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technical & practice

Should architects have a role to play in designing out unhealthy environments; or are they overstating their influence?

'Breathing Space: Towards an Aesthetic for Cancer Care' was an ambitious conference organised by Dundee Contemporary Arts (DCA) to coincide with the opening of Gehry's Maggie's Centre at the local Ninewells Hospital.

It set itself the task of examining the relationship between architecture and health - using case studies, medical evidence and personal testimony - and to identify the ways in which architects and practitioners can improve patients' well-being. This, at least, was the objective, and even though there could be some debate about whether the conference achieved its aims, it remained a fascinating arena in which to try to tackle the myths, hype and reality of healthcare design and implementation.

In this respect, praise must go to Faith Liddell, DCA's director, and her staff, whose efforts made this conference - which, on paper at least, had seemed slightly unappealing, with unrelenting references to the C-word - into an enjoyable affair. Similarly, Nick Barley, editor of The List magazine, who chaired the event with consummate ease, managed sympathetically to address difficult and emotive issues while putting forward some searching questions to the various panellists.

Michael Spens, reader in architecture at the University of Dundee, kicked off proceedings by saying that Gehry's Maggie's Centre was 'born out of an individual's courageous fight against cancer'. Gehry's building 'has no historical precedent and there is no typology', he said.'There is only one leitmotif human compassion.' While this introduction was touchingly presented, it represented a slightly over-indulgent acceptance of Gehry's work and a day that often gave uncritical primacy to emotional responses over rational analysis.

When, in one of the workshops, I asked if anyone had any critical ('in the the best sense of the word') comments to make about Gehry's building, an architect rebuked me for 'obviously wanting to write a scurrilous article'on the new building.The sense that an emotional, rather than rational, response was sacrosanct hindered a truly free and frank discussion about the issues at stake. After all, it has to be said that even though the new Maggie's Centre is very interesting, with excellent finishes and a simple palette of materials, the rafter/wall junction in the disabled WC was absolutely terrible and the bare concrete terrace must have been an aberration.Call me scurrilous.

Calm down, calm down Frank Gehry was suitably self-effacing.He apologised for maligning the 'poor architect' of the original hospital, by default, in the debate about inadequate extant care facilities, recognising that he/she may have been constrained by a brief and bureaucracy. Of his own design process, he flicked through slides of scrunchedup paper developmental models saying, 'maybe this design would have been better than what we built; (next slide) or this; (next slide) or this' and admitted that he had lost sleep wondering whether the £1 million for the building could have been better spent on research into a cancer cure.'I still have residual feelings to the point of being a bit guilty but know that that's stupid buildings do have a role.'

This was the central thematic of the day.That: a) architecture has a role in providing a calming environment; and b) that by providing a 'better' environment, patients would enjoy an improved quality of life.Both beg several questions.Why, for example, should cancer care units be designed to encourage calm introspection? Do calm spaces necessarily provide a better quality of life? Could sitting in a turret overlooking the Tay estuary lead to resignation? Who knows?

If this was just about providing a better facility for oncology ward patients, there could be no room for complaint; it is hardly controversial to recognise that it is about time that hospital wards were brought into line with modern standards of decor, space standards and hygiene. However, when simple demands for decent buildings become theorised concepts of 'healing environments', then the project becomes a little worrying.Emotional expression as a healing mechanism meant that it was but a short leap to architectural environment as therapeutic device. Enter Charles Jencks, who exuded untouchable moral authority on the issue.

High Jencks 'In the old days, people used to die in factories, ' he said, 'called hospitals.' From this hugely popular witticism, he set out a history of deterministic responses to healthcare, although it was at times difficult to work out which, if any, he subscribed to. 'Modernists, ' he chided, 'really believed that buildings influenced behaviour, ' before going on to describe the Hawthorn effect - whereby the mere act of making people feel wanted will spur them on to perform better.But this was just one of many 'complex and contradictory positions' on what cause has a consequent effect on human well-being. As Frank Furedi says in his latest book, Therapy Culture: Cultivating Vulnerability in an Uncertain Age, 'the feeling of contentment is increasingly seen as the defining moment of individual health'.

Not surprisingly, the notion that cancer might not be the earth-shatteringly depressing event that the panellists were pandering to, didn't have many advocates. Instead, as one delegate said, 'once you have cried, you are on the road to recovery'- not medically, obviously.

Jencks himself stated that 'when you hear (you have) cancer, you will yourself to die (but) I believe that reading books on cancer can extend your life by one month'. In the Dundee Maggie's Centre library, of 200 books, every single one was about cancer. Even though I couldn't think of anything more depressing, Sue Francis of Future Healthcare Network (see following pages) told me that patients wanted to learn as much as possible about their disease to give them a sense of empowerment. Maggie's Centres allow you to do that in a caring environment.

Apparently other scientific studies show that 'relief of stress helps with lifespan', and other gems included a belief that 'the placebo effect is real' and 'there's a spiritual edge to Maggie's Centres'. As far as I was concerned, his post-Post-Modern critique seemed to have a touch of medievalism about it. Irrational determinism, maybe? In this scenario, people are defined more by their biology than their actions.

During the day, contributors suggested that quietude is necessary so that people can come to terms with their illness. However, I was reminded of Dylan Thomas' poem on the demise of his father from throat cancer, where he craved him to 'rage against the dying of the light/Old age should burn and rave at close of day'.Maggie's Centres do not, it seems, cater for expressions of rage, but rather try to promote quietude, reflection and tears - the more spiritual side to pain relief. Indeed, during Zaha Hadid architect Jim Heverin's presentation of the designs for the Maggie's Centre in Kirkaldy, Gehry lauded Hadid as 'maturing rapidly into a very important architect', before offering his reservations about the use of Corten in the Maggie's Centre scheme as being too harsh.His interpretation of the brief had called for a quiet, welcoming 'American family room' where people could give support to one another.

Furedi notes that 'if the search for selfknowledge becomes an end in itself, little insight will be gained today it is opinion formers who tell us how to feel'.

Alternative medicine If science was to fight back, then it was not for consultant radiation oncologist Professor Alastair Munro to accept the challenge. 'Florence Nightingale, ' he said, 'could teach modern scientists a thing or two.' Alluding to her support for natural ventilation (which was reasonable given that she visited hovels of unimaginable stench and squalor), he passed over the fact that she still accepted the (incorrect) miasma theory that held that diseases were caused by noxious odours.OK, she opened the windows and had good bedside manner. Give her a carrot. But let's not lose sight of the progress that has been made in medical expertise during the past 150 years.

In a rather flippant speech about the polarities of traditional medicine and complementary medicine, Munro refused to recognise the established consensus of words like 'therapy' in relation to phrases such as 'therapeutic culture'. Innocently, he stated that he 'always thought that therapy was what I do', disingenuously ignoring the broader social debate around the new counselling culture, which had informed much of the conference agenda. In a later interview with Dundee's Courier, he stated that as an 'institutional person in a sense I'm not part of the solution, I'm very much part of the problem'. Not the most reassuring statement for cancer patients to hear, I would argue.

While there are worthwhile debates to be addressed, such as how do we equate perception with reality, at times I recalled that on the way to the conference I had passed a bill-sticker advertising the 'Psychic Healing Fair' offering 'clairvoyance, Tarot, complementary techniques, healing and aura photography'. If we attempt to theorise around the fact that people sometimes feel better with complimentary techniques (like Maggie's Centres) - which in no way implies that they are better - how then should we prioritise between treatment, and perceptions of treatment; between medicine, counselling and the laying on of hands.

Surely, we need to have a determined critique that prioritises clinical medical treatment over notions of the empowering benefits of architecture, books or wallpaper. Arguing for brand-spanking new wards is imperative, but as a sign of investment and modernity - not as a complimentary treatment.

It was left to Sue Francis, architectural advisor to more than 50 NHS Trusts and jointly employed by the NHS Confederation and NHS Estates, to be more circumspect.Employed near the heart of healthcare initiatives, she was broadly supportive of the new therapeutic environments, but reflected that 'easing stress takes our minds off our immediate worries and puts us in a better mood'. This simple statement - devoid of hifalutin theorising - was uncontroversial, but which she still usefully backed up by saying that 'the precise impacts are debatable(and) there are lots of hypotheses'. This was a useful addition to the debate and contributed to the sense that we had just engaged in a day-long work-in-progress. Many attendees suggested that we should regroup in five years' time and compare notes.

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