MORTALITY AND IDENTITY EXPECTATIONS OF “GOOD DEATH” AND AGING IN HONG KONG CARE HOMES
Jacqueline Fan Yan Tsang
MORTALITY AND IDENTITY EXPECTATIONS OF “GOOD DEATH” AND AGING IN HONG KONG CARE HOMES
Jacqueline Fan Yan Tsang
Girton College April 2020 This design thesis is submitted in partial fulfilment for the degree of Master of Philosophy in Architecture and Urban Design 2019-2021
This thesis is the result of my own work and includes nothing which is the outcome of work done in collaboration except as declared in the preface and specified in the text. It is not substantially the same as any work that has already been submitted before for any degree or other qualification except as declared in the preface and specified in the text.
CONTENTS 0 | INTRODUCTION
2
1 | THE HONG KONG EXPERIENCE OF DYING Avoiding Fear: Kind Ignorance Cultural Philosophies: The Foundation of “Good Death”
6
2 | EMERGENCE OF THE MODERN “GOOD DEATH” Pacifying Death: The Techno-Economic Lens Identity Before Death: The Socio-Political Lens Permitting Death: The Legal Lens
12
3 | MORTALITY, THE INCURABLE ILLNESS Spaces at the End of Life Unnatural Aging Protection Against Time The Vanishing Social Role
22
4 | REMOULDING “GOOD DEATH” Urban care as Reconciliation
30
5 | CONCLUSION
36
Illustrations
39
Bibliography
41
0 | 零 INTRODUCTION
MORTALITY AND IDENTITY
At the epicentre of SARS and now COVID-19 outbreak, the citizens of Hong Kong find death at the forefront of minds. Faced with death, the unfolding trauma has shattered assumptions to the meaning of living and dying for current generations (Janoff-Bulman, 1992). Not only has it revealed various cultural ideologies on health, it has called to question our approach to death, shining light on our mortality and those most vulnerable: the elderly. For most Hong Kong Chinese, an extraordinary superstitious fear of death may have been exacerbated by the events. Built upon layers of knowledge on health, this immense fear has embedded a determination to purge any thoughts of death. Yet a coexisting reverence for the otherworldly dimension of dead ancestors defines many death rituals and belief principles in daily life regardless of age or education. The physical occupation of the dead in cemeteries and columbaria manifest as liminal landscapes of power and danger – a ‘Total’ social phenomenon, as theorised by Mauss (1969), containing all elements of the social fabric. The intensely interdependent families of Hong Kong Chinese society hold high familial values and filial expectations (Lee, 1997), and it is vital descendants ensure a “good death” for their ancestors: to die a prosperous death and become a benevolent spirit. Our conceptualisation of the state of dying influences how we engage with the process (Neimeyer, 2016), but the pacification of death and medicalisation of dying through hospitals and care homes have diminished expectations of aging in society and the hierarchal role of elderly who play a major role in shaping identity in families. Viewed as a “dumping ground” where the elderly “idle till death” (Lee, 1997, p. 602), the clinical, internalised design of Hong Kong’s Residential Care Homes (RCHEs) have designated a new passive social role to the elderly as a result (Cottrell, 1942), cut off from community. A dissonance in cultural identity of the aging has devalued their presence in society (Fig.1). Hong Kong has preserved Chinese tradition whilst adapting to Western theory and knowledge, but set to return under China’s system in 2047, the city is once again at a cultural crossroad. More than ever, the final memories and traditions passed on at the end of life will define our identity. This project proposes a reconceptualization of residential care homes through architecture as means to reintegrate and adapt the social role of elderly and humanise death; Part 1 examines cultural philosophies and how they laid the foundations for the Hong Kong experience of aging and dying, Part 2 3
0 | INTRODUCTION
analyses how the current concept of “good� death been reshaped and pacified over time, and its effect on designing for end of life. Part 3 will spatially analyse how modern care home design has removed the aging population from society and designated them an unsustainable social role, finally leading to an exploration of a possible design approach in Part 4. This research serves to highlight challenges of the changing socio-political climate and open opportunities for further exploration in designing end of life environments.
Figure 1: Devalued presence of the aging 4
Figure 2: Elevator missing the number 4 in 625 King’s Road, Hong Kong (Chow, 2019)
1 | 一 THE HONG KONG EXPERIENCE OF DYING
MORTALITY AND IDENTITY
AVOIDING FEAR: KIND IGNORANCE Fear and complete rejection of death as “pollution” has impacted the built environment such that omitting labelling a floor or estate block the number 4 is permitted as the Cantonese pronunciation sounds like “death” (Watson, 1982, p. 155) (Buildings Department, 2010) (Fig.2). Furthermore, this fear has inhibited construction of new columbaria despite the increasing demand for niches (Yeung, 2016). Today, the population is projected to have 31% of residents aged 65+ by 2036 (Census and Statistics Department, 2017), which will result in an unavoidable rise in deaths. Despite 93% of deaths now occurring in hospitals and rarely at home (Zhao et al, 2017), death-denying beliefs have been carried forward into the modern era. Hong Kong has been ranked 20th on the Quality of Death index ranking endof-life care and 22nd on the index ranking palliative care as researched by the Economist Intelligence Unit (2010) (2015). In both reports, the social taboo of discussing or contemplating death has been indicated as factors limiting community engagement and causing difficulty in choosing appropriate treatment plans for those with non-communicable, degenerative diseases (ibid.). In the latter case, the individual may not disclose the extent of prognosis to their family, or the reverse if the family is alerted first – this is depicted in the 2019 film The Farewell (Wang), where main character Billi faces a dilemma: listen to her family who forbid her from disclosing the life limiting extent of grandmother’s lung cancer to her as an act of kindness, or revealing the truth (Fig.3). Many healthcare providers and patients are unwilling to discuss the topic under belief that conversing on and contemplating death pollutes the mind and brings bad luck, considering it “intrusive” and possibly dampening hopes of life (Chan et al, 2017, p. 38).
Figure 3: Kind ignorance - The Farewell (Wang, 2019) 7
1 | THE HONG KONG EXPERIENCE OF DYING
CULTURAL PHILOSOPHIES: THE FOUNDATION OF “GOOD DEATH” Cultural beliefs in Hong Kong primarily stem from the philosophies of the “Three Teachings” or Saam Gau: Buddhism, Taoism, and Confucianism. Key ideologies of the three shape obligations and philosophies surrounding life and death; Confucianism specifically schooled moral codes such as respecting elders and ancestors, practicing honesty and filial piety (Wong, 2010). Filial piety has long been considered the “primary duty” of all Chinese, requiring descendants to care for their parents during life and continue to do so even after death (Hsu et al, 2009, p. 159). As such, care homes are perceived as “dumping grounds” (Lee, 1997, p. 602). In contrast, parents are forbidden from attending the funeral of their own child (Chan et al, 2005), reflecting a priority in social order and age hierarchy. These philosophies helped to construct the concept of a “good death” in Chinese culture – to pass away naturally of old age at home, surrounded by family (Chan et al, 2006). The body would be removed from the premises out the window in a coffin, carried down to street level using bamboo scaffolding (Wilson, 1960). An extravagant funeral would typically follow to soothe the spirit and assist in the transformation to an ancestor. Treated as deities in a relationship of trade, a “good death” contributes to the benevolence of these ancestors, rewarding blessings to the family in exchange. Furthermore, the practice of Feng Shui guided cemeteries to be located on hills as high elevations with views of water are believed to be auspicious for the luck of the living and dead (ibid.). Hillside burials tied into knowledge of hygiene, shaping the landscape of death at distance from urban areas for decomposition of corpses to not affect crops (Fig.4). However, the definition of “good death” has been reshaped with time. This was explored through a large-scale survey on the extent of agreement on definitions based on literature and frontline experience (Chan et al, 2006). Results found that primary concerns were formed around the “physical factor” of death such as a “painless death” and “not dependent on others”. “Psychosocial factors” were the second important criterion, with family related items such as “reconcile with family” and “financial planning for family” placed at the top. Traditional death requirements such as “extravagant funeral” and “dying at home” were in fact ranked lowest. A similar study 8
MORTALITY AND IDENTITY
by Mjelde-Mossey and Chan found beliefs about death and suffering that would give comfort to the terminally ill included “I did my best for family or loved ones” and “Forgiveness will let me die peacefully” (2007). Deeply interpersonal relationships are revealed; Selfhood in Chinese culture is defined through others (Koo et al, 2006), where the event of death and dying threatens sense of identity in losing part of the relational self. However, there is no longer a focus on age hierarchy and public face – instead, the elderly’s desires prioritise the safety and happiness of descendants. The lasting legacy of the deceased was no longer a matter of image but relationships (Fig.5-6).
Figure 4: Urban landscapes of death (Fallon, 2019) 9
1 | THE HONG KONG EXPERIENCE OF DYING
Figure 5 (Top): Lasting
image - Chinese funeral procession (No author, 1930)
Figure 6 (Bottom): Lasting
relationships - Chinese funeral (Smith, 2016)
10
Figure 7: Street Scene (Ho, 1956)
2 | 二 EMERGENCE OF THE MODERN “GOOD DEATH”
MORTALITY AND IDENTITY
PACIFYING DEATH: THE TECHNO-ECONOMIC LENS Hong Kong’s death rituals have been linked to historic knowledge of hygiene, such as burning clothes worn at funerals and not visiting a home where someone died – this likely stemmed from rural communities in China where “a significant number of deaths might have been caused by infectious diseases” (Chan and Chow, 2006, p. 5). Although such measures were performed to prevent an epidemic, they may have only reinforced existing preconceptions of death and funerals carrying bad energy or qi (ibid.). Over the Colonial period, the government assisted in perpetuating ideologies of death as a pollutant by mandating racial and class segregation of tombs (Chan Y W, 2016), physically distancing cemeteries for the Chinese population away from the city centre and designing them based on functionality. Healthcare faced a similar fate; the first hospitals were reserved for colonial settlers, introducing western or conventional medicine to Hong Kong (ChanYeung, 2018). The Seamen’s Hospital was opened in 1843, functioning as a private hospital admitting officers for $1.50 HKD and reimbursing senior civil servants – in comparison, a day’s wage for unskilled labourers was $0.15 per day and lower grade civil servants were not reimbursed (Fig.8). The Chinese population had no use for western medicine – they trusted their own Chinese medicine practitioners, and were further off-put by the racist, disrespectful attitudes from European settlers and classist hospital service (ibid.). However, with the advancement of medical knowledge and invention of medical technology such as the microscope and antiseptic and anaesthetic techniques, western medicine became more reputable within a short period of time. This was cemented by the professionalisation and regulation of medical practice through the establishment of the British Medical Association in 1856 and General Medical Council in 1858, and institutionalisation with the founding of medical schools (Chan-Yeung, 2018). Healthcare focused primarily on curative elements to combat diseases and global emergencies. Western medicine prevailed as time passed and the “Self-Strengthening Movement” of 1861-1895 took place, leaving Traditional Chinese medicine reduced to “traditional cultural practice” (Chinese Medicine Regulatory Office, 2007, p. 7). The improved hygiene in medical techniques influenced treatment of the dead, such as use of stainless-steel trolleys to transfer bodies to the mortuary typically located at a lower ground level adjacent parking and 13
2 | EMERGENCE OF THE MODERN “GOOD DEATH”
refuse lots for convenience of transport to funeral halls (Fig.9). Participants of a survey conducted by Chan et al (2019) found the process dehumanising and environment miserable. In 2018, Hong Kong was globally ranked second in highest life expectancy in the United Nations Development Report, yet the Quality of Death indexes have indicated lower satisfaction for end-oflife services and environment. Death is no longer simply separation from the living world and transformation to an ancestor, but also the failure of medical treatment and to protect loved ones from illness. Death “ceased to be a spiritual passage, and became a natural process overseen by doctors.” (Walter, 1994, p. 12).
Figure 8: The Seamen’s Hospital (on the current site of Ruttonjee Hospital)
Figure 9: Lower Ground floor plan of North Lantau Hospital - Hidden mortuary 14
MORTALITY AND IDENTITY
IDENTITY BEFORE DEATH: THE SOCIO-POLITICAL LENS The traditional family hierarchy in Chinese culture grants status to older generations, venerated by successive generations and respected amongst society as “repositor[ies] of tradition” (Mjelde-Mossey, 2007, p. 110). Old age is anticipated as a “clearly defined traditional role” in the most honoured social position whilst remaining productive and of importance by contributing to the well-being of younger generations – a “cultural imperative”, teaching values of “family centrality and collective orientation” (ibid.) (Fig.10). As such, the elders’ social role is hypothesised as “kin-keepers” of family and society (Lou, 2011). However, throughout the colonial era, Hong Kong saw waves of emigration under political changes and economic growth, shifting the plates of traditional family structure. The impending 1997 return of sovereignty to China triggered a mass emigration with an estimated total of 795,137 persons between 19841997 (Sussman, 2010, p. 21). In contrast to nineteenth and early-twentieth century migrants, this wave was primarily “urban, highly educated, middle or upper class” (ibid.). Migrating to foreign countries for higher education and returning with foreign citizenship or staying beyond graduation slowly became the norm. As remigrants worked long hours to keep up with Hong Kong’s economic boom, the elderly continued actively contributing to childrearing, income and household chores. However, the past decade saw rapid social changes where families have less children and often live separate from their elderly family, challenging the traditional family hierarchy and the grandparenting role to adapt as “educators” and “daily life helpers” (Lou, 2011, p. 188). As adult children worked, they were increasingly unable to care full-time for their aging parents, drawing need for care homes.
15
2 | EMERGENCE OF THE MODERN “GOOD DEATH”
Figure 10: Renting to read (Ho, 1961) 16
MORTALITY AND IDENTITY
Believing elderly care was the responsibility of families, the government only provided financial support to residential care services which were established in the 1960s by religious and non-profit groups (Hong Kong Counsel of Social Service, 2005). Subsidised facilities were in shortage and in response, unregulated private facilities began establishing until the enactment of the Residential Care Homes Ordinance (1994) (ibid.). Despite the growing demand for facilities, the understaffed care environment have left residents neglected and maltreated, resulting in high profile cases such as the Hong Kong Cambridge Nursing Home controversy in 2015 where the Social Welfare Department failed to make prosecutions despite issuing warnings over 5 years for elderly resident abuse (Ming Pao, 2015). With an average waiting time of 40 months for subvented and contract homes today (Social Welfare Department, 2020), the battle for space in the urban fabric have constrained the elderly population in a waiting game to be institutionalised, or for the institutionalisation to end (Fig.11). They have been socially excluded to an inactive role, devaluing their identity to defenceless patients – a jarring contrast to their past deeply integrated “kin-keeper� role. The expectations of aging are now a medical issue, and care homes have emerged as an autonomous waiting ground for death.
Figure 11: Waiting game - Between April and December of 2018, approximately 3487 people died in a queue of 33,385 for RCHEs
17
2 | EMERGENCE OF THE MODERN “GOOD DEATH”
PERMITTING DEATH: THE LEGAL LENS Legal barriers have discouraged allowing elderly to die outside of hospitals. Under the Coroner’s Ordinance (1997), a list of 20 types of deaths must be reported to the Coroner via the police, and failure to report is considered a criminal offense. Only those occurring within hospitals or nursing homes, persons diagnosed with terminal illness, or attended to by a registered medical practitioner within 14 days prior to death may be exempted. However, the requirements for death within Residential Care Homes do not align with the Ordinance – all deaths must be reported (Food and Health Bureau, 2019). Despite its position as an institutional setting as residents require assistance, RCHEs are legally placed at a hazy threshold between institutionalised and independent living, unable to be considered a place of potential or permitted death (Fig.12). It has become usual practice for RCHEs to rush their residents to the hospital whenever they are unwell or the A&E when they near death, resulting in repeat admissions over their residence. More than 96% of elderly patients aged 65+ died in hospitals in 2017, and 40% of hospital death cases lived in either RCHEs or nursing homes (Food and Health Bureau, 2019). In comparison, approximately 19% of death cases in the UK in 2015 were care home residents that were transferred to hospital (Public Health England, 2017). The large percentage of elderly deaths in Hong Kong public hospitals has placed an evident pressure on medical care: bed occupancy rates frequently exceed 100% capacity (Yip, 2018). Although it is the Government’s policy to promote dying in place to allow a dignified and private death, RCHEs do not have the physical space, infrastructure or manpower to facilitate it even if reporting exemption from the Coroner’s Ordinance is obtained (Food and Health Bureau, 2019). Design for RCHEs have no requirements for provision of end-of-life care rooms for elderly to spend their last moments in private or provision of mortuaries. Deaths not permitted Permitted Reportable Deaths
Self-care setting
RCHE: Moderate assistance living
Dependent living setting
Permitted Deaths
Figure 12: Hazy threshold 18
MORTALITY AND IDENTITY
These conditions have made passing away an unnatural process of panic and being rushed to the hospital not to live, but to die. Lack of statute or case law to legally protect advance directives, although practiced, has further taken dying out of one’s own control. When taken to the hospital in an ambulance, the ambulatory personnel are bound by their own ordinance to resuscitate in medical emergencies (Fire Services Ordinance, 1954) – in absence of clear legal directives the ambulatory personnel are liable if there is conflict in the patient’s wishes and dutiful obligation. As such, death can only be expected in hospitals. Common law and legal complications have designated a place of die without any sense of self – medicalised and alien. Over its history, Hong Kong’s society has indeed experienced cultural trauma that has shattered traditional assumptions on the meaning of living and dying. Death has been processed and packaged such that it is no longer a natural occurrence, but an illness that must only be found in hospitals. The desire for eternity and perfection, denied to us by the human body, aims to be achieved through science and medicine in the confines of an institution. The Hong Kong population has put faith in technology to provide a long life in this world and thus a prosperous death, yet now the image of this “good” death – the image of transition to the spiritual realm – is chained to the hospital bed by medical tubes and monitoring wires (Fig.13). As result, the elderly population has been boxed into the role of patients, and care homes take on the image of waiting terminals for those unable to overcome mortality. This modern day “good” death is unsustainable, not merely on a financial standpoint for healthcare, but for current Hong Kong identity that many strive to preserve. In denying the elderly a part of our lives, the deep relational bonds of family and community will find many traditions and cultural behaviours cut away before the occurrence of physical death. The care home must serve to allow and compel the elderly to continue actively taking part in society, a place where life stimulates health as opposed to the health stimulating life.
19
2 | EMERGENCE OF THE MODERN “GOOD DEATH”
Figure 13: “Good death” chained to the hospital 20
Figure 14: Residential Care Home dormitories (Social Welfare Department, 2020)
3 | 三 MORTALITY, THE INCURABLE ILLNESS
MORTALITY AND IDENTITY
SPACES AT THE END OF LIFE Themes of self-identity and control in the experience of dying have emerged along with their impact on design. Whilst the medicalisation of death has limited the parameters of dying such that life expectancy can be elongated, the experience has also been spatially and temporally compressed. Life is now in the hands of the medical profession and death in the hands of law, coming together under the same roof of hospitals. With an aging population and constant societal change, I argue that the current model of Residential Care Homes negatively impacts self-conception and identity of the aged population through spatial analysis based on Cottrell’s social role theory (1942): How does the care home and hospital environment curate behavioural expectations and challenges in the conceptualisation of end of life? The Kwu Tung North Residential Care Home, funded by the Hong Kong Lotteries Fund, will be used as the primary example.
UNNATURAL AGING Despite being described as a home, as a place of protection and untroubled living (Harries, 1982), the configuration of rooms and building harkens more to living within a hospital. As depicted in Figures 15-16, the layout of a dormitory in the RCHE is cellular, much like an extended stay ward in the North Lantau Hospital excluding storage space and door to the unit than an opening. In accordance to the Code of Practice for Residential Care Homes (1999), a minimum area of 6.5m2 for exclusive use per resident is applied, but with no requirements for partition walls there is use of curtains instead of solid dividers, whilst allowing visibility and access for nurses, provides little privacy or room for personalisation. With movable curtains, the floor plan depicts the threshold with a dashed line – a porous division. As such, the area of shared space spills into the private, the shelter only temporary. There is acknowledgement that the stay is only temporary but with limitations to ownership of space, the residents are treated as patients awaiting release through death than through a cure.
23
3 | MORTALITY, THE INCURABLE ILLNESS
Figure 15a: Kwu Tung North RCHE
Figure 15b: Kwu Tung North RCHE
Figure 16a: North Lantau Hospital
Figure 16b: North Lantau Hospital
dormitory - 1:200 plan
ward - 1:200 plan
Shared
dormitory - shared and private space
ward - shared and private space
Private
24
MORTALITY AND IDENTITY
PROTECTION AGAINST TIME The Residential Care Home expresses building form around its linear circulation, with static façades consisting of sleeping spaces and hiding the communal space between (Fig.17a-b). There is implication of a certain direction of movement and time; There is order and expectation, a form designed around pre-planned schedules. A similar arrangement is found in the North Lantau Hospital wards, with additional medical facilities islanded between routes (Fig.18a-b). In both plans, long corridors with minimal openings can be seen – lacking natural light, the passage of time within corridors are difficult to track, becoming spaces where the residents define the time with their movement. However, there is little spatial tolerance for residents or patients to stop within the circulation and elongate time in experiencing the shared flow of space. In comparison, the radial configuration of typical residential buildings such as Bayshore Apartments building in Aberdeen create personal points of intersecting time, shared only by the residents on the circulation branch (Fig.19a-b). These points give freedom to stop without inhibiting the movement of the wider community. Within the barriers of the RCHE, the floor plans express no expectation or opportunity for residents to actively contribute to upkeep of the care home environment and community – “provider” spaces such as kitchens and laundry rooms are closed off and hidden away. Excluded from such activities, elders are placed in an expectation to care only for themselves unlike their typical “kin-keeper” role. Instead, the RCHE only provides one primary communal space for daily experience, pulled away from the street front – a protective gesture (Fig.20a-b). Internalising the residents of the care home, they are distanced from the neighbourhood, permitted observation but unable to partake. The care home attempts to dominate time by enclosing and designating the space and expectations of daily life. Yet in a culture where sense of self is relational, elders are unable to see themselves reflected in the community. The sense of self becomes lost over time.
25
3 | MORTALITY, THE INCURABLE ILLNESS
Figure 17a:
Figure 17b:
Figure 18a:
Figure 18b:
Figure 19a:
Figure 19b:
RCHE Dormitory Typical Floor Plan
North Lantau Hospital Extended Stay Unit Plan
Bayshore Apartments Typical Floor Plan
RCHE Dormitory circulation
North Lantau Hospital Extended Stay Unit circulation
Bayshore Apartments circulation
26
MORTALITY AND IDENTITY
Figure 20a: Kwu Tung North RCHE - Typical Floor Plan
Figure 20b: Kwu Tung North RCHE - Static versus Active
27
3 | MORTALITY, THE INCURABLE ILLNESS
THE VANISHING SOCIAL ROLE Whilst the elderly population is physically protected by institutionalisation, at what point does protection become restriction? A hospital resuscitation and trauma room – a space where death is expected – is entirely enclosed without openings as if to contain it (Fig.21). Similarly containing their residents in a figurative notion, care home residents are concurrently perceived as the incurable ill. By seeing aging as illness, we are compelled to continue understanding death as failure of medicine and allow fear to distance us. One begins to question if the care home protects aging residents from dangers of society, or society from the reality of aging. Whilst social roles that come with age in Western cultures become increasingly ambiguous (Cottrell, 1942), the institutionalisation of elders have created a cultural discourse. Care homes are undeniably needed, but thrust into an inactive social role, the older generations begin to lose grip of their prominent role in family and societal structure. Their identity and sense of purpose may begin to be perceived as unneeded, devalued. As strongholds of traditional behaviours and values, the intangible cultural characteristics they have carved into today’s Hong Kong identity begin to fade in a westernising world. Our desire to preserve this calls for the concept of RCHE environments to be remoulded; the institutionalised setting must allow older generations to continue as active members of communities and adapt new social roles alongside society without the restraints of movement, behaviour and visibility in current care homes. Mortality and vulnerability to time is not an illness to be shielded from, but a natural process we must reconcile with.
Figure 21: North Lantau Hospital Resuscitation and Trauma room 28
Figure 22: Site plan in Aberdeen, 1:500 at A1 N
4 |死 REMOULDING “GOOD DEATH”
MORTALITY AND IDENTITY
In the previous chapters, I have discussed the challenges faced in the perception of death and vanishing social role of elders. End of life and care environments have become a locus for elderly to become devalued, a place of cultural dissonance in identity. Bhabha comments on the post-colonial interrogation of identity: “The very place of identification, caught in the tension of demand and desire, is a space of splitting.” (2004, p. 63). The care home, a critical place of identification, as such has the potential to reinforce, adapt or discard existing expectations of social role. An opportunity to design a new definition of the mutable “good death” opens, with which I experiment through this project. Situated at a former school building bordering Aberdeen district and Aberdeen cemetery (Fig.22) – the first formal cemetery to be designated to the Chinese population – the physical threshold between the built environment of the living, the dead, and the natural landscape opens as a space of reconciliation.
URBAN CARE AS RECONCILIATION This design envisions RCHEs as a space shared by community and environment. Physical form seeks to reconcile with mortality by negotiating with topography, carving into the earth (Fig.23). According to Plato, the beauty of geometry and spirit is not subject to time, a perfection the body is denied. The organic body conflicts with and is unable to reconcile with the precise, man-made built environment to accept its vulnerability to time. This proposal is shaped through a push and pull of landscape, to at once be an institution yet a natural habitat. Designed to naturally move through the topography with both exposed and sheltered spaces, the care home opens to the neighbourhood to encourage continued visibility (Fig.24-25). Existing public health interventions such as elderly fitness corners, open park space adapted for tai chi and walking routes around the city act as socialisation hubs and reflect upkeep of physical health as quintessential daily routine, for which the design accommodates for by exploiting its position on the edge of the urban environment to intertwine with an existing hiking trail (Fig. 26). Programmatically, the proposal attempts to allow an adjustable ongoing “kin-keeper” role – with the professionalisation of trades, integration of a childcare centre extends opportunity for elders to continue the “educator” 31
4 | REMOULDING “GOOD DEATH”
role. This strategy bears semblance to Kotoen, a joint care Yoro Shisetsu facility in Tokyo that has proven successful in imbuing “sense of community” and “fulfilment” for both elderly and children (Baseel, 2015). By injecting care homes as urban playgrounds of care accommodating both child and health care facilities amongst maker spaces, elders can receive support whilst maintaining proactive social roles and positive relationships in the neighbourhood (Fig.27). Care homes can be reshaped as places of meaningful time for all, rather than places of limited time.
Figure 23: Carved form 32
MORTALITY AND IDENTITY
Figure 24: Massing 1 -
Exposed and sheltered
Figure 25: Massing 2 -
Push and pull
33
4 | REMOULDING “GOOD DEATH”
Figure 26: Circulation strategy - Intertwining routes
Figure 27: Programme strategy - Urban playground of care 34
Figure 28: Residents spending time outside to socialise in Kwun Tong Garden Estate public housing estate (Cheung, 2013)
5 |五 CONCLUSION
MORTALITY AND IDENTITY
The design project of this research uses care homes as means to underline relationships with death and tensions in identity within Hong Kong. Drawing from literature, Hong Kong’s history, cultural foundations, and Cottrell’s social role theory, the proposal frees the care home from its enclosing and programmatic barriers, aiming to create a less autonomous and isolating care environment. In encouraging family and inter-generational engagement, elders will be able to adjust to more distinguishable social roles and see themselves reflected in the community, carrying forward knowledge and cultural traditions of the Hong Kong identity. Institutionalisation and medicalisation of elderly care is not a result of lacking compassion, but one of great compassion reflecting fear of losing a fragment of self. There are limitations to this project – it relies on the assumption that familial interactions will carry on, and that Hong Kong’s elderly population in care homes desire to continue being active within an institution instead of sheltering to focus on health as they have now. Cottrell states that “The degree of adjustment to a future role varies directly with the completeness of the shift in the responses and expectations exhibited by the society to the individual in his new role.” (1942), highlighting the risk that this strategy may publicly be deemed incompatible with societal trajectory. Additionally, the design has yet to account for the consequences of COVID-19 and potential government plans to adapt care home design and programme policies. Care homes have been identified as an “area of risk” where vulnerable persons reside (Whitty, 2020), thus requiring further research as to how future global health crisis’ can be accommodated in an RCHE without progressing as an increasingly anonymising medicalised space. This essay highlights the challenges faced in Hong Kong’s changing sociopolitical climate for identity and care environments. Of course, one cannot entirely predict and enforce a new definition of “good death” and social role that comes in hand, but architecture has proven to have the ability to facilitate transformation. Bhabha quotes “The question of identification is never the affirmation of a pre-given identity, never a self-fulfilling prophecy – it is always the production of an image of identity and the transformation of the subject in assuming that image.” (2004, p. 64). Although further research is needed and anticipated, the proposed strategy hopes to provoke thought for alternative design in care and end of life environments – not simply for the aging population, but also for future generations. 37
5 | CONCLUSION
Figure 29: A place of meaningful time` 38
MORTALITY AND IDENTITY
ILLUSTRATIONS Figure 1: Author’s own image Figure 2: Chow, R. (2019) 625 King’s Road. [Photograph] Figure 3: Wang, L. (2019) The Farewell. [Film] Figure 4: Fallon, F. (2019) Dead Space. [Photograph] Available at: http:// finbarrfallon.com/portfolio_page/dead-space/ (Accessed: 21 April 2020)
Figure 5: Chinese Funeral Procession (1930). [Photograph] Available at: https://
www.hippostcard.com/listing/china-hong-kong-chinese-funeral-procession-1930srppc/579635.
Figure 6: Smith, B. (2016) Chinese Funeral, Mong Kok. [Photograph] Available
at: https://brentsmith.nz/wp-content/uploads/2016/06/DSC_0691.jpg (Accessed: 21 April 2020).
Figure 7: Ho, F. (1956) Street Scene. [Photograph] Available at https:// fanhoforgetmenot.com/ (Accessed: 22 April 2020)
Figure 8: Old Wanchai School to the south of Seamen’s Hospital (1873). [Postcard] Available at: https://gwulo.com/atom/16895 (Accessed: 21 April 2020).
Figure 9: Author’s own image Figure 10: Ho, F. (1961) Renting to read. [Photograph] Available at https://fanhoforgetmenot.com/ (Accessed: 22 April 2020)
Figure 11: Author’s own image Figure 12: Author’s own image Figure 13: Author’s own image
39
ILLUSTRATIONS
Figure 14: Social Welfare Department (2020) Type of Residential Care Homes,
SWD Elderly Information Website. Available at: https://elderlyinfo.swd.gov.hk/en/ rches_natures.html (Accessed: 24 April 2020).
Figure 15a: Author’s own image Figure 15b: Author’s own image Figure 16a: Author’s own image Figure 16b: Author’s own image Figure 17a: Author’s own image Figure 17b: Author’s own image Figure 18a: Author’s own image Figure 18b: Author’s own image Figure 19a: Author’s own image Figure 19b: Author’s own image Figure 20a: Author’s own image Figure 20b: Author’s own image Figure 21: Author’s own image Figure 22: Author’s own image Figure 23: Author’s own image Figure 24: Author’s own image Figure 25: Author’s own image 40
MORTALITY AND IDENTITY
Figure 26: Author’s own image Figure 27: Author’s own image Figure 28: Cheung, C.N. (2013) Kwun Tong, Kwun Tong Garden Estate Lotus Towers. [Photograph] Retrieved April 25, 2020 from http://www.citylab.com/ housing/2015/02/inside-hong-kongs-public-housing-estates/384726/
Figure 29: Author’s own image
BIBLIOGRAPHY Baseel, C. (2015) ‘Yoro shisetsu: Japan’s progressive joint care centers where kids and seniors interact’, SoraNews24, 1 February. Available at: https://soranews24. com/2015/02/01/yoro-shisetsu-japans-progressive-joint-care-centers-where-kidsand-seniors-interact/ (Accessed: 28 February 2020). Bhabha, H. K. (2004) The Location of Culture. [New edn.]. London: Routledge. Blanchot, M. (1989) The Space of Literature. University of Nebraska Press. Buildings Department (2010) ‘Standardization of Floor Numbering’. Buildings Department: The Government of Hong Kong Special Administrative Region. Available at: https://www.bd.gov.hk/en/resources/codes-and-references/practicenotes-and-circular-letters/index_pnap.html. Census and Statistics Department (2017) Hong Kong Population Projections for 2017 to 2066. The Government of the Hong Kong Special Administrative Region. Chan, C. L. W. and Chow, A. Y. M. (eds) (2006) ‘Introduction’, in Death, Dying and Bereavement: A Hong Kong Chinese Experience. Hong Kong: Hong Kong University Press, pp. 1–14. Chan, C. L. W., Chow, A. Y. M., Ho, S. M. Y., Tsui, Y. K. Y., Tin, A. F., Koo, B. W. S. and Koo, E. W. K. (2005) ‘The Experience of a Chinese Bereaved Persons: A Preliminary Study of Meaning Making and Continuing Bonds’, Death Studies, 29(10), pp. 923–947. doi: 10.1080/07481180500299287.
41
BIBLIOGRAPHY
Chan, H. Y. L., Lee, D. T. F. and Woo, J. (2019) ‘Diagnosing Gaps in the Development of Palliative and End-of-Life Care: A Qualitative Exploratory Study’, International Journal of Environmental Research and Public Health, 17(151). doi: 10.3390/ijerph17010151. Chan, H. Y. L., Lee, D. T. F., Woo, J. and Yi, H. (2017) ‘A Study on the Development of Palliative and End-of-Life Care Services in Hong Kong’, Central Policy Unit The Government of Hong Kong Special Administrative Region. Chan, W. C. H., Tse, H. S. and Chan, T. H. Y. (2006) ‘What Is Good Death: Bridging the Gap between Research and Intervention’, in Chan, C. L. W. and Chow, A. Y. M. (eds) Death, Dying and Bereavement: A Hong Kong Chinese Experience. Hong Kong: Hong Kong University Press, pp. 127–135. Chan-Yeung, M. M. W. (2018) A Medical History of Hong Kong. Chinese University Press. Available at: www.jstor.org/stable/j.ctvbtzp1t (Accessed: 6 April 2020). Chinese Medicine Regulatory Office (2007) ‘A New Era of Chinese Medicine in Hong Kong’. The Government of the Hong Kong Special Administrative Region. Available at: https://www.cmro.gov.hk/html/b5/health_info/doc/A_New_Era_of_ Chinese_Medicine_in_Hong_Kong_(2007).pdf (Accessed: 6 April 2020). Coroner’s Ordinance 1997, Cap. 504. Hong Kong. Cottrell, L. S. (1942) ‘The Adjustment of the Individual to his Age and Sex Roles’, American Sociological Review. [American Sociological Association, Sage Publications, Inc.], 7(5), pp. 617–620. doi: 10.2307/2085687. Fire Services Ordinance 1954, Cap. 95. Hong Kong. Food and Health Bureau (2019) ‘End-of-life Care: Legislative Proposals on Advance Directives and Dying in Place’. Available at: https://www.legco.gov.hk/yr19-20/ english/panels/hs/papers/hs20191108-ppr201909-e.pdf (Accessed: 26 March 2020). Harries, K. (1982) ‘Building and the Terror of Time’, Perspecta. The MIT Press, 19, pp. 59–69. doi: 10.2307/1567050. Janoff-Bulman, R. (1992) Shattered Assumptions: Towards a New Psychology of Trauma. Free Press.
42
MORTALITY AND IDENTITY
Koo, B. W. S., Tin, A. F., Koo, E. W. K. and Lee, S. (2006) ‘When East Meets West: The Implication for Bereavement Counselling’, in Chan, C. L. W. and Chow, A. Y. M. (eds) Death, Dying and Bereavement: A Hong Kong Chinese Experience. Hong Kong: Hong Kong University Press, pp. 261–272. Lee, D. T. F. (1997) ‘Residential care placement: perceptions among elderly Chinese people in Hong Kong’, Journal of Advanced Nursing, 26, pp. 602–607. doi: 10.1046/j.1365-2648.1997.t01-22-00999.x. Lou, V. (2011) ‘Life Satisfaction of Chinese Grandmothers: The Impact of Grandparenting Role Changes’, Journal of Ethnic & Cultural Diversity in Social Work, 20, pp. 185–202. doi: 10.1080/15313204.2011.594992. Mauss, M. (1966) The Gift: Forms and Functions of Exchange in Archaic Societies. London: Cohen & West Ltd. Ming Pao (2015) 長者遭脫光露天等冲涼, 明報新聞網 - 每日明報 daily news. Available at: https://news.mingpao.com/pns/%e8%a6%81%e8%81%9e/ article/20150526/s00001/1432577551357/%e9%95%b7%e8%80%85%e9%81%ad %e8%84%ab%e5%85%89%e9%9c%b2%e5%a4%a9%e7%ad%89%e5%86%b2%e 6%b6%bc (Accessed: 15 April 2020). Mjelde-Mossey, L. A. (2007) ‘Cultural and Demographic Changes and Their Effects Upon the Traditional Grandparent Role for Chinese Elders’, Journal of Human Behavior in the Social Environment, 16(3), pp. 107–120. doi: 10.1300/1091135080210778. Mjelde-Mossey, L. A. and Chan, C. L. W. (2007) ‘Survey on Death and Dying in Hong Kong’, Social Work in Health Care. doi: 10.1300/J010v45n01_04. Neimeyer, R. A. (2006) ‘Foreword’, in Chan, C. L. W. and Chow, A. Y. M. (eds) Death, Dying and Bereavement: A Hong Kong Chinese Experience. Hong Kong: Hong Kong University Press, pp. ix–x. Ponzetti, J. J. (ed.) (2003) International Encyclopedia of Marriage and Family. 2nd edn. USA: Macmillan Reference. Public Health England (2017) The role of care homes in end of life care: Briefing 1 - Care home bed provision and potential end of life care need in people aged 75 or older in England. Department of Health and Social Care. Available at: https://assets. publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/ file/828120/Briefing_1_Care_home_provision_and_potential_end_of_life_care.pdf. 43
BIBLIOGRAPHY
Social Welfare Department (2020) Statistics on ‘Waiting list for subsidised residential care services for the elderly’, ‘Waiting time for residential care services’ and ‘Turn for placement offer for cases applying for residential care services’. The Government of the Hong Kong Special Administrative Region. Available at: https:// www.swd.gov.hk/storage/asset/section/632/en/LTC_statistics_HP-Eng(202002). pdf#page=1&zoom=auto,-108,443 (Accessed: 6 April 2020). Sussman, N. M. (2010) Return Migration and Identity: A Global Phenomenon, A Hong Kong Case. Hong Kong University Press. Teather, E. K. (1998) ‘Themes from Complex Landscapes: Chinese Cemeteries and Columbaria in Urban Hong Kong’, Australian Geographical Studies, 36(1), pp. 21–36. The Economist Intelligence Unit (2010) The Quality of Death: Ranking end-of-life care around the world. The Economist Intelligence Unit (2015) The 2015 Quality of Death Index: Ranking palliative care across the world. The Hong Kong Counsel of Social Service (2005) 香港安老服務的簡史. Available at: http://webcontent.hkcss.org.hk/el/ (Accessed: 6 April 2020). Ting, V. (2019) Hong Kong NGO shows care homes they can stop keeping elderly in restraints, South China Morning Post. Available at: https://www.scmp.com/news/ hong-kong/health-environment/article/3037128/hong-kong-ngo-shows-care-homeshow-they-can-stop (Accessed: 7 April 2020). Whitty, C. (2020) ‘UK could be reaching coronavirus peak, chief medical officer says’. Downing Street, London: Evening Standard. Available at: https://www. standard.co.uk/news/health/uk-could-be-reaching-coronavirus-peak-with-signsrate-of-new-infections-flattening-chief-medical-a4415546.html (Accessed: 19 April 2020). Walter, T. (1994) The Revival of Death. Routledge. Wang, L. (2019) The Farewell. [Film] Watson, J. L. (1982) ‘Of flesh and bones: The management of death pollution in Cantonese society.’, in Bloch, M. and Parry, J. (eds) Death and the Regeneration of Life. Cambridge: Cambridge University Press, pp. 155–186.
44
MORTALITY AND IDENTITY
Wilson, B. D. (1960) ‘Chinese Burial Customs in Hong Kong’, Journal of the Hong Kong Branch of the Royal Asiatic Society, 1, pp. 115–123. Wong, Y. H. (2010) Spirituality and ageing: a qualitative study of religiosity of Chinese older persons in Hong Kong. Master of Philosophy. Lingnan University. doi: 10.14793/soc_etd.1. Yeung, R. (2016) ‘Giant Hong Kong columbarium plan blocked amid government opposition and local protests’, South China Morning Post, 30 September. Available at: https://www.scmp.com/news/hong-kong/education-community/article/2023974/ hong-kong-columbarium-proposal-voted-down-town. Yip, P. (2018) How to make Hong Kong’s ailing health care system better, South China Morning Post. Available at: https://www.scmp.com/comment/insight-opinion/ hong-kong/article/2177980/hong-kongs-ailing-health-care-system-needs (Accessed: 5 April 2020). Zhao, J., Tu, E. J.-C. and Law, C. (2017) ‘The incomparability of cause of death statistics under “one country, two systems”: Shanghai versus Hong Kong’, Population Health Metrics, 15(1), p. 37. doi: 10.1186/s12963-017-0155-z.
45
BIBLIOGRAPHY
46