients.Estimated health benefitsBased on the above parameters andassumptions, the health benefits of eachregional expansion and redevelopment areestimated for each year over an analysisperiod of 20 years. The present value usinga range of alternative real discount rates(4%, 7% and 10%) is then calculated.Results and sensitivity testingThe economic appraisal of regional healthcapital projects has yielded a benefit costratio (BCR) within the range of 1.2 and 2under a real discount rate of 7%. In eachinstance, sensitivity analysis is undertaken totest the robustness of the BCR to changesin key parameters and assumptions. As theproject benefits encompass other benefitsbeyond patient health, the result of thequantification exercise is a conservativeestimate of the project’s total benefits.LimitationsIt is acknowledged that there are constraints/limitations in the above approach, as healthbenefit valuations may differ betweenindividuals due to differences in age,education, risk aversion or time preference.The mapping of the disability weights tothe SRG is notionally based on the rangeof disability weights for various diseaseswithin each SRG. Collection and analysis ofdetailed activity data will help inform thejudgement in formulating the appropriatedisability weight for each SRG.Assuming a uniform 20% reduction indisability burden due to treatment meansthe method can put a value to treatmentactivity. The challenge is to base thereduction more on evidence rather than onuniform assumptions. In taking this methodforward, an area for further improvementis to base the assessment of reduction inburden of disability on the health impact ofthe specific treatments and models of careunder each project option considered.ConclusionsSubjecting capital proposals to benefitcost assessment supports sound decisionmakingon strategic investments in thehealth system underpinning improvementsin efficiency, access and outcomes ofhealthcare. Capital investment in healthinfrastructure will impact on the operationof health facilities and contribute toimprovements in healthcare delivery. Thehealth impacts (benefits) usually includepatients’ quality and quantity of life. Thesebenefits need to be evaluated against thecapital and operating costs associated withthe project in question. The health benefitquantification or monetisation is a key stepin providing a picture of each project’seconomic, environmental and social merits.In NSW, the approach and methodoutlined in this paper has been used toimprove the rigour and quality of economicappraisals of health infrastructure projects.In the projects where quantification ofhealth benefits is feasible, it has beendemonstrated that the health benefitsassociated with the capital investmentsexceed the resource costs.Valuing health benefits is less complexfor specific-purpose health infrastructuresuch as emergency department upgrades orcancer centres. There is an opportunity forfurther study of the link between a capitalinvestment and its resulting health, social,community and other benefits. For example,it would be helpful to better understandhow the design of health facilities contributesto improvements in health services deliveryand patient health outcomes.AcknowledgementsThis paper is jointly sponsored by HealthInfrastructure and NSW Treasury. Thebenefit assessment method describedin this paper was developed by HealthInfrastructure over the past three years in62 April 2013 | WORLD HEALTH DESIGN www.worldhealthdesign.com

Capital InvestmentTable 5: Mean age of patients and average length of disease by Service RelatedGroup. Source: Calculations from AIHW (2003) 1Service Related GroupMean age(years)Table 6: Health benefit estimation assumptionsLength of disease(years)Infectious and parasitic diseases 45.2 36.8Acute respiratory infections 29.4 52.6Maternal conditions 40.2 41.8Neonatal causes 35.5 46.5Nutritional deficiencies 40.2 41.8Malignant neoplasms 59.7 22.3Other neoplasms 52.5 29.4Diabetes mellitus 59.7 22.3Endocrine and metabolic diseases 45.3 36.7Mental disorders 41.9 40.1Nervous system and sense organ63.1 18.9disordersCardiovascular disease 64.1 17.9Chronic respiratory disease 50.7 31.3Diseases of the digestive system 54.9 27.1Genitourinary diseases 49.4 32.6Skin diseases 43.8 38.2Musculoskeletal diseases 57.4 24.6Congenital abnormalities 32.3 49.7Oral health 46.5 35.5Unintentional injuries 49.0 33.0Intentional injuries 47.5 34.5Ill-defined conditions 44.3 37.7Proportion of day-only toovernight benefitsProportion who wouldhave received treatment inother hospitals without theredevelopmentProportion of patients avertingmortality as a result of beingtreated at the hospitalReduction in disability burden dueto treatmentAdjustment factor to account for the fact thatpatients with overnight stays tend to have moreserious conditions that those admitted to thehospital for the day only – 50% (that is, thebenefits of treatment for overnight patients aretwice that of day-only patients)Proportion of patients who cannot be treated atthe hospital in question under the base case whowill find treatment at some other hospital in thenetwork – the assumed value is subject to caseby case assessment.Proportion of patients treated at the hospitalin question who have very serious illnesses isassumed to be 2%Size of the reduction in disability burden for therest of the patients (with less serious illnesses)after receiving treatment at the hospital inquestion – 10% to 20% (case by case assessment,supplemented by sensitivity analysis)conjunction with NSW Treasury and itseconomic adviser. The invaluable commentsby Mr Robert Rust and Mr Onnes Hendrataof Health Infrastructure, Mr Rick Sondaliniand Ms Clare Wilde of NSW Treasury, MsCathryn Cox of the NSW Ministry of Health,and Mr David Greig and Dr Yuan Chou ofACIL Tasman are gratefully acknowledged.AuthorElsie Choy is general manager, BusinessStrategy for Health Infrastructure, NewSouth Wales.References1. Begg S, Vos T, Barker B, Stevenson C, Stanley L & LopezAD, The burden of disease and injury in Australia 2003,AIHW Cat. No. PHE 82, Canberra; May 2007. www.aihw.gov.au/publications/hwe/bodaiia03/bodaiia03.pdf2. World Health Organization (WHO). InternationalStatistical Classification of Diseases and Related HealthProblems, Tenth Revision. Geneva; 19923. Murray CJL & Lopez AD (eds). The global burdenof disease: a comprehensive assessment of mortality anddisability from diseases, injuries, and risk factors in 1990and projected to 2020. Vol I. Cambridge, MA: HarvardSchool of Public Health on behalf of the World HealthOrganization & the World Bank, 1996a.4. Stouthard ME, Essink-Bot M, Bonsel GJ, Barendregt JJ,Kramers PGN, van de Water HPA et al, Disability weightsfor diseases in The Netherlands. Rotterdam: Departmentof Health, Erasmus University Rotterdam; 1997.5. Australian Bureau of Statistics. Australian SocialTrends March 2011. Accessed at www.ausstats.abs.gov.au/ausstats/subscriber.nsf/LookupAttach/4102.0Publication25.03.114/$File/41020_HealthOMC_Mar2011.pdf6. Abelson P. Establishing a Monetary Value for LivesSaved: Issues and Controversies, Working Papers in Costbenefit Analysis WP 2008-2, Department of Finance andDeregulation; 2007. Accessed at www.finance.gov.au/obpr/docs/Working-paper-2-Peter-Abelson.pdf7. Mathers C, Vos T & Stevenson C, The Burden ofDisease and Injury in Australia. Australian Institute of Healthand Welfare, AIHW Cat. No. PHE 17, Canberra; 1999.Further readingMathers C, Bernard C, Iburg KM, Inoue M, Fat DM,Shibuya K, Stein C, Tomijima N & Xu H, 2004, GlobalBurden of Disease in 2002: Data Sources, Methods andResults, Global Programme on Evidence for Health PolicyDiscussion Paper No. 54NSW 2021, A Plan to make NSW Number One, NSWGovernment; 2011NSW Department of Planning & Infrastructure.Population NSW Bulletin, No 14; 2011.NSW Health. Guidelines for the Economic Appraisal ofCapital Projects (Supplementary to NSW GovernmentGuidelines); 2011.NSW Treasury. NSW Government Guidelines forEconomic Appraisal, Policy & Guidelines Paper, Sydney,Office of Financial Management; 2007.NSW Treasury. Infrastructure Statement 2010/11,Budget Paper No.4, Sydney, Office of FinancialManagement; 2010.Office of Best Practice Regulation, Value of StatisticalLife, Office of Best Practice Regulation, Departmentof Finance and Deregulation; November 2008. www.finance.gov.au/obpr/docs/ValuingStatisticalLife.rtfwww.worldhealthdesign.com WORLD HEALTH DESIGN | April 2013 63

Design & Health Scientific ReviewMixed-use environments:Retrofitting the shopping mallto support healthier communitiesHow can the US turn car-centric, run-down retail spaces into health-promotingenvironments? This study proposes turning them into mixed-use ‘villages’ thatstrengthen communities and are more friendly to walking and public transportAnthony R. Mawson, MA, DrPH, Jackson StateUniversity; Thomas M. Kersen, PhD, JacksonState University; Jassen Callender, MFA,Mississippi State UniversityDuring the post-war era of lowgasoline prices and prosperity,suburbs and subdivisions havebeen constructed in formerly rural areas,usually far from workplaces and shoppingfacilities, accessible only by automobile.Public transportation has usually beeninsufficient, inefficient or lacking. The needfor a personal motor vehicle to drive towork, shop and visit family and friends hasbeen taken for granted. Although the useof automobiles and the larger houses andlots available in the suburbs have providedfreedom of movement, they have also ledto the loss of forest and farmland, the lossof small-town life and the creation of urbansprawl, lacking defined communities orneighbourhoods, where people increasinglylive in comparative social isolation. 1 Thelong-term effects of these changes onhuman health, wildlife, habitat and otheraspects of the environment are not yet fullyunderstood. Living mainly indoors and outof sight of neighbours because of modernappliances such as air conditioners, clothesdryers, televisions and computers, peopleare connecting more today by text message,email and social media than face-to-face. 2In recent years, political, social andeconomic trends have combined tochallenge the habits of suburbanites andthe places they frequent, such as shopsand shopping malls, as well as the exclusiveuse of automobiles for transportation.Foreign wars and financial crises have led toeconomic decline and trillion-dollar deficits.Gasoline reserves are in question andoverall buying power has declined.There has been much discussion of theisolating nature of urban and suburban life aswell as the disruptions in social relationshipsand their adverse health effects. 3-5 At oneend of the socio-economic spectrum, therazing of old neighbourhoods for “urbanrenewal” led to massive social displacementand the loss of supportive social networks. 6Among suburbanites, family connections andfriendships are fewer and weaker; familiesare smaller and both family and friends areincreasingly scattered across the country.Membership of civic organisations is also indecline. In his book Bowling Alone, RobertPutnam 1 uses the pastime of bowling toexemplify this decline, noting that althoughthe number of people who bowl hasincreased in recent years, the number ofpeople bowling in leagues has decreased. Hesuggests that declining membership of suchsocial organisations threatens democracybecause, by “bowling alone”, people donot participate in the civic discussions thattend to occur in a league environment. Theoverall decline in personal interaction – thetraditional basis of social life, enrichmentand education – has reduced the active civilengagement required for a strong democracy.Disengagement from political involvementis seen in declining voter turnout, attendanceat public meetings, serving on committees,and working with political parties.Americans are said to be increasinglydistrustful, not just of government 7 but ofone another, witnessed by the many walledand gated communities that have arisento meet a rising tide of paranoia and fearof crime. Tenuous contacts with one’sneighbours not only contribute to distrustbut mean that such people cannot berelied upon for assistance in times of crisis.According to Putnam, 1 the social capitalFigure 1: Overbuilding, recession and the internet mean that many US malls are no longer financially viableMarcmoss/Foter.com64 April 2013 | WORLD HEALTH DESIGN www.worldhealthdesign.com

Urban Design(ie, goodwill and tangible help from thecommunity) that was once available hasdeclined in the US since the early 1960s.Participation in national organisations andin social activities such as picnics, dinnerparties and card games has also declined.Social bonds and connections in Americahave weakened over the past half centuryand social networks have become smallerdue to reduced social interaction. 8 Supportfor this observation comes from theGeneral Social Survey (GSS) on changesin social networks between 1985 and2004. 9 In 1985 the GSS collected the firstnationally representative data on “confidantswith whom Americans discuss importantmatters”. In the 2004 GSS, changes in coresocial networks were reassessed. The majorfindings were as follows:• Discussion networks were smaller in2004 than in 1985• The number of people saying they had“no one to discuss important matterswith” nearly tripled• Average network size decreased byabout a third, from 2.94 in 1985 to 2.08in 2004 (a loss of one confidant in three)• The typical respondent reported havingno confidant, whereas in 1985 the typicalrespondent had three confidants• Both kin and non-kin confidants were lostin the past two decades, with a greater lossof non-kin ties. This has led to networkscentred on spouses and parents, withfewer social contacts through voluntaryassociations and neighbourhoods.The shrinkage of social networks reflectsan important social change in the US,where the greatest decrease in close bondsoccurred between neighbours and voluntarygroup members. McPherson et al 9 concludethat community and neighbourhood tieshave weakened dramatically. Virtual socialmedia’s impact has been to create a largernetwork of weak social relationships ratherthan to strengthen bonds between closefriends and family. Spending time on theinternet has moreover been found to reduceinteractions with family members; for everyminute spent using the internet, a third of aminute less was spent with family. 10 In a studyof internet users over a one- to two-yearperiod, time spent using the internet wasinversely related to family communicationand to the size of participants’ local anddistant social networks. 11Figure 2: Broadway Malyan’s Forum Coimbre, an award-winning suburban shopping centre in Portugal; the bestcontemporary malls connect with nature, and with the wider communityDeclining social networks and personalinteraction are not only a threat todemocracy, according to Putnam, 1 but athreat to health and social wellbeing. Manis a social animal with needs for physicalcontact and nurturance that have profoundimplications for health and disease. Multiplestudies have shown that the existence ofclose personal relationships and frequentsocial interaction are essential to goodhealth, and those lacking strong social tiesare at increased risks of illness and deathfrom all causes. 12-15The positive effects of close communityties on health and longevity were revealedin a now-classic 30-year study of membersof the town of Roseto, Pennsylvania, madeup largely of Italian immigrants. 16 In the early1960s, the town was noted for having anexceptionally low death rate from ischemicheart disease (myocardial infarction), lessthan half that in an adjacent town, Bangor,which lacked strong community ties. Yetsmoking and unhealthy dietary habits wereas common in Roseto as in neighbouringcommunities. In the early 1960s, Rosetowas a close-knit community where familiesoften ate together, enjoyed frequent socialwww.worldhealthdesign.com WORLD HEALTH DESIGN | April 2013 65

Design & Health Scientific Reviewgatherings and entertaining, and had manystrong civic organisations. In later years, asRosetans adapted to the American way oflife and began to seek better paying jobsand moved to the suburbs, their death ratefrom MI rose to equal that of Bangor.Rosetans who had been tested in 1962-63 and experienced a fatal MI by the year1990, or had a well-documented heartattack and survived, were compared tounaffected controls. As expected, highcholesterol levels were associated with atwo-fold increased risk of MI. Yet fewer than20% of those with high cholesterol levelsexperienced an MI over the 30-year period.There were also no significant differencesbetween the coronary patients (survivors orotherwise) and matched controls in termsof the standard risk factors of smoking,hypertension, diabetes or obesity. Thesefindings were interpreted as suggesting that,despite having these risk factors, Rosetanstended not to succumb to MI because ofthe protective effect of strong social bondsand networks against heart disease. 17Even more impressive are studiesindicating that coronary heart disease canbe reversed by participation in programmesthat include frequent and intense socialinteraction. In his interventional studies ofhigh-risk patients with heart disease, DeanOrnish included dietary restriction, smokingcessation and meditation as well as frequentgroup meetings in which participants wereencouraged to interact openly and warmlywith one other. Ornish et al 18, 19 reported thatthe extent to which participants “opened uptheir hearts” to other people in these groupsover the one- to two-year programme wasparalleled by the increase in the patency oftheir coronary blood vessels, as shown bypercutaneous coronary angiography.Taken together, these observations suggestthat the suburban way of life and associateddecline in social relations have adverseeffects on health and longevity. At the sametime, there has been a drastic change in thegeneral economy: consumer spending isexpected to decline to what it was about10 years ago, and a new pattern of frugalitywill remain. 20, 21 Retail material goods saleswill likely suffer most and not rebound fromrecessionary spending levels. Consumersare also less oriented towards spending andmore inclined towards family, communityand the support of local businesses. 22Overbuilding, global recession, increasinginternet sales, the decline of departmentstores and changing consumer valueshave combined to create what has beendescribed as the “perfect storm” forshopping centres and malls. Retail andrestaurant sales have declined and storevacancies are accelerating. Many shoppingcentres and malls are in serious financialtrouble and are searching for strategies tobecome viable again. According to WhiteHutchinson, “root causes rather than justsymptoms need to be determined and thenaddressed in order to cure the ills. Fixes arenever simple or easy. An overall strategy,often requiring repositioning and someredevelopment of the shopping centre,must be formulated. Such an analysis andstrategy is often best accomplished by anoutsider, lacking pre-existing biases.” 23From shopping centre to villageWe co-authors – an epidemiologist, a socialscientist and a professor of architectureaffiliated with a Community Design Center– propose herein a practical solution thatcould be applied to any ailing shoppingmall and could lead to increased consumeractivity, profitability and sustainability. Ourcentral idea is that malls can be kept vitalby retrofitting them to serve additionalessential purposes; that is, by transformingthem into village-like communities. Thiscould entail building several levels ofapartments and offices above the shopsbelow (if structurally feasible) or designingadjacent new residential structures.To create a village it will be necessary toprovide all of the amenities of a village orsmall town, ie, a butcher, baker, grocer, postoffice, auto repair shop, hair salons, cafes,restaurants, newsagents, etc, as well as anadministrative structure, community centreand meeting room. The size of major storesthat depended on a high volume of trafficmay have to be reduced, but smaller shopscould be added, allowing “mom and pop”stores to reappear. It may also mean morebusiness for stores that have not done wellcommercially in traditional shopping malls,such as custom framing and art shops.While the custom of “going out to themall” may be declining in the US for the manyreasons described above, people may bemore likely to take advantage of the facilitiesoffered by shopping malls if they lived there,as part of a village-like community wherethey would meet and interact regularlywith others and where store owners wouldbecome neighbours. This concept couldresolve the simultaneous problems thatbeset the current suburban lifestyle: firstly,having to drive great distances in somecases, often in different directions, to accessworkplaces, schools, shops, churches andfriends; and secondly, the lack of availability ofclose friends and family and of face-to-faceinteraction. Retrofitting and transformingailing shopping malls into villages would atonce bring new life and business to thesefacilities as well as bring people into closerproximity to their everyday needs; it wouldcreate opportunities for employment,enhance social networks and relationships,and at the same time reduce the need forand use of motor vehicles. The proposedretrofitting utilises existing infrastructure,entails less need for vehicular use, andwould serve to increase social interactionand the quality of social relationships.The vision is to transform ailing shoppingmalls into self-sustaining residential, shoppingand office spaces that would be identified asvillages, where people of all types and agescan live comfortably and access all essentialand desired amenities on foot or bicycle.In addition to physical retrofitting, supportand guidance would also be provided tothe new residents and tenants to establish avillage social administrative structure.Implementing the proposed retrofittingprogramme would comprise the following:• Building two to three storeys aboveshopping malls or designing new structuresin adjacent former parking lots to providemixed-use residential/office space• Arranging for parking close to residencesand offices• Organising a village administrativestructure, driven by community members• Organising weekly markets inside oradjacent to malls, eg farmers’ marketsand/or flea markets and activities such asfairs, exhibitions, musical or other events• Creating (or modifying) essentialfacilities and shops in addition to thosealready provided in the shopping mall,including but not limited to a post office,butcher/fishmonger, bakery, hair salon,fitness facilities, medical/dental clinics, acommunity centre, cinema and tavern.Retrofitting shopping malls into village-likeplaces would be expected to ensure a highlevel of social interaction and contentment66 April 2013 | WORLD HEALTH DESIGN www.worldhealthdesign.com

Urban DesignAnguskirk/Foter.comFigure 3: The walkable, sociable, multi-use nature of the traditional English village was the part-inspiration for this researchas well as commerce. Visitors would beattracted by the excitement and intimacyof the new “villages”, with all their addedadvantages and amenities. Many readers willrecall the American TV programme Cheers,and its portrayal of a tavern with a closeknitclientele where “everybody knows yourname”. Shopping malls could similarly bealtered to become villages where peoplewould quickly grow acquainted with oneanother; where shopping can be done onfoot; where people can also be employed inmany cases; and where all of the amenitiesof a “true” village are provided, including avillage administrative structure.Determining feasibilityWhat would be needed to determine thefeasibility of such a venture at a given site? Weenvision a two-phase process: 1) backgroundresearch, and 2) specific applications.Phase I: Background research• Case Studies: To prepare for work of thiscomplexity and to ground it in termsof financial viability, up to five successful“live and work” revitalisations of existingshopping centres in mid-size Americancities would be sought and described,comparable to that of the mall in question(the “target mall”).• Sociological Analysis: To determinethe social-psychological impact ofthe proposed architectural and socialtransformation at each site, and historicalsurvey and socio-cultural analysis wouldbe carried out as well as an opinionsurvey of shoppers at the site, to assessthe level of community readiness andinterest in participating as potentialresidents or tenants.• Materials and Structural Research:Construction materials and methodsutilised in many American shoppingcentres are structurally insufficient tosupport vertical expansion. Traditionalmethods for adding structural capacity arealso costly and commercially invasive interms of downtime to existing occupants.To overcome this, existing methods andmodels would be analysed and alternativesolutions proposed. This research wouldallow for rapid structural feasibilityassessment of selected existing structures.• Code/Zoning Analysis: Existing codesand zoning regulations enforced in manymunicipalities limit building density andfoster segregation of activities. Zoningordinances and building codes at eachsite would be reviewed and comparedwith best practices being enacted incommunities around the country.Phase II: Specific applications• Case Studies/Demographic Comparisons:Results of the Phase 1 review would becompared to the specific demographicand other features of the target mall andto the immediate context and surroundingneighbourhoods. This information wouldhelp determine the economic viabilityand percentage of space to be allocatedto various uses at each site.• Materials/Structural Research: Existingstructural conditions would be reviewedin relation to the results of research fromthe Phase 1 materials/structural analysis,to provide a guide for proposals relatingwww.worldhealthdesign.com WORLD HEALTH DESIGN | April 2013 67

Design & Health Scientific ReviewFigures 4&5: Built on the site of an abandoned 1960s mall, Belmar, in Lakewood, Colorado, offers residential, retail and leisure space on one 115,000sqm siteto the targeted mall. This would providean estimate of the maximum extentof vertical expansion. These researchfindings would be turned over to theselected licensed design professionals forthe implementation phase.• Code/Zoning Analysis: Localdemographics and proposed buildingusage would be compared to existingcodes and ordinances enforced at thesite of the target mall. Drawing on bestpractices revealed in the Phase 1 analysis,recommendations would be offeredand assistance provided to the owner/manager in preparing documents neededto apply for zoning modifications.• Architectural Programming: Informationgleaned from the three immediatelypreceding steps would be combined witha survey of existing conditions (parking,total footprint, net-to-gross ratio, sizeand location of existing mechanicalinfrastructure). An overall report onproposed uses, square footages, keyproximities and other relevant issues thenwould be prepared for implementationby licensed design professionals.• Concept Design: Although the finaldesign would be the responsibility of thesponsor’s architect, conceptual sketchesand renderings would be developed toestablish the project’s image and to assistin marketing efforts.• Preliminary Cost Estimate: Based onthe programme and conceptual design,a preliminary cost estimate would beprepared to facilitate initial discussionswith the sponsor and/or investors andto establish phasing priorities should thetotal scope of work prove too large forimplementation in a single phase.• Report Preparation: These activitieswould include discussing and synthesisingthe data, creating appropriate graphicsand tables, and offering evidence-basedrecommendations.DiscussionAn entire way of life is changing in America,and with it, traditional concepts andmethods of shopping and the use of certainshopping facilities. Shopping for necessitieswill continue, of course, but the habit ofdriving to malls to shop is increasingly underpressure to change. With ready accessto multiple suppliers and catalogues andinstant access to prices, discounts and easymethods of payment, shopping is increasinglydone online for more expensive items,saving petrol and saving time. As noted,several emerging trends now challenge thecontinued viability of shopping centres andmalls. At the same time, there is increasingawareness of attenuated connections tofamily, friends and community, and many feelthe need for a more permanent “home”. 24With the seemingly endless recession, risingfuel prices and declining buying power,excitement at the prospect of shopping atthe mall has dimmed. A new perspective onlife is emerging: people are “making do” andfocusing more on others for activities andentertainment, while confronting the realityof having fewer close friends and family tovisit than they would wish. This may actas a stimulus for seeking a small town orvillage way of life, possibly one that, for olderpeople, was experienced in childhood.The strategy proposed here for addressingthese diverse trends, while salvaging theexisting infrastructure, is to retrofit ailing andabandoned malls into village-like places suchas Roseto, Pennsylvania, where, a generationago, a thriving community, with strong socialnetworks and low cardiovascular diseasemortality rates, was lost. This occurred whenthe residents, mainly Italian immigrants,followed the American dream of suburbanliving, prosperity and self-determination thatled to their gradual dispersal and resultantsocial isolation.The conversion of shopping malls intovillages would combine residential living withbusiness and shopping facilities and provideall of the amenities and services that aretypically available in a village; it would alsooffer residents multiple opportunities toestablish social networks and to recreatea more communal lifestyle. Communitieswould develop in which people comfortablylive, shop for basic necessities, enjoy otheramenities and, in many cases, work on site,68 April 2013 | WORLD HEALTH DESIGN www.worldhealthdesign.com

Urban Designwhile continuing to enjoy the mall’s features.The growth of shopping malls paralleledthe rise of suburbia in the 1950s throughto the 1970s. Planners then had little regardfor fuel economy, the environment or forfostering walkable spaces. This exuberantperiod of growth in America did not last,however, and many shopping malls aroundthe country are failing or abandoned. 3Of the 2,000 regional shopping mallsnationwide in 2001, 19% were consideredin danger by the Congress for the NewUrbanism and PricewaterhouseCoopers. Inmany cases, poor economic performancewas compounded by site or locationcharacteristics that made a turnaroundunlikely as long as a conventional retail mallformat was retained. This has created areasknown as “greyfields”, largely abandoned orunderused spaces that nevertheless offeropportunities for mixed-use areas thatcombine work, home and other facets.Such models clearly require major changesin thought and practice with regard to zoning,developer/community leader commitment,and other factors. The vision and support oflenders, developers, and community leaderswill be critical in facilitating the conversionof ailing or abandoned shopping malls intomixed-use locales. However, when all ofthe necessary elements come together,the vision can be realised. For instance,Belmar community in Lakewood, Colorado,on the site of a 115,000sqm (1.4m sq ft)abandoned shopping mall built in the 1960s,has become a mixed-use development withshops, homes, and offices in close proximityto one another. 25In her book Retrofitting Suburbia, EllenDunham-Jones 26 discusses the retrofittingof ailing shopping malls as part of a broaderagenda to retrofit suburban areas as a whole(see also Dennis-Jacob 27 ), making them moredesirable places in terms of aesthetics andconvenience but also in terms of the overallhealth of the population. She addressesshopping malls as a modern, indoor versionof the traditional marketplace and notestheir growing struggle to survive in anincreasingly competitive retail environment.She suggests that shopping malls, as“core” areas of many suburbs, presentopportunities for retrofitting as mixeduseenvironments that can also contributeto making suburbs more sustainable whilemaintaining the malls’ commercial functions.Noting that the retrofitting of malls isan increasing practice in North America,Dunham-Jones proposes that parking areassurrounding malls could be converted intohigh-density buildings, including residentialunits, and that improved conditions forwalking and biking should be provided aswell as increased public transportation,thereby creating a livable and sustainablepart of the suburban environment.Here we have sought to contribute tothis perspective by suggesting that ailingshopping malls could be usefully retrofittednot just as mixed-use places but specificallyas “villages” within the larger suburbanenvironment, acquiring their own identityin relation to surrounding areas. We havealso outlined a method for assessing thearchitectural, regulatory, economic andsocial feasibility of implementing such plans.Subject to establishing the feasibility andacceptability of such concepts at a givensite, a masterplan would be developed forimplementation and evaluation. Retrofittingshopping malls into villages could save thesecommercial structures and in some casesthe retail facilities themselves, as well asreduce encroachment on greenfield areas,and help to strengthen the community andspiritual life of the country.AuthorsAnthony Mawson is an epidemiologist andsocial scientist and a visiting professor in theSchool of Health Sciences, College of PublicService, Jackson State University, Jackson,Mississippi. The inspiration for this paper washis early life in the English village of KingsLangley, Hertfordshire. Thomas M. Kersen,PhD is assistant professor, Department ofCriminal Justice and Sociology at JacksonState University. Jassen Callender is associateprofessor at Mississippi State University anddirector of the School of Architecture’sJackson Center; his areas of researchinclude the analysis of urban systems, visualperception, and philosophical constructionsof desire. He has presented internationallyon issues of sustainable urbanism.References1. Putnam, RD. Bowling Alone: The Collapse and Revival ofAmerican Community. New York: Simon and Schuster; 2000.2. Zhao, S. Do Internet users have more social ties? Acall for differentiated analyses of Internet use. Journal ofComputer-Mediated Communication 2006. 11(3), article 8.Accessed at: http://jcmc.indiana.edu/vol11/issue3/zhao.html3. Baumgartner, MP. The Moral Order of a Suburb.Oxford University Press: New York; 1998.4. Greer, S. Urban Renewal and American Cities. Bobbs-Merrill: Indianapolis; 1965.5. Stein, M. The Eclipse of Community: An Interpretationof American Studies. Princeton University Press: Princeton,New Jersey; 1960.6. Fullilove, MT. Root Shock: How Tearing Up CityNeighborhoods Hurts America, and What We Can Do AboutIt. Random House, New York; 20057. www.nytimes.com/2011/10/26/us/politics/howthe-poll-was-conducted.html?_r=18. Myers, DG. Close relationships and quality of life.In Kahneman, D, Diener, E. and Schwarz, N. (eds.). Well-Being: The Foundations of Hedonic Psychology. Russell SageFoundation: New York; 1999.9. McPherson, M, Smith-Lovin, L, Brashears, ME.SociaIsolationAmerica: changes in core discussionnetworks over two decades. American Sociological Review2006, 71:353-375.10. Nie, NH, and Hillygus, S. The impact of internetuse on sociability: Time-diary findings. IT and Society 2002,1(1):1-20. www.ITandSociety.org11. Kraut, R, Patterson M, Lundmark, V, Kiesler, S,Mukopadhyay, T, and Scherlis, W. Social involvement andpsychological well-being? American Psychologist 1993,53(9):1017-1031.12. Montagu, A. Touching: The Human Significance of theSkin. Columbia University Press: New York; 1971.13. Ornish, D. Love & Survival: 8 Pathways to Intimacyand Health. Harper Collins: New York; 199814. Thoits, PA. Mechanisms linking social ties andsupport to physical and mental health. Journal of Health& Social Behavior 2011, 52(2):145-61.15. House, JS. Social isolation kills, but how and why?Psychosomatic Medicine 2001, 63(2): 273–274.16. Bruhn JG, Wolf, S. The Roseto Story: An Anatomy ofHealth. University of Oklahoma Press: Oklahoma City; 1979.17. Wolf, S. and Bruhn, JG, with Egolf, BP, Lasker, Jand Philips, BU. The Power of Clan: The Effect of HumanRelationship on Coronary Heart Disease. TransactionPublishers, Rutgers University: New Brunswick, NewJersey; 1992.18. Ornish, DM, Brown, SE, Scherwitz, LW, et al. Canlifestyle changes reverse coronary atherosclerosis? TheLifestyle Heart Trial. Lancet 1983, 336(8708):129-33.19. Ornish, D. Dr. Dean Ornish’s Program for ReversingHeart Disease. Random House: New York; 1990/Ballantine Books; 1992.20. Standard & Poor’s Equity Research,www.standardandpoors.com21. Moodys Analytics, www.economy.com22. Demise of the stuffed; birth of the groundedconsumer. www.whitehutchinson.com/leisure/ar ticles/demise-of-the-stuffed.shtml23. The Grounded Consumer: Changing the Paradigmof Shopping Center Entertainment. www.whitehutchinson.com/leisure/articles/Grounded_Consumer. shtml24. Smith, K, and Zepp, I. Search for the BelovedCommunity. Valley Forge, PA: Judson Press; 1974.25. Congress for the New Urbanism; 2005. Mallsinto Mainstreets. An In-Depth Guide to Transforming DeadMalls into Communities. Accessed at www.mrsc.org/artdocmisc/cnumallsmainstreets.pdf26. Dunham-Jones, E, and Williamson, J. RetrofittingSuburbia, Updated Edition: Urban Design Solutions forRedesigning Suburbs. New York: John Wiley & Sons; 2011.27. Denis-Jacob, J. Retrofitting SuburbanShopping Malls: A Step Towards MetropolitanSustainability. N.p., 6 May 2011. Web. 20 Jan. 2013.www.geographyjobs.com/article_view.php?article_id=243.www.worldhealthdesign.com WORLD HEALTH DESIGN | April 2013 69

Design & Health Scientific ReviewThe future of healthy communities:Humanism in our designed environmentsA salutogenic approach to landscape design can help bridge the gap between creating sustainableenvironments, and making community resources that improve individual health and wellbeingDavid Kamp FASLA, LF, NA, DirtworksLandscape Architecture, PCOur capacity and potential asa collective society and thetechnological, scientific andeducational resources we have at ourdisposal are unprecedented. Yet so are thethreats to the basic health of the planetand its inhabitants. Biodiversity declineswhile greenhouse gas emissions increase;the balance between resource depletionand regeneration grows more precariousas the earth’s climate grows more erratic.Population soars in developing countries,concentrated in unprepared mega-urbancentres. Vast portions of the world’s fastestgrowing cities are built on ecologicallysensitive, unstable landscapes; densequarters in poverty and environmentaldegradation that lack the support systemsto provide a basic quality of life for itsinhabitants.This is, indeed, the best of times and theworst of times. Although we have advancedtechnology at our disposal, it will do nolong-term benefit unless we also take intoaccount ideas of a healthy environment thattie individual wellbeing to larger communitygoals. The following two concepts, I believe,will help make a bridge between individualand larger concepts of health: first,sustainability – creating and maintaining theconditions for life to thrive in balance withits environment; and second, salutogenesis– the promotion of health and the roleof individual perception and motivation inmaking choices towards health.Sustainable development 1 is based upona sense of connectedness – the relationshipbetween societies, the environment andits resources. The term was coined in 1987by the Brundtland Commission (formerlythe World Commission on Environmentand Development), which framed it asdevelopment that “meets the needs of thepresent without compromising the abilityof future generations to meet their ownneeds”. This mandate, to balance resourceuse and environmental preservation,has expanded to encompass a largerresponsibility: to not only accommodatebut improve the life of future generationsby restoring and repairing natural systemsand preventing future ecosystem damage.It is concerned with the carrying capacityof natural systems and the stress placed onthe environment by the social challengesof humanity.Salutogenesis, 2 on the other hand, is aperspective of personal health proposedby Aaron Antonovsky. Rejecting the longstandingmedical model of dichotomy,Figure 1: Rockefeller Center Chanel Gardens, New York. Sustainability and salutogenesis are two concepts that can provide a link between a healthy environmentand wider community goals70 April 2013 | WORLD HEALTH DESIGN www.worldhealthdesign.com

Landscape Designwhich separates health and illness,Antonovsky proposed that these extremesbe understood as a continuum. In addition,salutogenesis describes an approach thatlooks at the factors that promote healthrather than factors that cause disease,focusing on the relationship betweenhealth and stress. 3 At its core is his Sense ofCoherence construct, which describes therole of stress in human functioning, and theneed to maintain an orientation towards theworld that is comprehensible, manageableand meaningful. In essence, a fortified senseof coherence – comprehending a situation,managing effective actions, and findingmeaning or purpose – better prepares usfor life’s challenges. Antonovsky’s constructemphasises the importance of a personaldefinition of life’s quality and how thatquality influences behaviour and choices.The future of humanism in ourdesigned environmentsIt is not too much of a stretch to claimthat all design aims to be salutogenic. Ifnot explicit, then by implication, designis the art (and sometimes science) ofrendering the elements of the designedenvironment comprehensible, manageable,and meaningful. Our quality of life is directlyinfluenced by the quality of the designedrelationship between the built and naturalenvironments. Design is an expression ofpersonal and social values. It is an expressionof our hopes and aspirations in what wechoose to build. Unfortunately, trouble indesigning today’s environment begins withthe complex and often conflicting goalsvarious essential and peripheral agenciesimpose on the process and demand fromthe results.It has become a struggle for designers(architects, landscape architects, planners) tounderstand and balance the myriad physicalsystems that need to be accommodatedwith the political forces that influence asocieties’ ability to manage natural, technical,economic and human resources. No wonderfinding personal meaning in urban settingscan be daunting. But if Antonovsky’s senseof coherence is to be strong in individualsliving in these complex circumstances, it isessential for designers to try and lay barethe threads that tie individual experiencesto larger social and environmental needs.Trusting that this theory has merit, thefuture of personal health may well dependFigure 2: Responsive Infrastructure – rediscovering a connection between natural systems andengineered systemsupon it: each of us must not be hamperedby the environment in finding meaning inour lives or else we will not care enough tofind the strength to persevere. In essence,designers, like doctors, should develop anenvironmental version of the Hippocraticoath; not the encapsulated “first do noharm” mantra, but the oath with all itsawareness that professionals have anexpertise and therefore a responsibilityto inform, educate, and, if required, warnagainst possible problems.Nowhere is that challenge more evidentthan in our urban environments. More thanhalf the world’s population lives in cities. Thispercentage is predicted to increase to morethan 75% by the middle of the century.Cities once had an organic relationship tothe resources that made them work. Today,we find immense concentrations of peoplein places that cannot support them. Thereis no longer that organic connection topopulation growth and resources, to theinfrastructure that supports our cities andthe carrying capacity of the land’s naturalresources. Even in large developed centres,much is antiquated, inefficient and notsustainable going forward.In addition, there are landscapes notdirectly linked to urban centres that havebeen laid waste through overproductionand stripping that should be reclaimed andmade vital. In the following examples, andthroughout the world, we need to applyboth sustainable and salutogenic ideas toour designed interventions as we come toappreciate the interconnectedness of all thelandscapes we inhabit.Global planning is well beyond the scopeof this investigation. However, the two casestudies discussed here make creative useof designed infrastructure integrated withnatural systems. Both deal with resources:in one, resources that have been forgotten;and in the other, resources that have beenexhausted. Each offers insightful ideas for asustainable future, one in which individualsare engaged and participating in health.More importantly, each design strategymerits review because the solutions pointto larger, more encompassing design issues.Responsive Infrastructure: a casestudyBuilt within one of world’s largest naturalestuaries, New York City evolved into agreat commercial centre. Over the courseof centuries, this vast ecosystem and itsintrinsic natural capital was exploitedin efforts to provide the expedientengineered infrastructure necessary for arapidly growing population. As the city grewin size, its connection to the land and waterwas compartmentalised in ways best suitedto commercial interests and economicpressures. Natural watercourses wereobliterated or piped, and landform mouldedand paved to accommodate expandingpopulations. The shoreline was filled andthe waterfront buried under bulkheadswww.worldhealthdesign.com WORLD HEALTH DESIGN | April 2013 71

Design & Health Scientific ReviewFigure 3: Remnant pilings of abandoned piers lining Manhattan’s East and Harlem Rivers form an inspiration forcreating a new waterfront. The design respects the ecological, physical and social forces that have shaped the cityFigure 4: Using three areas along the waterfront, the piling system forms an adaptive network for a host of sitespecificusesFigure 5: Within a protective cove, pilings create a dynamic neighbourhood centre with recreational access,floating community gardens and links to public transportationfor maximum commercial and industrialefficiency. Economic forces changed, andover time so did the dynamic of the city. Awaterfront once pulsing with vibrancy fromshipping and industry eventually morphedinto only convenient motorways, restrictingwaterfront access altogether. Mixingrecreational and commercial uses – or evenrecreational and industrial uses – can be avital part of city life. That vitality disappears,however, when any natural and thereforeemotionally satisfying resource is removedfrom personal experience. So as the cityevolved from a vegetated waterfront, toan industrial engine, and now to a postindustrialurban centre, the waterfront’snatural and then built infrastructure systemsbecame defunct; mere echoes of pastidentities and values.This first case study explores a responseto ageing urban infrastructure and aforgotten connection to nature. TitledResponsive Infrastructure, the design seeksto rediscover a connection between naturalsystems and engineered systems; New YorkCity’s industrial and commercial past hasbeen rethought for a sustainable future,honouring the past as one looks forward.The design uses the remnant pilings ofabandoned piers that stretch along theEast and Harlem Rivers as an inspirationfor creating a new waterfront that respectstwo historic forces that once shaped thiscity: the natural ecosystem, influenced byriver currents and tidal forces; and the socialecosystem, influenced by human habitation.Looking like a border of hybridised rivetsalong the Manhattan waterfront, ResponsiveInfrastructure repurposes the pilings, fusingtogether social, ecological and physicalenvironments. Together, the infrastructureforms an adaptive network for a host ofnew site-specific uses.Respecting ecological, physical andsocial forcesThree areas were identified for achievingthese goals, based upon environmentalconditions, cultural connections and usage:• An area for energy production. BlackwellNarrows forms a section of river with fastflowing,turbulent currents. The adjacentneighbourhood is densely developedwith housing and commercial buildingsand sits on a high bluff overlooking theriver. With no direct access possible tothe river, pilings are used to support a72 April 2013 | WORLD HEALTH DESIGN www.worldhealthdesign.com

Landscape Designturbine farm, capturing the strong riverand tidal currents for energy. Beaconsatop each piling reveal the currents’direction and intensity of flow, permittingpublic awareness of the river’s changingconditions. Energy created from theturbines is used to light an adjacentelevated walkway and bikeway, providinga riverfront promenade to an otherwiseinaccessible area.• An area to celebrate connectionsand community. Mill Rock Cove takesadvantage of a slow-moving river current,a naturally formed protective cove with agentle surrounding terrain, the terminusof a major city thoroughfare and nearbypublic transportation to create awaterfront community centre. Forming aportal between land and water, the coveis a dynamic intersection of active andpassive functions. The pilings provide thepublic with protected recreational accessto the water within a series of floatingwetlands. The concept for the floatingwetlands – a buoyant foam and matstructure containing growth media andplants – also serves as the frameworkfor floating community gardens, providingfresh vegetables to the neighbourhood.The pilings also provide pier access toa water/land transportation link, a newpart of the city’s public transportationsystem. The link encourages walking andprovides commuters with “everyday”access to nature.• An area for ecological restoration andenvironmental study. The river’s HarlemChannel section, a confluence of tidaland river currents, creates a distinctecological environment with the ebband flow of tides mixing salt and freshwater ecosystems. The adjacent landformallows for the recreation of the area’snatural watershed, creating a uniquesetting that combines a natural stormwater treatment structure within thecity structure. This intervention of anatural stormwater system within thedense urban fabric helps accommodateperiodic storm surges and erratic rainfalloccurrences. The pilings are used to createnatural habitat and establish a local waterquality treatment facility – serving bothas an outdoor environmental laboratoryfor adjacent education institutions and aninformal educational opportunity for thesurrounding neighbourhoods.Figure 6: Forming a portal between land and water, the cove celebrates connections and communityFigure 7: Creating habitat, a natural storm-water treatment facility, and an outdoor environmental educationlaboratoryThe piling system crafts a new vision forthe iconic waterfront piling, adapting it fornew uses that respond to today’s challenges.It is based on a single modular base elementto which customised components maythen be attached. The attachments supportthe development of aquatic habitat, avianhabitat, oyster beds, hydropower turbinesand standard pilings for a variety of otheruses (floating wetlands, moorings, docksetc). Assembled into combinations that bestrespond to specific conditions and needs,this system provides ongoing flexibility associal and environmental needs evolve overtime. For example:• Habitat creation. For avian habitats,the pilings have attachments and cutawaysections to support nesting sites.For aquatic habitats, vertical screensprovide protection and feeding areas.For recreating oyster reefs, metal meshsleeves create protected areas andsupport for the oyster beds.• Floating wetlands. Shoreline areas thathave shallow water depth and weakcurrents can support the simulationof a marsh habitat. Here, the pilingscontain and provide support for floatingvegetated pads that function to filterthe water and create additional aquaticand avian habitats.• Turbine farm. In response to heavy rivercurrents and tidal changes, the pilingsact as supports for turbines, which canharness the water’s energy and thenconvert it to hydropower. The multibladehelical turbines are calibrated tothe current’s directional flow, to allow formaximum efficiency in capturing watercurrentenergy.www.worldhealthdesign.com WORLD HEALTH DESIGN | April 2013 73

Design & Health Scientific ReviewFigure 8: The system of new modular pilings ispart of a strategy to break down the city’s hardedge – an echo of a past reliance on an efficientcommercial borderIn light of an increasingly erratic climate,this concept also builds upon the basicframework of sustainability to supportresilience and adaption. A system of newmodular pilings creating a grid helps ensureflexibility as social and environmentalneeds evolve over time. This system isalso part of a strategy to break down thecity’s hard edge – a remnant of the past’sreliance on an efficient commercial border.The scheme breaks down this conditionwherever possible, providing a morediffused, modulated, green edge – one thatis more conducive to human interactionand coping with periodic storm surges andrising sea levels.Here is a living demonstration of healthbenefits to both the environment and toindividual wellbeing. We can experience andsee its benefits. It is tangible and, drawingupon historic and cultural influences, itis intellectually and emotionally engaging.Our second design project poses a moresubtle challenge: how to make a visceraland intellectual connection to processesthat come to fruition only after many years.Growing soil: a case studyIn 1937, US President Franklin Rooseveltsaid: “The nation that destroys its soildestroys itself.” 4 This powerful statementwas framed within the context of the DustBowl, a period in the 1930s when severedust storms caused significant ecologicaland agricultural damage to NorthAmerican prairie lands. The phenomenonwas caused by a combination of factors:severe drought, extensive farming andpoor soil conservation practices. Naturalecosystems, containing a web of plant andanimal communities that help maintainresiliency in times of environmental stress,were replaced by vulnerable, extensive andintensive farming practices that lacked suchresiliency. This scenario continues to beplayed out in communities throughout theworld with a combination of new and oldprotagonists: congested population centres,unchecked production (agriculture andindustrial) and erratic climate, along withother factors have left the land vulnerableand fragile. Soil is infrastructure.The concepts shown here are part ofa competition entry to find new uses foran abandoned industrial site, a 106-hectare(260-acre) former quarry in the north-westof England. Years of unrestrained activitywith no efforts towards remediation leftthe land barren and unusable. Exposed towind and rain and adjacent to a major river,erosion is a continual threat to the nearbycommunity and communities downstream.Ironically, productive agricultural land is at apremium in this area. As part of a regionalgovernment environmental remediationeffort, the project’s goal is to providesocial and economic benefits to thesurrounding community while restoringnatural woodland.We saw the project as an opportunity tostrengthen community – human and nonhuman– through the land by asking thequestion, “How do you heal an unhealthysite?” The resulting design revolves aroundtwo interventions: land forming andmanaged succession.Land forming is based upon the principlesof Keyline design, 5 an agricultural techniquedeveloped by PA Yeomans. This system ofland planning and management, used inboth rural and urban settings, is based onthe natural topography of the land and itsrainfall. It uses the form of the land itself tohelp determine the layout of agriculturalcomponents, maximise the absorption ofrainfall and minimise rainfall runoff.Managed succession is based upon thebiological processes of the nitrogen cycle tobuild a fertile soil. A progression of managedplant successions help fix nitrogen levelsand increase the development of biomass inthe soil. Plant succession is complementedby soil conditioning, including specialisedtilling to loosen compacted soils andprovide channels for water absorption andmanaged intensive grazing.Taken together these interventionsreinforce the creation of a supportiveenvironment: improving the soil’s structureand fertility, improving water quality,providing economic productivity, andestablishing a shared connection to the land.A phased implementation plan isproposed to address the immediate needfor stabilisation within a long-term vision.Once the ongoing process of topsoilproduction is in place, the site will beconfigured to incorporate several typesof protected natural habitat, a workingdemonstration farm and training centre witha commercial outlet for the surroundingcommunity, and an ecological researchcentre focused on the study of sustainableagricultural practices within the context ofclimate change. The project establishes theframework for creating community:• The human community, by honouringa traditional livelihood while alsoestablishing a “new” agrarian identitywith its eye to the future. For example,creating a programme of growing biobasedbuilding materials to supportthe local community and establishingaquaculture in the restored water system.• The non-human community, by creatinga biologically rich, vibrant and resilientecosystem with local and regionalimplications. For example, improving waterquality in the surrounding rivers, lakes andwetlands and the re-establishment ofmigratory species habitat.This design is about demonstratingthe hidden aspects of landscape – how itfunctions environmentally, hydrologically,economically and socially. How does thissite tap into evolving ecological and socialFigure 9: “The nation that destroys its soil destroysitself” – US President Franklin Roosevelt, 193774 April 2013 | WORLD HEALTH DESIGN www.worldhealthdesign.com

Landscape DesignFigure 10: Managed plant succession builds upon the biological processes of the nitrogen cycle and biomassdevelopment to help create a fertile soilFigure 11: The design explores the hidden aspectsof landscape – how it functions environmentally,hydrologically, economically and sociallydynamics to become healthy and resilient?Can the site be abundant enough toanticipate an unknown future? How do wedemonstrate process – at the small scale ofsoil-making activity and at the larger scaleimposed by changing climate? These issuesare not tangible. And while some of theprocesses can be witnessed on site, likethe yearly changes in crops, others must beappreciated through more abstract means.Building awareness for these issues couldbe part of the research centre’s mission.In this way, individuals can appreciate andparticipate in the long-term processes thatmake each of us stewards to the earth.An awareness of health in itsbroadest senseWhat both projects demonstrate is agreater awareness to long-term effects ofour technological interventions and theopportunity this awareness offers lookingto the future. The western medical modelhas been altered from a reductionist one oftreating isolated symptoms to seeing patientcare holistically. It has embraced complexity.Environmental design must follow a similarpath in order to address the complex issueswe face and offer hope and health to futuregenerations. It must be more sophisticatedas we use natural resources more efficientlywith technologies that neither merely delayharmful consequences to future generationsnor benefit one part of the environment atthe expense of another.Faced with the dramatic circumstances ofclimate change, communities are at increasedrisk of crisis and disruption. Resilience mustbe thought of in terms of environmentaland human systems. Salutogenesis drawsour focus towards human and socialsystems – creating design solutions that canguide individual and collective interactionsand choices in times of crisis. Salutogenicdesign allows us to reconsider the design ofour infrastructure and communities tobetter equip people with the resourcesto adapt. Working together, designersand scientists can better understand thefactors shaping these choices and theirinfluence on our communities and theenvironment we share.All built environments, both urban andrural, are complex living systems withinter-dependent social, biological andtechnological components. Salutogenicconcepts can be extrapolated to informdesign choices, enhancing individualexperiences and health-promotingoutlooks within the framework oflarge-scale sustainable developmentinitiatives. A holistic design methodologyincorporating salutogenesis, natural systemsand technology with physical and socialinfrastructure can help create a healthy,vibrant, resilient and equitable future.AuthorDavid Kamp, FASLA, LF, NA, is the foundingprincipal of New York-based DirtworksLandscape Architecture, PC. The firm wasestablished to explore the role of nature inthe designed environment to promote healthand wellbeing. Current work includes civic,healthcare, cultural and academic projects.References1. Report of the World Commission on Environmentand Development. Final report, New York (USA):UnitedNations Department of Economic and Social Affairs(DESA). 1987 December. Report No.: A/RES/42/187.2. Antonovsky, A. The salutogenic model as a theory toguide health promotion. Health Promotion International.1996 11(1): 11-18 doi:10.1093/heapro/11.1.11.3. Dilani, A. Psychosocially Supportive Design as atheory and model to promote health. Asian Hospital& Healthcare Management; c2005. Accessed at: www.asianhhm.com/knowledge_bank/articles/supportive_design.htm4. Roosevelt, Franklin D. Letter to all State Governorson a Uniform Soil Conservation Law. February 26, 1937.Online by Gerhard Peters and John T. Woolley, TheAmerican Presidency Project. Accessed at www.presidency.ucsb.edu/ws/?pid=153735. Keyline design, accessed at www.keyline.com.auFurther readingBeatley, T. Biophilic Cities. 1st ed. Washington, DC (USA):Island Press; 2011.Brown, H. Eco-logical Principles for Next-GenerationInfrastructure. The Bridge 41(1): 19-26. Accessed at www.nae.edu/File.aspx?id=43182Bugliarello, G. Perspectives on Urban Sustainability.The Bridge 41(1): 3-4. Accessed at www.nae.edu/File.aspx?id=43182Sachs, JD. World Happiness Report. Chapter 1.Introduction. Commissioned report, New York (USA):Columbia University, The Earth Institute. 2 April 2012.Accessed at www.earth.columbia.edu/articles/view/2960Smith, CE. Design with the Other 90%: Cities. Adaptedfrom the essay Designing Inclusive Cities by Cynthia E.Smith. New York (USA). Smithsonian Cooper-Hewitt,National Design Museum, October 2011. Accessed athttp://places.designobserver.com/feature/design-withthe-other-90-percent-cities/30428/The Eden Project. Our story. Accessed at www.edenproject.com/whats-it-all-about/behind-the-scenes/about-us/our-storyCompost. Case Study: Making the Garden of Eden withRecycled Products. Accessed at www.wrap.org.uk/sites/files/wrap/Eden%20Project.pdfwww.worldhealthdesign.com WORLD HEALTH DESIGN | April 2013 75

Arts and CultureGenius lociCarl Andre: Mass and MatterRosa Barba: Subject toConstant ChangeTurner Contemporary, Margate, UK,until 6 MayDavid Chipperfield’s Turner Contemporary in Margate is an aptsetting for the minimalist artist Carl Andre’s first UK exhibitionfor a decade, which has been paired with the elemental andmaterial musings of artist Rosa Barba. Veronica Simpson reportsRichard Bryant/Arcaid / Rheinisches Bildarchiv KölnCarl Andre was a leading minimalist artist of the 1950s and 1960s, acontemporary and friend of Donald Judd, Dan Flavin, Robert Morris andSol LeWitt, and – then and now – a hero to many a modernist architect.Andre’s preference for boiling his sculptures down to the elementals puts thematerials themselves in the spotlight. In a single gallery there are eight of hissculptures created between 1967 and 1983, and several of his typed poems fromthe same period. The sculptures are assemblages of ‘raw’ industrial materials.It was his celebration of the ordinary and the industrial that is credited withredefining the world of sculpture for a whole generation of artists. It also openedup to many architects the power of generous, repetitive and simple slabs of purematerial, whether brick, wood, stone, slate or metal.In Timber Piece, a collection of uniform, thick cedar blocks is neatly stacked likea giant game of Jenga. Elsewhere, a carpet of 100 worn metal plates, blotchedwith slate grey and petrol blue (4x25 Altstadt Rectangle, 1967) are laid out on thefloor, and visitors are encouraged to walk across them. There is nothing to disturbthe line of plates, nothing out of alignment, and the same is true of the timberblock. The simplicity and repetition is powerful. It enables the materials to sing out,highlighting their patina, sheen, coloration and texture – the density and quality oftheir presence. The effect is calming, sensuous, visceral; in the same way that thepresence of natural, ‘industrial’ material (and nature in its wilder form) is humanisingin even the most severe and sterile of buildings.Carl Andre’s Timber Piece, a stack of cedar blocks76 April 2013 | WORLD HEALTH DESIGN www.worldhealthdesign.com

Arts and CultureThe rhythm of languageBut his dismantling of words into poems is just as affecting. Typed (usingthe instantly recognisable font of the distant manual typewriter era) onyellowed paper, clusters of words are blown together in drifts, shaken intoseemingly casual patterns that have nothing to do with standard grammar orpunctuation but create rhythms and linguistic worlds of their own. Layeredtightly on top of one another, they become visually and sonically pleasingin a uniquely deconstructed way; my favourite ‘poem’ being the word ‘sea’repeated in dense, gapless strings so that it soon ceases to resemble theword we know and transforms into poetic mark-making.Andre’s work plays with weight, scale and density in ways that makeyou acutely aware of the collective and individual presence of eachcomponent, like the best modern buildings – like David Chipperfield’sTurner Contemporary itself, standing right on the seafront in its quietlymonumental, shed-like bulk. Its simplicity – six identical volumes, enclosed ina grid of clear and opaque, acid-etched glass – make it a building both denseand light, quietly complementing the drama of the churning sea and skies.Sculpture, reduced: Andre’s 4x25 Altsdat Rectangle (1967)Above and top: stills from Rosa Barba’s Subconscious Society (2013)Meditations on decayPaired with Andre is the work of Italian/German visual artist RosaBarba. The first piece you encounter is a film (Subconscious Society,2013) noisily broadcast onto a screen from the large, clunkingspools of a bisected vintage projector. Commissioned speciallyfor this exhibition (jointly with Manchester’s Cornerhouse gallery),this piece apparently used the last remaining reels in the world ofFuji 35mm film to record the neglected and wild spaces aroundMargate and Manchester. First, the camera pans across a ghostlycollection of what appear to be rusting oil platforms: rotten,uninhabited, they are eerily enhanced by the film’s soundtrack ofindustrial noise, whose grindings, groans and low resonant clangsplay a duet with the clack of the projector. The rusting platformsgive way to aerial shots of grassy, wild coastline, with scrubbygreenery and bracken appearing – like mould – to creep up tothe sea’s edge. Veins and arteries of sand split these clumps offoliage into delicate patterns.At another point a girl leans at the edge of a wooden platformin a great hall (Manchester’s derelict Albert Hall) with the flotsamof neglect all around her, motionless in a space designed forcongregation and clamour. Then we’re surveying the crumblingremains of an old pier, the camera panning slowly and lovinglyover a broken bridge, pressing the pattern of the damaged planksagainst the bleached out sky into your retinas – a mesmerisingmeditation on decay. And then back to more swampy dunes.But here, the paths that time and tide have wrought betweengrass clumps emerge as complex and beautiful as hieroglyphics,as elaborate as Moorish tilework, but more wonderful in that nohuman hand was involved in their design.In a second room, a line of anatomised projectors spool loopsof transparent film through their metal hinges, revealing nothingof what is on them, but hypnotising the viewer with their endlesschurning. Meaning is not the issue, but feeling and being takepriority for both Barba and Andre. The effect on the viewer isof a heightened awareness of time and matter, substance andspace, leaving you far more alive to the physical qualities of theworld around you; a happy state which the quiet generosity of thegallery’s spaces – and vistas – only serves to enhance.www.worldhealthdesign.com WORLD HEALTH DESIGN | April 2013 77

Arts and CultureThe Rediscovery of the WildEdited by Peter H Kahn, Jr and Patricia H HasbachMIT Press 2013£17.95/US$25With the world’s population heading inexorably for mass urbanisation,and every aspect of our lives increasingly mediated – and observed– by technology, the lure of the wild seems to reach ever moretotemic status. We crave that which is untamed, unmediated, unmanageable in ourlandscapes, as evidenced by the increasing market for extreme adventure holidaysor – at the luxury end – exclusive experiences in the world’s wildest outreaches,from ice hotels to minimal-impact (but maximum comfort) safari retreats.What is it about the wild that speaks to us so profoundly, right now in ourevolution? Architects and urbanists increasingly recognise the impact on ourcollective and individual wellbeing of proximity to nature (if not actual wilderness).They try to deliver some craved-for rebalancing through the skilled deploymentof natural materials and the creation of places or spaces that maximise ourawareness of diurnal patterns and the changing seasons, through vistas and parksand greenery. But what role can the wilderness play in rebalancing our urban lives– and how wild does it have to get before we feel the benefits?This book, with essays culled from a wide range of disciplines (anthropology,environmental activism, psychotherapy, biology and philosophy) is less interestedin answering these questions than generating a greater awareness of what we, asa species, are doing to harm our wild cohabitants on this planet – and in so doing,harming our own habitat as well as our prospects. A beautifully written essay byCristina Eisenberg (Quantifying Wildness: A Scientist’s Lessons about Wolves andWild Nature) takes us deep into the forests around the Montana mountain ranges, tracking wolves and keeping amaternal eye on their breeding (despite the local ranchers’ enthusiasm for shooting them). Eisenberg reveals howinterdependent the wolves and the local ecosystem are, highlighting the damage that removing ‘apex predators’ likethe wolf then inflicts on the indigenous flora, leading to massive overgrazing by the untrammelled deer population.Losing track of natureIn among the ecological evangelism, there are nuggets to take away and apply to improve our own narrow urbanexistences. Biologist and ornithologist Bridget Stutchbury highlights the pleasures of connecting to wild nature simplythrough observing birds at a backyard feeder, but she also shows through her own deeper investigations – tuningin to the rituals of bird life, and watching patterns of territorial and reproductive behaviour – that this is where realriches lie for anyone who has time, opportunity and inclination to properly observe them.Gail F Melson’s chapter, Children and Wild Animals, is probably the most clearly illustrative of the potential thatour wilderness encounters hold. She suggests that engagement with wild animals helps foster children’s perceptual,cognitive, social, emotional and even moral development in the way that they “reflect and refract the self, act as socialothers, and prompt moral reasoning about other species and one’s place in the universe.” Zoos, parks and aquariumsare all educational in this respect, says Melson – though it’s the accompanying adult that needs to mediate theseexperiences to help children extract the maximum insight and engagement.For psychiatrist Ian McCallum (as expressed in his chapter, A Wild Psychology), “the human psyche is alive withtokens of the wild. And yes, I think we have been negligent. We dropped these tokens… We have gradually butprogressively lost track of our animal nature and what wildness really means.” Both McCallum and environmentalactivist Dave Foreman (Five Feathers for the Cannot Club) wish to reinstate in our consciousness the insights andphilosophy of Charles Darwin with his belief that we as humans are on the same evolutionary continuum as ourfellow animals, our desires and behaviours no more nor less important than theirs. As Foreman says: ”We are allkin, from microscopic wrigglers to cloud-catching coastal redwoods and burly great blue whales. Such a kinship…should broaden our view of life.”This book won’t convert the sceptical hedonist nor cure the worst resource-depleting consumerist tendencies,but if it does nothing else, it provides convincing encouragement to weave opportunities in our daily life, in the designof our homes, our workspaces and our institutions, for regular re-engagement with nature and the wild. And in theprocess maybe we’ll become a slightly better, less greedy, more grounded in the here and now version of our species.Veronica Simpson is an architectural writerWe crave thatwhich is untamed,unmediated,unmanageable inour landscapes78 April 2013 | WORLD HEALTH DESIGN www.worldhealthdesign.com