RE-Humanizing Healthcare

RE-HUMANIZING HEALTHCARE MANUSHI SHETH | I.E.S. C.O.A. DESIGN DISSERTATION

UNIVERSITY OF MUMBAI

DESIGN DISSERTATION Submitted in partial fulfilment of the requirements of the degree of Bachelor of Architecture (B. Arch)

RE-HUMANIZING HEALTHCARE PROPOSAL FOR A LODGING & CARING INSTITUTE FOR CANCER OUTPATIENTS IN MUMBAI

SUBMITTED BY SHETH MANUSHI PIYUSH

IES COLLEGE OF ARCHITECTURE 2017-2018

DECLARATION OF PLAGIARISM I hereby declare that this written submission entitled ‘Re-Humanizing Healthcare’ represents my ideas in my own words and has not been taken from the work of others (as from books, articles, essays, dissertations, other media, and online) and where others ideas or words have been included, I have adequately cited and referenced the original sources. Direct quotations from books, journal articles, internet sources, other texts, or any other source whatsoever are acknowledged, and the sources cited are identified in the dissertation references.

No material other than that cited and listed has been used.

I have read and know the meaning of plagiarism, and I understand that plagiarism, collusion, and copying are grave and serious offenses and accept the consequences should I engage in plagiarism, collusion or copying.

I also declare that I have adhered to all principles of academic honesty and integrity and have not misrepresented or fabricated or falsified any idea/data/fact source in my submission.

Manushi Sheth 18 th November 2017, Mumbai

ACKNOWLEDGMENTS First and foremost, I would like to express my gratitude to my thesis guide, Prof. Shilpa Chandawarkar for her constant guidance, support, and inspiration. This thesis would not turn out how it did if not for her faith in me.

To Aayushi, Prachi and my sister Shweni, this project would not have materialized without your constant and unconditional support and encouragement. I am truly grateful to Yesha and Harsh for their help.

Sincere thanks to Shreyas, Smriti, Anvi, Malav, Harsh G. and all my classmates and friends who have been a part of my life during the course of architecture.

Finally and most importantly, I would like to thank my parents and sister for all their love and moral support through these 5 years.

Separation by Nunzio Paci

ABSTRACT The journey of anything tangible depends on its ability to evolve in response to its environmental context. Evolution is a never-ending process. Matter continually adapts to survive the ever-changing environment. Be it the evolution of man, that depends on the climate he lives in, the availability of resources he uses for survival, the culture he adopts, and the mutation of his genes; or the evolution of styles of design, art, buildings, etc. which change from time to time to create new trends and endure in the market.

The evolution of tangible and intangible matter is in constant response to the other.

It is an endless cycle. A classic example of which is climate. Man adapts to the climate he lives in, though it is none other than him who is responsible for the changes in the climate due to the resources he utilizes. The best reference for this is global warming.

The immediate environment in which man lives, works, recreates, and rejuvenates influences his activities and capabilities. The design of a workplace can influence one’s intellectual or productive behavior. Design here consists of not just the aesthetic features but also the environment comprising of climate, nature, sound, light, etc.

The thesis aims at studying this correlation between the environment and man and addressing its impact on the physique and psyche of man. It also intends to investigate the effect of psychology on physical well-being through control of the immediate built and unbuilt environment.

The target study is focused on cancer patients and their needs and requirements during and after treatment.

P R PROCESS O C E S S EXPERIENCE

RESEARCH

INVESTIGATION

POSSIBILITIES

RESULT

An evening at the Shree Gadge Maharaj Dharamshala in Mumbai lead to the realization of problems faced by the ‘low-income medical migrants availing outpatient services’ or the ‘outpatients.’

Further, on conducting a study on cancer care in Mumbai, numerous shortfalls of the healthcare sector for these outpatients were revealed.

The infrastructure and environments treating and housing them were found to be inadequate and unhealthy. Private and public charitable facilities lacked the funding and availability of space to resolve these issues. On a more advanced level, the needs and issues of the patients and their caregivers were not understood beyond the basic necessities of food, clothing, and shelter. The healthcare environments were not supportive of healing.

This lead to the question of ‘what could be the solution?’ Was it establishment of a medical institution in the city? Or in the rural areas?

Was it need for a palliative and hospice care center? Was it need for more lodgings? Was it the shortage of charitable funds? Was it incorporating a healthy environment in all of these? If so, how to incorporate this ‘healthy environment?’ And which of these need to be prioritized?

Architecturally, the input is limited to control via design of the built and, to some extent, the unbuilt environment within a space. To resolve the imminent problems, it is essential to first understand healthcare and its features. The evolution of healthcare and the reason for its current situation along with its needs and requirements needed to be investigated before catering to the ‘outpatients.’

The resulting report starts with an understanding of healthcare environments and its therapeutic abilities; followed by a study of the intangible and tangible needs of cancer patients and their families along with an insight into cancer care facilities in Mumbai; and concludes with the need for a cancer caring center integrated into a lodging facility, located in the proximity of the Tata Memorial Hospital, incorporating design features derived from the previous studies.

CONTENTS

01

i Background of the study

02

ii Topic justification

03

iii Objective of the study

04

iv Hypothesis statement

05

v Methodology

06

vi Scope & Limitations of the study

07

vii Design intent & Site

08

viii The ‘Prologue’

09

SUBJECT OF RESEARCH

12

THERAPEUTIC ARCHITECTURE 1. What is Therapeutic Environment?

14

2. Healthcare Architecture through the Ages

17

3. Holistic Healthcare

29

4. Healing Landscapes

31

5. Psychological Impacts of Architecture

35

6. Environmental Factors & the Psyche

37

7. Architecture that’s built to Heal

45

8. The ‘Epilogue’

47

02 03

TOPICS OF RESEARCH

50

HEALTHCARE IN INDIA , CANCER, CANCER CARE IN MUMBAI 1. Healthcare in India

52

2. What is Cancer?

60

3. Cancer Care in Mumbai

86

DESIGN INTERVENTION

98

FUNCTIONS, SITE , BRIEF, APPROACH 1. Design Functions

100

2. Site

130

3. Deriving a Design Brief

142

4. Design Approach

146

References & Bibliography

150

List of figures

153

“I believe that the way people live can be directed a little by architecture.”

- Tadao Ando

“We shape our buildings; thereafter they shape us.”

- Winston Churchill

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BACKGROUND OF THE STUDY Hundreds flock to clinics, hospitals, and other healthcare facilities daily. These institutions treat ‘the body’ and the patients return home, content with the treatment received, eager to resume their routine life. Everyone is prepared to pay ‘as much as it takes’ to ensure a complete recovery, unaware of its reliability or after effects. In case of failure of treatment, they start preparing themselves for dysfunction of their body. The focus in all scenarios in case of any diagnosis is ‘the body.’

Numerous studies and researchers have established that the health of an individual is made up of not just the body but the mind and spirit as well. It is not enough to treat a person’s body while snubbing the mind and spirit. Is the function of a healthcare limited to diagnosing and treating an ailment physically? Does physical treatment ensure complete recovery in all cases? Who caters to the psychological and social aspect of treatment?

The built and unbuilt environment of a healthcare facility has a direct impact on a patients medical outcome. This impact can be positive or negative; no impact is neutral.

Typical planning for medical wards is based on the Church’s acceptance of healthcare responsibility and their priority to keep the ailing close to their spiritual self, back when they held the reins of administration. Thus, the large general wards with beds lined up on both sides of the altar are seen till date in our general wards with the altar replaced by the nurse’s station.

Time has progressed, and priorities have changed, but healthcare planning remains persistent. The spatial quality is given minimal priority, or none in most government hospitals whereas in private hospitals the emphasis is on luxury. Few cater to the psychological and social needs of the patients or their family.

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TOPIC JUSTIFICATION A study through time and evolution of healthcare architecture reveals the importance that was laid on holistic treatment even before the concept of hospitals came around. Healthcare is not all about the treatment of the body, as signposted by some sectors of medicine.

As described by Flavio Albanese, the meaning of ‘wellness’ is the balance of mind-bodyspirit. To attain this balance, it is essential to study the role that architecture plays in healthcare, in addition to the one played by the community and the ever-progressing technology.

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OBJECTIVE OF THE STUDY Spaces can create hope and positivity or gloom. They can boost the healing process or add further to an unhealthy environment leading to further amplification of an illness. For a person, undergoing physical and mental trauma due to his ailment, this space can have far-reaching effects. Thus, it is imperative to understand the concept of ‘healing spaces’ to efficiently integrate this pre-requisite in healthcare design.

Treatment is complete only when all facets of health are addressed. The focus should be on holistic treatment and not solely on efficiency or functionality of the building as is the case in most existing healthcare institutes. This design of spatial atmosphere should not be limited to the time the patient spends in the healthcare center but extend to the home, workplace, and any other environment they spend quality time in. Thus, a study of healthcare environment extending to the home and work atmosphere of a patient is essential.

The relation between space and health, vital as it is, is seldom addressed. If addressed correctly, it would be a turning point in the medical world. Hence, it is crucial to understand the psychological impacts of architecture on the human mind and body as also spatial therapy.

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to the materials of construction and ease of functionality but extends to intangible aspects

such

as

comfor t,

experience,

ability to heal and empower, etc.; both of which together ar ticulate a healing space.

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‘

‘

The architecture of healthcare is not limited

METHODOLOGY In an attempt to comprehend what ‘therapeutic spaces’ in terms of a healing environment for cancer patients stand for, the study has been broken down into two sections. The former encompasses research based on universal therapeutic environments while the latter narrows the study to cancer patients and their immaterial requirements.

The research in the first section, being a theoretical subject, is qualitative and derived from research papers published by distinguished authorities and studies conducted by established institutions.

The second section is quantitative as well as qualitative, comprising data based on interviews conducted personally and derived from news readings along with statistics. It also includes research on the intangible needs of cancer patients and the situation of cancer care facilities in Mumbai.

The third section deals with a proposal for the manifestation of the conclusions from previous chapters. Function-based case studies are used to derive a detailed design programme and justify a site for the proposed project.

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SCOPE & LIMITATIONS OF THE STUDY Research on healthcare and its environment provides an opportunity to identify the missing elements in the prevailing system. With the community preparing for a change in healthcare and demanding a patient-oriented and holistic environment, this study helps to understand these concepts theoretically.

It is to be kept in mind that it is not the building itself that fuels healing but the ethos of both the community and architecture along with technology that enhances the contribution of a built environment to the healing process. The built environment merely plays its role as one of the members, but only gives results when all the members perform together.

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DESIGN INTENT & SITE The executed study leads to a proposal for a cancer caring institute situated amidst the typical urban context to address the needs of medical migration. The proposed institute offers housing and a caring center for the medical migrants.

The proposed project aims to avoid disruption of regular routine, at the same time provide a healing abode.

On analyzing the statistical data of medical migration for cancer treatment and the shortcomings of the existing facilities, the proposed site is located in Mumbai.

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THE ‘PROLOGUE’ The existential purpose of architecture is primarily to be at the service of the body. We experience architecture every day, not sparing a thought to how the design of the built environment affects us physically, mentally and emotionally. Do we stop and take a note of how different spaces and atmospheres affect our emotions?

David Leatherbarrow, in his book Architecture Oriented Otherwise, states, “An atmosphere, like a mood, impresses itself on experience...” As architects, how do we give shape to this experience?

All our senses simultaneously engaged together help us to perceive the world. However, we currently live in a world where visual stimulation takes superiority over other senses and aspects such as emotion, perception, and remembrances are not accommodated in the design.

Most often, what a building looks like is what matters in our assessment of architecture. Instead of it being understood as a space with different layers of experience, it is reduced only to the visual. As a result, there is a lack of sensuality and experience in our lives. With the dominance of vision over other senses, our perception of the world relies so predominantly on an image that our built environment has become sensually bland.

What would our world be like if sensory response was treated as a critical design factor, equally as structure and programme?

There exist multiple approaches to create an experiential space. Sensory architecture, therapeutic architecture, placebo architecture, lighting in architecture, environmental architecture, scale and proportion, etc. are different means of adding value, more than just aesthetics and functionality, to a built mass. Architecture is more than bricks and mortar, programme and budget. It is about the spaces we create.

Spaces, unlike buildings, are not influenced by merely the physical matter. Factors such as

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quality and quantity of light, sound, scale, proportion, color, vegetation, use of materials, etc. woven together in an appropriate proportion create an experiential space. Spaces can arouse emotions. They can affect the quality of the planned activity. Spaces can stimulate targeted responses.

“I don’t think that architecture is only about shelter. It should be able to excite you, to calm you, to make you think.”

- Zaha Hadid Design should not limit itself to being able to produce beautiful looking buildings. It should be able to generate beautiful emotions. It should be able to give an impetus to the desired function of the space.

Stephen Holl points out that while a picture or a film might give us some idea of space, ‘Only the actual building allows the eye to roam freely among inventive details; only architecture itself offers the tactile sensations of textured stone surfaces and polished wooden pews, the experience of light changing with movement, the smell and resonant sounds of space, the bodily relations of scale and proportions. All these sensations combine within one complex experience, which becomes articulate and specific. Some may say that the building speaks through the silence of its perceptual phenomena.’

The experience of an arbitrary building is exhausted within its first visit. However, buildings which incorporate experiential qualities can be visited many times. Attention to tangible and intangible details affect how a building is going to be experienced by those who inhabit it.

(Derived from - Yvonne Osei, Exploring Sensory Design in Therapeutic Architecture, Carleton University, Ottawa, Ontario, 2014)

There are myriad ways to articulate an experiential space. Different programmes demand different experiences. As this thesis intends to investigate the aspect of healthcare, therapeutic architecture has been chosen as the medium of spatial design.

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SUBJECT OF RESEARCH

CHAPTER 01 14 WHAT IS THERAPEUTIC ENVIRONMENT? A brief insight into the concept of Therapeutic Environment and its need.

17 HEALTHCARE ARCHITECTURE THROUGH THE AGES A study of the evolution of healthcare architecture to derive a conclusion for the current architectural healthcare needs.

The Sanctuary of Asklepios at Epidaurus 19 The Church & Spiritual healing 21 The Pavilion system & Nightingale wards 23 Hospital as a Machine 25 The Origin vs. current requirement 27

29 HOLISTIC HEALTHCARE A short introduction to the principle of Holistic Healthcare and its relevance in architecture.

31 HEALING LANDSCAPES The requirement of ‘Healing gardens’ and their impact on healthcare backed up with a case study.

The Elizabeth And Nona Evans Restorative Garden, Cleveland, Ohio 33

THERAPEUTIC ARCHITECTURE

35 PSYCHOLOGICAL IMPACTS OF ARCHITECTURE The effect of architecture and spaces on the human mind, supported by scientific experiments.

37 ENVIRONMENTAL FACTORS & THE PSYCHE The impact of various environmental factors on the human body and their consideration in architectural and spatial design.

39 Wayfinding 40 Acoustics 41 Color 42 Odor 43 Views 44 Natural light

45 ARCHITECTURE THAT’S BUILT TO HEAL Review of a TED Talk by Ar. Michael Murphy.

47 THE ‘EPILOGUE’ The conclusion.

Figure 1.1 Castle and I | by Tran Nguyen

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1.1 WHAT IS THERAPEUTIC ENVIRONMENT? 1.

Reduce or eliminate environmental

stressors such as noise, crowding, odors, PSYCHO-SOCIAL EFFECTS OF ENVIRONMENT

THERAPEUTIC ENVIRONMENT

EFFECTS OF ENVIRONMENT ON THE IMMUNE SYSTEM

pollution, etc.

2.

Provide

positive

distractions

for

example, view of nature from patient rooms, lobby, waiting and other ‘high stress’ areas; access to nature by means

HOW THE BRAIN PERCEIVES ARCHITECTURE

of healing gardens, chapel or meditation room; artwork, music, pets and other activities or elements that allow for a sense of stimulation which can help nurture a

Patients in a healthcare facility are often fearful and uncertain about their health, their safety and their isolation from normal social relationships. The complex environment of a typical healthcare center adds on further to the traumatic situation. Stress can suppress a person’s immune system and dampen their emotional and spiritual resources, thus, hampering their recovery and healing.

[1]

patient’s sense of positive well-being.

3. Enable social support by means of spaces where patients can engage with others

easily,

for

example,

non-fixed

seating, round tables, etc.

4. Offer a sense of control over the immediate environment such as quantity of light, noise, visual content, ability to locate, etc.

[2]

Researchers have identified four key factors that can measurably improve patient outcomes if implemented in the design of a healthcare environment: RE - HUMANIZING HE ALTHC ARE |

14

The term therapeutic architecture has

state-of-the-art medicine and technology,

evolved into a recognized concept as a

patient safety, and quality patient care, but

reaction against the austerity of modern

also to embrace the patient, family, and

treatment facilities. It does not propose

caregivers in a psycho-socially supportive

that architecture itself has the ability to

therapeutic environment.

[4]

heal, but that the architectural manipulation of space can provide the platform

The need for this soothing, healing

for other natural factors like sound, light,

atmosphere is not limited to the place

color, privacy, views, and even smell to

and duration of treatment. Patients

promote a healing environment that affects

need to be enveloped by this milieu

the physical and psychological healing of

all through their treatment process

patients.

until total recovery; physical as well as

[3]

psychological.

Healthcare facilities should be designed not

only

to

support

and

facilitate

Figure 1.2 State of mind of a patient undergoing Trauma | by Disha Vanzara

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Figure 1.3 L’EsthÊtisme du Cri (the Aestheticism of the Scream) | by Antoine Stevens

The mind of a patient undergoing psychological or physical trauma experiences many painful and negative emotions. In order to counter these negative impacts, a therapeutic environment should be a prescribed pre-requisite for every healthcare facility.

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1. 2 HEALTHCARE ARCHITECTURE THROUGH THE AGES In recent decades new concepts have

This leads to the question of the absence

emerged for the design of healthcare

of these features in the existential crisis

institutes, seeking to offer the patients a

of deteriorating health care. Were these

homely atmosphere through architec-

factors never considered for the design

ture and interior design by incorporating

of healthcare? If so, what lead to their

the patient’s everyday representations in

elimination?

the design. These concepts also propose the integration of healthcare environments

In order to address the query of the current

with outer space as a promoter of healing.

catastrophe, it is essential to head back

Current research on the length of stay and

to the roots. A study of the evolution of

quality of care point to the humanization of

healthcare is required to comprehend

these environments to alleviate the suffering

when and how healthcare, in terms of

and anguish during hospitalization, adding

holistic treatment, began to fail and to

family

attain a better understanding of the current

life

practices

and

personalized

spaces, and involving professional teams

healthcare practices and requirements.

and families as care partners in offering therapies to achieve the desired cure.

Figure 1.5 Medieval home centered care system

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[5]

Figure 1.6 Religious institutions providing medical care to the common masses

Figur Main pool at Sweet Sp Spas an

Figure 1.4 Timeline of healthcare architecture | by Author

e 1.7 prings, Missouri, 1873 nd Baths

Figure 1.8 Mobile field hospital, United States Army, 1917 - Redeployable hospitals

Figure 1.9 Hospital Beaujon, near Paris, 1932 International style high-rise hospital RE - HUMANIZING HE ALTHC ARE |

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1.2. 1 THE SANCTUARY OF ASKLEPIOS AT EPIDAURUS In ancient Greece and Rome, an Asklepion

The theatre of Epidaurus, a shell-like

was a healing temple, sacred to the Greek

structure with remarkable acoustics and

God of medicine Asklepios. The Sanctuary

harmonious

at Epidaurus comprising of the theatre,

visitors could attend performances and

the Temples of Artemis and Asklepios, the

‘escape’ from their debilitating problems.

architecture,

was

where

Tholos, the Enkoimeterion, the Propylaia, the Banqueting Hall, the baths as well

After the necessary cleansings, having

as the sports and hospital facilities is an

attained a calm and mentally relaxed state,

eminent example of a Hellenic architectural

they were led to the main therapeutic space,

ensemble of the 4th century BCE

the Abaton; a dome-shaped structure, with

[6]

It is

the earliest organized sanatorium.

corridors and complex circular mazes.

Archaeological evidence provides proof

This preparatory stage was followed by

that

antiquity

the main healing phase, known as enkoi-

what we nowadays call holistic health

mesis. During sleep in the Enkoimeterion,

care. Each activity that took place at

the patient allowed himself to dream of

Epidaurus was designed to harmonize

the God, who would visit him and offer the

the mind, body, and soul.

healing treatment that was needed.

Asklepieia

offered

in

Figure 1.10 The Sanctuary of Asklepios at Epidaurus

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PROPYLAIA

PORTICO OF KOTYS

CISTERN TEMPLE

ABATON

EPIDOTEION

DORIC FOUNTAIN ALTAR OF ASKLEPIOS

TEMPLE OF ASKLEPIOS THYMELE

ALTAR

TEMPLE OF ARTEMIS PROPYLON

GYMNASIUM

BANQUETING

HOSTEL BUILDING

HALL STADIUM

GREEK BATHS

THEATRE

Figure 1.11 Site plan, the Sanctuary of Asklepios at Epidaurus | by Author

N

The layout of the sanctuary served to

themselves.

focus the concentration of the patient

a patient from entertainment to sleep, from

and draw strength from his inner world.

physique to hygiene. Thus, it is the ultimate

The sanctuary, with its peaceful natural

example of holistic care.

[7]

It catered to all the needs of

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1.2. 2 THE CHURCH & SPIRITUAL HEALING Early in history, the sick were cared for in

institutions continued to provide most of

their homes. As the Roman Empire turned

the healthcare to the poor in large, open

to Christianity, the Church’s role in looking

wards, while physicians continued the

after the infirm within their churches or

practice of making house calls to the upper

cathedrals

class.

became

firmly

established.

After 400 AD, numerous monasteries were constructed, generally including accom-

The wards housing multiple patients

modations for travelers, the poor, and the

continued to expand and became the

sick. The Catholic Church became the

standard for the public hospitals for

most powerful provider of health care, and

hundreds of years. Often the wards

monastic orders were the caretakers for

were configured so the sick could see

the sick.

the altar to assist with their recovery.

The cross-shaped plan achieved this

The

monarchs

of

the

6th

century

goal with the altar in the middle and

reinforced this role with emperors such as

multiple wards radiating from it. The

Charlemagne, who directed that a hospital

plan is similar to many hospitals today,

should be attached to every cathedral

with the nurse’s station instead of the

that was built in his empire. Religious

altar at the center.

[8]

Figure 1.12 The Carolingian Abbey of Saint Gall | by Johann Rudolf Rahn

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The Church emphasized in the healing

Thus, except for proximity of the altar, no

power of prayer and encouraged spiritual

other factors were prioritized for planning.

interventions as treatment procedures.

PHYSIC GARDEN DR’s HOUSE

HOUSE OF NOVICES

INFIRMARY

CEMETERY

BLOOD BANK ALTAR

SCIPTORIUM HIGH ALTAR

ABBOT’s HOUSE

VESTRY

NECESSARY

CALEFACTORY

REFECTORY

SCHOOL CLOISTER

NAVE

BAKE HOUSE CELLAR

KITCHEN BREW HOUSE

GUEST HOUSE

ALTAR

GUEST HOUSE

Figure 1.13 Diagrammatic ground floor plan, the Abbey of Saint Gall | by Author

PARAD ISE TOWER

MENIAL DEPARTMENT

TOWER

MONASTIC BUILDINGS

CHURCH

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1.2. 3 THE PAVILION SYSTEM & NIGHTINGALE WARDS TERRACE

In the late 1700’s a re-evaluation of the

light, air, landscape, attention to diet, as

hospital form was prompted by the new

well as a clean, sanitary environment.

recognition of clean hygienic WARD condiWARDair and WARD tions as agents of health, especially in hospital environments. Of the two architec-

[9]

WARD WARD WARD DINING The pavilion system incorporated with ROOMS

Florence Nightingale’s proposals took

tural proposals made, the pavilion system

shape. The general plan of these pavilion BATHS

prevailed.

style hospitals included a primary supply WARD

WARD

WARD corridor for circulation ofWARD people and LIBRARY

KITCHEN Florence Nightingale was a very influential

supplies with finger plan patient wards

figure in nursing following the Crimean war

that extend off of this linear spine. The

in 1854. Her approach towards a healing pavilion plan allowed light and fresh air ADMINISTRATION environment for patients not only looked at

to penetrate and created garden views

the physical surroundings but also at the

between the building crenellations. This

social welfare of her patients. She focused

design emphasized function over form.

on providing patients with access to natural

BATHROOM STORE

NURSE’S LOUNGE

BATHROOM

Figure 1. 14 Typical plan of a Nightingale ward | by Author

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LOBBY

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CORRIDOR

WARD

DAY ROOM

TERRACE

WARD

WARD

WARD

WARD

WARD

WARD

WARD

WARD

DINING ROOMS BATHS WARD

WARD

LIBRARY KITCHEN

ADMINISTRATION

Figure 1.15 Schematic ground floor plan, The Royal Herbert Hospital, Woolwich, London | by Author

BATHROOM STORE space in cities, the typology died out. It

extensive space, would have triumphed

was one of the most well-conceived ideas

through history. Due to its spread out

of healthcare architecture.

horizontality of DAY ROOM and the imminent crunch WARD

LOBBY RE - HUMANIZING HE ALTHC ARE |

BATHROOM

NURSE’S

CORRIDOR

The pavilion system, had it not required

24

HO

CI ITA

L

AD

RO TA L

II, Florence Nightingale’s original concept

in form related to human health, stress,

of hospitals was replaced by hospitals

and comfort.

AD

without evaluating how these changes

‘healing’ centers. They were taken over by

floor block (or platform) with a patient tower

equipment and machinery. With everything

placed on top (as a podium).

from ventilation to circulation mechanized, the only scope for architectural interven-

Building technology aided in this trans-

tion remained in the design of smooth

formation with a new ability to create

functionality to support the mechanics and

long-span

mechanically

the aesthetics. Thus, the huge chunks of

ventilated interior spaces, and movement

mass or rather the ‘platform and podium’

of

elevators.

transformed into decorated blocks of

Circulation patterns were confusing without

buildings from the outside as well as

any external cues of directionality, setting

inside.

structures, vertically

with

or hierarchy. Ultimately, the attitude of the hospital as a well-tuned machine took precedence over more humanistic factors for the patients, staff, and visitors to these facilities.

Through time, with the progression of diagnostic and treatment facilities, this platform has gotten bigger and taller, limiting access to the aspects of natural air, light, and view that Nightingale attributed to her patient’s well-being.

Designers and builders maximized the efficiency

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of

hospitals

Figure 1.16 The John Hopkins Hospital - Decorated blocks | by Author

TY

configuration became a deep span, multi-

CI

The hospitals no longer functioned as HO

comfort and healing. A typical hospital

RO

TA L

RO

[10]

SPI

that prioritized efficiency over human

25 |

AD

RO

SPI

AD

In the hospital boom following World War

machine-like

RO

HO

YR O CIT

HOSPITAL AS A MACHINE

people

TY

AD

1.2. 4

SP

Figure 1.17 Schematic site plan, King Edward Memorial Hospital, Mumbai Town within a hospital | by Author

N

SP

CI ITA

L

TY

RO

AD

RO

AD

AD RO TY CI

HO

SPI

TA L

RO

AD

CIT

P I TA

YR OA D HO S

LR O

AD

HO

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1.2. 5 THE ORIGIN VS. CURRENT REQUIREMENT The architecture of healthcare facilities has

Hospitals in the current times are home

undergone drastic changes along the way.

to machinery and designers attempts

During this evolution, the healing ability

to conceal this machinery. Healing is

of architecture is lost in the transition

prioritized from the medical and techno-

from healing spaces to functionalist

logical point of view. The psychological

buildings.

effects on the patients waiting in long dingy

corridors

or

family

awaiting

Healthcare today focuses on the ease

results of their loved ones in the dingy,

of functionality and has side-lined the

emotionless

well-being of the patients and caregivers in

considered relevant as opposed to the

architectural design and spatial planning.

efficiency and smooth functioning of the

Aesthetics of the building are given prece-

hospital.

waiting

rooms

are

not

dence over the quality of space. With the space crunch and high real estate rates, healthcare buildings have expanded vertically

without

consideration

of

therapeutic spaces.

“During the modern era, … the hospitals became more machine than monument, a stripped-down,

functional

series of boxes

accommodating the increasingly complex technical apparatus for prolonging life. Architecture flat-lined.”

- Edwin Heathcote, Architect 27 |

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Greek sanctuaries of fered Holistic care

Healthcare at home enjoyed by the privileged while the commons looked to the church

CORRIDOR

PL ATFORM

WARDS

PODIUM Patient-oriented care of fered by the Pavilion system

The star t of stacking due to space crunch

The advent of machiner y lead to the star t of ver ticality in the form of the Podium and Platform

Contemporar y hospitals

DEPARTMENT E

DEPARTMENT C

DEPARTMENT D

DEPARTMENT B

DEPARTMENT A

The growing needs lead to ‘town within a hospital’ as a result of which the therapeutic needs of patients and caregivers were neglected to achieve optimum ef ficiency.

Figure 1.18 Evolution of healthcare architecture | by Author RE - HUMANIZING HE ALTHC ARE |

28

1.3 HOLISTIC HEALTHCARE Holistic healthcare is a form of healing that

The role of architecture in this concept is

considers the whole person - body, mind,

limited to the psychological impact it leaves

spirit, and emotions - in the quest for

on the human mind. Healthcare buildings

optimal health and wellness. According to

should be designed with the idea of

the holistic medicine philosophy, one can

holistic treatment in mind, in addition

achieve optimal health by gaining a proper

to treatment through technological and

balance in life.

scientific advances.

[11]

A holistic approach to healing goes beyond simply eliminating symptoms. In holistic medicine, a symptom is considered a message that something needs attention.

The symptom is then used as a guide to look beyond the surface for the root cause.

After which, what really needs attention can be addressed.

Holistic

[12]

healthcare

is

an

ongoing

process. It is not a remedy to turn to in times of sickness but a principle to abide by through life. It consists of adopting various daily practices such as exercise, nutritional choices, meditation to achieve a calm state of mind, and many such factors.

29 |

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Figure 1.19 Holistic Healthcare

“Calling medicine’

holistic is

no

medicine

‘alternative

longer

appropriate.

The best approach now is ‘integrated medicine’ in which we take the best of both worlds.”

- Candess M. Campbell, Ph.D. in Clinical Hypnotherapy

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30

1.4 HEALING LANDSCAPES Regardless of age or culture, man finds

negative comments from nurses, took less

nature restorative. It provides a sense of

pain medication and experienced fewer

relief from stress. Often man tends to lose

minor post-operative complications than

himself in nature. This ability of nature can

those with a view of a brick wall.

be used to the benefit of healthcare. Hence, the Pavilion system emphasized on the

The sound of the birds chirping in a

view of a garden from every patient’s

garden or that of water along with the

bed.

smell of the flowers and soil tends to mentally transport a patient to a world

Modern

advances

in

technology

away from the pain and sickness. It

towards healing have primarily dimin-

works as a distraction technique wherein

ished the importance of nature in the

one forgets about his worries and pain.

healing process, and this has been an unfortunate result of the ‘cure over care’ phenomena found within many aspects of the healthcare field.

[13]

Roger Ulrich, a professor, and director

2/3 rd

95%

PEOPLE

PEOPLE

of the Center for Health Systems and Design at Texas A & M University found that viewing natural scenes or elements fosters stress recovery by evoking positive feelings, thus, reducing negative emotions by effectively holding attention/interest and blocking or reducing stressful thoughts.

Further research by Ulrich showed that surgical patients with views of nature had shorter post-operative stays, fewer 31 |

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Mood improved after Choose a natural setting spending time outside; to retreat to when changing from depressed, stressed stressed, and anxious to more calm and balanced.

Figure 1.20 Results of a study by researchers Clare Cooper Marcus (architect) & Marni Barnes (psychotherapist and architect) | by Author

Visually pleasing, accommodating light and portable furniture and water features

Appropriate scale of vegetation with respect to the built mass

Smooth transitions using natural materials with reservations for various private and social activities

Facilitating easy maintenance and barrier-free access

SCREEN

Figure 1.21 Features for the design of a Therapeutic garden | by Author

Balanced design (symmetric/asymmetric) with focal points for easy orientation

NOISE SOURCE

Use of noise absorbers to ensure the audibility of the sounds of nature

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32

THE ELIZABETH AND NONA EVANS RESTORATIVE GARDEN, CLEVELAND, OHIO

Built in 1998

Chestnut oak and Magnolia provide a

Landscape architects: Dirtworks

sense of enclosure and seclusion as it unfolds into three distinct rooms.

The

Location:

Cleveland

Botanical

Garden, located in the city’s University

The first is a quiet respite offering

Circle neighborhood, is a combination of

an elegant square lawn and a restful

indoor exhibits, housed in a glasshouse,

reflecting pool. A white-only palette of

and ten acres of diverse outdoor gardens.

flowers enhances the serenity here.

The Elizabeth and Nona Evans Restorative Garden is a part of the Cleveland Botanical

The second room is a multi-sensory

Garden.

sampler with both annuals and perennials to see, touch, and smell.

Purpose: The Elizabeth and Nona Evans Restorative Garden was a renovation and

The wall, or third area, is made of native

expansion of a Library Reading Garden.

stones, interesting plants in nooks, and

It serves as an outdoor classroom where

cascading water to hear and touch.

[15]

healthcare workers from across the country learn how to use plants and gardening to

Use: People with various disabilities and

improve the quality of life for patients in

health conditions visit the garden for horti-

their care.

culture therapy as it offers a lush refuge.

[14]

The balance of private and public space Design: Among the abundance of calming

reinforces a sense of respect and sensi-

greenery, the sounds of water, and the

tivity. This calming, life-affirming garden is

calming scents one can enjoy absolute

a place where one can relax the mind, invig-

solace in this garden. Large trees like

orate the senses and renew themselves.

33 |

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[16]

ROOM 3

ROOM 3

ROOM 2

ROOM 1 LIBRARY

Figure 1.22 Schematic plan, the Elizabeth and Nona Evans Restorative Garden, Cleveland, Ohio | by Author

ENTRY

N

Inference: Access to a similarly functioning,

it also acts as a pain relief system and

healing garden in a healthcare institute

imparts a positive atmosphere in a built

can result in multiple benefiting outcomes.

environment.

Along with boosting the healing process,

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34

1.5 PSYCHOLOGICAL IMPACTS OF ARCHITECTURE Experiencing architecture has less to do

Christopher Day is of the opinion that

with the aesthetics than its engagement

‘we don’t notice the noise, the bad air,

with all our senses. People experience

the harsh conflict of hard-edged shapes

a space with their entire body, through

and forms. We become immune to the

movement, memory, and imagination.

negative forces in our environment –

There exists a sub-conscious dialogue

and that is when they do us most harm!’

between a person and architecture.

These factors subconsciously reflect on

[17]

our emotions and mindset.

In

architecture

and

spatial

design,

atmosphere refers to the sensorial quality that space limits. It is the impact of this atmosphere that affects the human mind and body.

‘Architecture

and

neuroscience are no longer two discrete

disciplines. Exploring the benefits of collaboration between neuroscience and perception, and architecture and the brain will yield a new dimension for design benchmarks, as human brains are continuously remolded by environmental forces and experiences.’

- A Design Index for Therapeutic Architecture, AIA 35 |

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COLOR OF A STOP SIGN COLOR OF A STOP SIGN

COLOR OF THECOLOR SKY OF THE SKY

RESULTS: at skills Subjects RESULTS: Subjects performed badly in RESULTS: Subjects were Subjects better at were skills betterRESULTS: performed badly in requiring accuracy to and attentionshort-term to detail memory short-term tasks.onThey scored on requiring accuracy and attention detail tasks. memory They scored COLOR COLOR OF COLOR AOF STOP A STOP OF SIGN A STOP SIGN SIGN COLOR COLOR OF COLOR THE OF SKY THE OFSKY THE SKY such spelling as catching spelling or tasks requiring imagination such as catching mistakes or mistakes tasks requiring imagination such as listing such as listing RESULTS: RESULTS: RESULTS: Subjects Subjects were Subjects were betterbetter were at skills better at skills atRESULTS: skills RESULTS: RESULTS: Subjects Subjects performed Subjects performed performed badlybadly in badly in in keeping random numbers in creative short-term creative uses a brick aor designing a keeping random numbers in short-term uses of a brick or of designing requiring requiring accuracy requiring accuracy and accuracy attention and attention andtoattention detail to detail to short-term detail short-term short-term memory memory tasks. memory tasks.

Theytasks.

They scored scored They on scored on on memory. toy outshapes. of geometric memory. child’s toy out child’s of geometric They shapes. They such such as catching such as catching as spelling catching spelling mistakes spelling mistakes or mistakes ortasksor tasks requiring tasks requiring imagination requiring imagination imagination such such as listing as such listing as listing REASON: People associate automatically generated associate double generated double ‘creative REASON: People automatically ‘creative outputs’ than outputs’ than keeping keeping random keeping random numbers random numbers innumbers short-term in short-term in short-term creative creative uses creative uses of a of uses brick a brick ofor adesigning brick or designing or adesigning a a redwhich with makes danger, them whichmore makes them more subjects in the red condition. red with danger, subjects in the red condition. memory. memory. memory. child’schild’s toy child’s out toy ofout toy geometric ofout geometric of shapes. geometric shapes.

They shapes.

They They blue color alert and aware.alert and aware. REASON: The REASON: blue colorThe doubled their doubled their REASON: REASON: People REASON: People automatically People automatically automatically associate associate associate generated generated generated double double ‘creative double ‘creative outputs’ ‘creative outputs’ than outputs’ than than imaginative power. imaginative power. red with red danger, with red danger, with which danger, which makes which makes them makes them more more them more subjects subjects in subjects theinred thecondition. in redthe condition. red condition.

alert and alertaware. and alertaware. and aware.

REASON: REASON: REASON: The The blue blue color The color blue doubled color doubled their doubled their their Figure 1.23 Experiment on ‘How the color of interior walls influences the imagination’ by the psychologists imaginative imaginative imaginative power. power.power.at the University of British Columbia, 2009 | by Author

LOW CEILING LOW CEILING

HIGH CEILING HIGH CEILING

LOFTY CEILINGLOFTY CEILING

RESULTS:wereSubjects were Subjects RESULTS: Subjects excelledSubjects RESULTS: Subjects engaged RESULTS: Subjects RESULTS: excelled RESULTS: engaged quicker at solving atanagrams puzzlesthein in which quicker at solving anagrams puzzles inat which in more styles of morethe abstract stylesabstract of LOW LOW CEILING CEILING LOW CEILING HIGHHIGH CEILING HIGH CEILING CEILING LOFTY LOFTY CEILING LOFTY CEILING CEILING involving confinement such touches as answer involving confinement such as answer on the touches theme on the themethinking thinking RESULTS: RESULTS: RESULTS: Subjects Subjects Subjects were were were RESULTS: RESULTS: Subjects Subjects excelled Subjects excelled RESULTS: RESULTS: RESULTS: Subjects Subjects engaged Subjects engaged engaged bound, restrained, and such of as freedom such asexcelled liberated bound, restrained, and ofRESULTS: freedom liberated quicker quicker at quicker solving at solving at anagrams solving anagrams anagrams at puzzles at puzzles at in puzzles which in which in the which the the in more in more abstract in more abstract styles abstract styles of styles of of restricted. restricted. and unlimited. and unlimited. involving involving confinement involving confinement confinement such such as as such answer as answer touches answer touches on touches the on theme theon theme the theme thinking thinking REASON: Airy spaces prime thinking REASON: Airy spaces prime

bound, bound,restrained, bound, restrained, restrained, and andof freedom and ofusfreedom such freedom such as liberated such asfree. liberated usas toliberated feel to of feel free. restricted. restricted. restricted. and unlimited. and unlimited. and unlimited.

REASON: REASON: Airy REASON: spaces Airy spaces Airy prime spaces prime prime us to us feeltofree. feel us to free. feel free.

Figure 1.24 Experiment on ‘The relationship between ceiling height and thinking style’ by psychologist Joan Meyers-Levy at the Carlson School of Management | by Author RE - HUMANIZING HE ALTHC ARE |

36

1.6 ENVIRONMENTAL FACTORS & THE PSYCHE Environmental factors such as noise,

enhance the soothing and calming qualities

crowding,

lighting,

of a space; inability to locate a particular

proportion, scale, colors, etc. affect the

room or facility may add to anxiety or stress;

immediate atmosphere of space.

crowding

odors,

pollution,

can

cause

uneasiness,

etc.

Consideration of these factors in design For instance, objectionable odors can

implementation can lead to life-changing

cause stress; artwork and aesthetics can

outcomes.

Figure 1.25 Factors affecting the human body in an enclosed environment | by Omar Youssef.

37 |

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‘Ar tificial ventilation may be necessar y, but it never can compensate for the want of the open window... Second only to fresh air, however, I should be inclined to rank light in impor tance for the sick...

Among the kindred effects of light, I may mention, from experience, as quite perceptible in promoting recover y, the being able to see out of a window, instead of looking against a dead wall; the bright colors of flowers; the being able to read in bed by the light of a window close to the bed-head. It is generally said that the effect is upon the mind. Perhaps so; but it is no less so upon the body on that account.’

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38

1.6. 1 WAYFINDING

An uncertainty of any manner can set off

destination.

negative emotions for a person undergoing

programme includes physical elements,

trauma. Inability to locate things or places

communications, and human interaction.

An

effective

wayfinding

can lead to anxiety.

Landscaping, Healthcare complex

facilities

are

environments.

elements,

color,

texture, and pattern should all give cues, in

inherently The

building

addition to artwork and signage.

built

environment should provide clear visual cues to orient and guide people to their

ADMIN > Using walls for bold signages of contrasting colors and sizes at eye level

Using plaques at nodes

C

WAY TO C

WAY TO B

WAY TO A

D B A A

Color co-ordinated path markers

39 |

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C

E D

F

B E

F

Design of a straight-forward flow of movement

Figure 1.26 Design features for wayfinding in architecture | by Author

1.6. 2 ACOUSTICS Noise in healthcare environments can lead

The planning of a building should involve

to negative impacts including elevated

consideration

psychological

stress

to achieve a productive environment.

levels that can worsen other outcomes

Acoustical separation of activity zones

and contribute to poor sleep quality. At the

from zones requiring peace and quiet

same time, natural sounds such as birds

should be considered.

and

physiological

of

acoustical

impacts

and trees create a calming atmosphere thus, contributing to the healing process.

SERVICES

ADMIN SEMIPRIVATE ACTIVIT Y

PUBLIC

BUFFER PRIVATE

Figure 1.27 Design features for consideration of acoustics in architecture | by Author

PRIVATE

Acoustical separation of zones

Use of landscaping as noise absorbers

in planning

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40

1.6. 3 COLOR Hilary Dalke, professor at the Kingston

For example, the color blue automatically

University, London, has discovered that

triggers associations with the sky and

both architecture and color have the

ocean. One tends to think about expansive

ability to visually stimulate patients and the

horizons and diffuse light, sandy beaches

surrounding society.

and lazy summer days. This sort of mental relaxation makes it easier for one to

Colors can provoke and elevate positive

daydream and think in terms of tangential

or negative emotions. These emotions

associations thus, focusing less on what’s

are

mental

right in front of him and being more aware

perceptions of colors in relation to the

of the possibilities simmering in his imagi-

association of these colors with certain

nation.

triggered

through

our

[19]

past personal events or cultural beliefs.

Society’s emotional response to color is

A careful selection of colors used in the

based on shared psychological associ-

interiors, on walls and ceilings, as well as

ations of certain emotions to certain

on the external facades of healthcare facil-

colors.

ities can affect patient outcomes.

[18]

W H I TE

RED

G RE E N

G RE Y

purity + hygienic + spatial sense +

love + power + energy + anger +

nature + fresh + tranquility + growth +

neutral + timeless + modern +

cold

defiance

stagnation

hibernation

B LACK

YEL LOW

B LUE

O RA N G E

elegance + power + bold + authority +

laughter + optimism + friendly + attention

serene + creative + reflective + loyal +

warm + vibrant + inviting + change +

oppression

seeking + anxiety

aloof

frivolous

Figure 1.28 The Psychology of Colors | by Author

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1.6. 4 ODOR The expression ‘it is a hospital smell’ is

performance.” This is proven by the use

familiar to most people because of the

of different incenses in spas to generate

smell associated with hospitals. Majority

a calming atmosphere.

scents

have

a

certain

emotion

or

memory attached to it. Though it may be

The smell of lavender has been proven as

subjective sometimes, typically a human

a successful pain relieving agent. It also

reaction to different smells is programmed.

has a powerful ability to treat insomnia.

The presence of these odors in a space

The smell of a freshly mowed lawn can

sets off emotional reactions associated

induce joyousness and relaxation. Citrus

with the idea of that smell.

can boost energy and awareness; vanilla can lift ones’ mood; peppermint boost

The executive director of the Smell

concentration whereas jasmine helps with

of Sense Institute says, “Scents can

depression.

[20]

have positive effects on mood, stress reduction, sleep enhancement, self-confidence, and physical and cognitive

“The act of smelling something, anything, is remarkably like the act of thinking. Immediately at the moment of perception, you can feel the mind going to work, sending the odor around from place to place, setting off complex repertories through the brain, polling one center after another for signs of recognition, for old memories and old connections.”

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42

1.6. 5 VIEWS Roger S. Ulrich revealed the ‘power of the window’ through a science experiment that confirmed that patients in hospitals recovered faster when their rooms had a direct view of the external natural environment rather than a blank wall.

A window is not seen merely as a functional necessity that provides light and ventilation, but also a gateway that has the ability to transport a patient from a harsh reality to a place of contemplation, serving as a temporary escape.

[21]

Numerous studies as also Nightingale’s ward have proved the success of this theory. In urban hospitals, sometimes the only view available for a patient is an artistic depiction of nature which comes without a breath of fresh air and natures sounds and smells. Windows allow sunlight and warmth inside a room while providing views to the outside, thereby adding a sense of openness, spaciousness, and orientation.

43 |

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Figure 1.29 Thong House by NISHIZAWAARCHITECTS

1.6. 6 NATURAL LIGHT The balance or imbalance of a space can

room that is not easily achievable with

easily be altered through the play of light

an electric illuminant. The warmth of

and in combination with forms, colors, and

sunlight cannot be replaced by artificial

natural elements. The quality of light can

lighting. Along with delivering vitamin

be manipulated and adapted to ultimately

D to the body, natural light also leads

create the ability to transcend individuals

to higher productivity; greater natural

into an alternate state of consciousness

light during the day can help stabilize

that could essentially be recollected in

circadian

memory, after its lived experience.

mood.

[22]

rhythms

and

improve

the

[24]

Fabrizio Benedetti, professor of physiology

The design of openings can control the

and neuroscience at the University of Turin

quality and quantity of light in a space.

Medical School, Italy proved that patients

Depending on the functionality of the space,

exposed to an amplified concentration

openings can be designed to control the

of natural sunlight perceive less stress,

mood of the space.

require less medication and even experience less pain.

[23]

A dark or dingy atmosphere generates a feeling of imprisonment, whereas an artificially lit space has no impact on the mood. The changing character of daylight adds a dynamic qualitative dimension to the ambiance of the

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44

1.7 ARCHITECTURE THAT’S BUILT TO HEAL TED TALK BY AR. MICHAEL MURPHY

Michael Murphy is the co-founder & CEO

for consultation on a broken leg but walked

of MASS Design Group, a non-profit archi-

out with tuberculosis due to the negligence

tecture firm that leverages buildings, as well

of basic designs for infection control. This

as the design and construction process,

led him to question the ignorance of archi-

to become engines for health, economic

tects and designers in healthcare design

growth, and long-term sustainability.

for the underprivileged.

REVIEW

In the design of Butaro hospital in Rwanda, with the guidance of Dr. Farmer,

Questioning the availability of the best, most

they implemented basic site oriented

innovative, and visionary architecture for

design strategies with a shift from the

the benefit of few, Michael Murphy comes

conventional model.

across as one of the architects who want to do more than just design masterpieces

He discusses the concept of ‘Ubudehe’

for a legacy.

which means community works for the community. Under this principle, they

He talks about architecture school where

attempted to involve the community as

he learned that “Recognition seemed to

much as possible from hand excavation

come to those who prioritized novel and

of the site to handcrafted furniture, with

sculptural forms.”

the involvement of at least 50% women laborers. Bruce Niveze, the engineer

A talk by Dr. Paul Farmer, attended by Mr.

attempted to use the process of building

Murphy, on healthcare for the poor shed

to heal the community as a whole.

light on a hospital in South Africa where people waited in an unventilated corridor 45 |

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They designed a sustainable hospital

by making use of simple techniques like

He went on to design multiple healthcare

planning hallways around the rooms,

facilities addressed towards answering

opening into the gardens, instead of

the problems of different localities through

corridors to ensure natural ventilation; at

architecture. His approach to architecture

the same time providing verandas. Beds

and built spaces backed up by the results

were reorientated with the bed-heads

his designs have achieved speak for

against each other in the center of the

themselves. His ideas prove that architec-

room, to facilitate views of the garden for

ture has the ability to resolve social issues.

the patients from their beds. The local

Buildings and spaces can do what

stone was used as a building material.

designers want them to do, not just

Though facing multiple stumbles in the

functionally and aesthetically but also

initial stages, the project eventually

socially.

executed still reaps the benefits of the design.

1. VERANDAS | 2. CROSS VENTILATION | 3. INOPERABLE VENTS | 4. INDUSTRIAL FANS | 5. ULTRA-VIOLET GERMICIDAL LIGHTS

Figure 1.30 Orientation of beds, Butaro Hospital, Rwanda

Figure 1.31 Sustainable design features, Butaro Hospital, Rwanda

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46

1.8 THE ‘EPILOGUE’ Healthcare today is broadly divided into

Implementation of these necessary design

hospitals

centers.

considerations will have a far-reaching

Though rehabilitation centers are, at

effect on the medical outcome of patients.

and

rehabilitation

times, designed with the idea of holistic medicine in mind, hospitals usually fail

Healthcare architecture needs to move

to do so.

beyond functionality and aesthetics, towards patient-oriented design. In a

Initiatives

undertaken

organizations,

studying

by

of the Greek sanctuaries, the Pavilion

been

system and Nightingale wards and the

successfully attempting to establish the

high-rise style in the town in a hospital

scientific

design

planning. This will not only provide a

features and their impact on health since

better environment for the patients but

the last two decades.

also reflect on their length of hospital

design,’

relationship

effects

way, we need to combine design features

of

‘evidence-based

the

numerous have

between

stays and treatment results, ultimately The discussed investigations lead to the

proving beneficial to both the patient

conclusion that architecture and the design

and the medical authorities.

of spaces play a colossal role in healthcare.

47 |

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48

49 |

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TOPICS OF RESEARCH

CHAPTER 02 52 HEALTHCARE IN INDIA A brief insight into the healthcare industry and non-communicable diseases in India.

The Industry 53 The Boom of Chronic diseases 55 Need for Cancer Care 57

60 WHAT IS CANCER? Introduction to the disease and the patients and their families various requirements and care options.

Issues and needs of The Patient 61 Physical + Psychological + Social & Spiritual Prevalent types of Cancer Care facilities 65 Hospital + Palliative Care Center + Hospice Care Center + Mukti Bhavan + Dharamshala + Caring Center & NGO Complementary Therapies 69 Animal-assisted therapy + Aromatherapy + Art therapy + Counseling + Horticulture + Massage therapy + Meditation + Music therapy + Support groups + Yoga & Exercise

HEALTHCARE IN INDIA , CANCER, CANCER CARE IN MUMBAI 73 77 79 81 83

A view from the front line Cancer and Economics The Caregiver Mapping Affordable Cancer treatment Medical Migration for Cancer Care

86 CANCER CARE IN MUMBAI A study of affordable cancer care options available in Mumbai for the ‘outpatient.’

88 Treatment within means Tata Memorial Hospital + Indian Cancer Society + St. Jude India ChildCare Centres 93 Shortcomings of the city for the ‘outpatient’ 95 Needs of the ‘outpatient’

“Indian healthcare industr y is best described as islands of excellence in an ocean of inadequacy. The Indian model of healthcare is innovative and of affordable quality, as it has used efficiencies of the six sigma, smar t and innovative IT, quality engagement with clinicians, and good use of local pharmaceutical industr y as well as the medical technology and devices sector, which together are paving the way for healthcare of the future.�

- Sangita Reddy, Chairperson, FICCI 51 |

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2 .1 HEALTHCARE IN INDIA India was ranked at 112 out of 190 countries

in rural areas and the concentrated

in a report published by the World Health

growth of healthcare services in the

Organization in 2000.

urban areas, internal medical migration is on the rise.

One

of

the

primary

reasons

for

the

backward lag of the healthcare sector in

This medical migration comes with its own

India is its rural-urban divide. There are

set of needs and requirements, which are

vast gaps between the facilities provided

not addressed due to the limelight being

to the rural and urban populations in India’s

focused on the rural-urban divide. While

healthcare system.

policies for the growth and development of healthcare need to be formulated for

Majority hospitals are centered in cities

rural areas, medical migration needs to

and urban areas, while the rural setup

be tackled too.

makes do with small hospitals or clinics.

With 70% of India’s population residing

Figure 2.1 Healthcare in India - Rural vs. Urban

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52

1991

2.1. 1

Population growth: +450 Million

THE INDUSTRY

2016

210 awareness is a rapidly growing healthcare GROWTH IN BILLION $

1991

People living in Poverty: -50%

industry. Despite this fast growth, the Population growth: +450 Million

healthcare sector in India comprises the 100 lowest government 66spend and public

People living in Poverty: -50%

spend as a 22 proportion of the Gross 5 Domestic Product (GDP) and amounts to 2010 1990 2000 the lowest per capita health2015 spend –2020 China

100

spends 5.6 times more, and the USA, 125

GROWTH IN BILLION $

Figure 2.2 Population trend in India between 1991 & 2016 | by 210 Author

The 1991

66

period between 1991 and 2016, 22

5

known as that of rising prosperity 2010 2015 2020 1990

2016 times more.

2000

in India, has been marked by a dual disease burden; a continuing rise in communicable diseases and a spurt in

Population growth:

People living in -50%

non-communicable/chronic or ‘lifestyle’ +450 Million Poverty: diseases.

Population

Infrastructure

Population

Infrastructure

GROWTH IN BILLION $

210

Insurance

Rural-Urban disparity

100

66 62%

5

22

Personal savings

1990

38% Insurance

2000 76%

2010 24%

Uninsured

Insured

Insurance

2015

2020

Figure 2.3 Growth trend of the healthcare sector in India | by Author

Rural-Urban disparity

Figure 2.4 Key roadblocks for India’s healthcare sector | by Author

62%

Personal savings

38%

Insurance

The Indian healthcare sector is divided The result of this disease burden on a

into private and public. While the private

growing and aging population, economic

76% healthcare 24%delivery sector dominates

development

Insured of the across theUninsured country, a majority

53 |

and

increasing

RE - HUMANIZING HE ALTHC ARE

Population

Infrastructure

health

Population growth: +450 Million

People living in Poverty: -50%

GROWTH IN BILLION $

210

1991

2016

100

66 population living Below the Poverty 22 Population growth: People Line 5(BPL) — the ability to spend `47

Government

contribution

to

insurance

living in at roughly 32%, as opposed to stands Million Poverty: -50% per 1990 day+450 in 2000 urban areas 32 per day 83.5 % in the UK. Estimates suggest that 2010 & ` 2015 2020 enrolling all BPL families in the country in

the under-financed and short-staffed

health insurance programmes would cost

public sector for its healthcare needs, 210

anywhere from `2,460 cr. to `3,350 cr.

GROWTH IN BILLION $

in rural areas — continues to rely on

as a result of which they remain unmet.

Moreover,

the

majority

of healthcare 100 professionals happen to be concentrated 66 in urban areas, where consumers have a 22 higher5 paying power.

With a large number of people from

Population 2010 Infrastructure 2015 2020 1990 2000 India meets the global average in the

an emergence of ‘frugal innovation’ in the

number of physicians, but 74% of its

referring to stripping non-essential or

doctors cater to a third of the urban

luxury features from a product to make

population, according to a KPMG report.

it marketable in developing countries,

low-income groups turning to the private sector for treatment due to the shortcomings of the public sector, there has been private sector. [1] Frugal innovation, initially

has come to encompass the features of The country is 81% short of specialists at

a product offering a lower price than its

Rural Community Health Centers, and the

first world counterparts without compro-

private sector accounts for 63% of the

mising quality and placing the needs of

Population hospital beds, to 38% Government 62%according Infrastructure

the overlooked customer above all.

Insurance

Rural-Urban disparity

Health Personal and Family Welfare statistics. savings Insurance For the purpose of catering to the population living below the poverty line, at the

76% Uninsured

24%

same time leveling the quality of care

Insured

offered by the private and public sectors,

Figure 2.5 Insurance disparity Ratio of Indians availing Rural-Urban healthcare insurance | by Author

62% Personal savings

38% Insurance

frugal innovations in the healthcare sector are the need of the hour.

[From IANS, India’s healthcare sector: A look at the challenges and opportunities faced by the $81.3 billion industry, Firstpost., 12th June 2017]

Figure 2.6 Source of healthcare expenses of Indians | by Author

76% Uninsured

24% Insured

RE - HUMANIZING HE ALTHC ARE |

54

98.16 lakhs No. of deaths

2.1. 2

58.69 lakhs

60%

No. of deaths due to chronic diseases

THE BOOM OF CHRONIC DISEASES A chronic disease is a long-term medical

25 lakhs 12 lakhs and6.6chronic lakhs Although cardiovascular

condition that is progressive. In recent

respiratory

times, chronic/non-communicable diseases

Cancer Diabetes Chronicis responsible Cardioshare of deaths, cancer

have been the leading cause of deaths in

respiratory vascularmortality. for maximum diseases

India. Industrialization, socio-economic development,

urbanization,

diseases

have

a

higher

diseases

changing

1,74,693

age structure, and changing lifestyles have placed India in a position where

No. of cases registered

it is facing a growing burden of chronic

57,400

diseases.

32.6%

Mortality rate Figure 2.9 Cancer mortality rate in India, 2014 | by Author

No. of deaths

98.16 lakhs

of deaths due to chronic diseases No. ofNo. deaths

Figure 2.7 58.69 lakhs Ratio of deaths due to chronic diseases in India, 2014 No. of deaths due to chronic diseases | by Author

60%

25 lakhs

12 lakhs

12 lakhs

6.6 lakhs

Cardio-

Chronic

vascular

respiratory

diseases

diseases

Cardio-

Chronic

vascular

respiratory

diseases

diseases

Cancer

6.6 lakhs

1.9 lakhs

Cancer

Diabetes

1,74,693

Figure 2.8

1,74,693 Deaths to chronic diseases in India, 2014 | by No. ofdue cases registered No. of cases registered

57,400

Author

32.6%

32.6%HE ALTHC ARE 55 Mortality | RE - HUMANIZING rate 57,400

S

Mortality rate

14

PREDICTION

12

10

registries across the country by the Nation 8 Cancer Registry Programme in 2014, the 6 highest mortality rate was recorded in 4 2 Mumbai at 63.75%.

The 1.9 lakhs on

25 lakhs

14

Based on the data collected from 27 cancer 9.62 9.79

60%

58.69 lakhs

CANCER PATIENTS IN LAKHS

98.16 lakhs

0

2006 2007 2008 2009 2010

2015 2020

International Agency for Research Cancer’s

GLOBOCAN

project’s

prediction states that India’s cancer Diabetes burden will nearly double in the next 20 years, from slightly over a million new cases in 2012 to more than 1.7million by 2035.

1.9 lakhs

vascular

respiratory

diseases

diseases

1,74,693 No. of cases registered

57,400

32.6%

CANCER PATIENTS IN LAKHS

Mortality rate

14 PREDICTION

12 10

9.62 9.79

8

As of 2015, the predicted cases have crossed the estimated number.

Cancer not only affects the patients and

6 4

their family and friends severely but also

2

the economy and development of the

0

2006 2007 2008 2009 2010

2015 2020

Figure 2.10 Cancer prevalence in India | by Author

nation. Thus, attention needs to be diverted towards cancer patients and their care and treatment.

RE - HUMANIZING HE ALTHC ARE |

56

2.1. 3 NEED FOR CANCER CARE

Cancer is becoming a common man’s

standards and inadequate medical facilities.

disease, the cure for which does not guarantee life. Hence, it is the ‘hyped’

It is essential to comprehend and address

disease overshadowing other diseases.

the needs and issues of these patients and to provide them with a better, more efficient

With less than 30% of Indian cancer

healing environment.

patients surviving five years or longer it is a disease with

With the shortfall of medical infrastructure

majority cases diagnosed in late stages

and the complexity of modern healthcare

and comes with an expensive treatment

facilities, cancer patients are more than

procedure. This makes it even harder for

ever in need of an architectural interven-

the patients, especially those below the

tion. Healthcare facilities need to be

poverty line.

designed to the benefit of the patient

after diagnosis,

[2]

and not just the system.

The magnitude of cancer problem is increasing due to poor to moderate living

57 |

RE - HUMANIZING HE ALTHC ARE

RE - HUMANIZING HE ALTHC ARE |

58

Figure 2.11 The before and after of a child suffering from cancer

59 |

RE - HUMANIZING HE ALTHC ARE

2.2 WHAT IS CANCER? Cancers are a group of diseases associ-

The

incidence

of

ated with abnormal growth of cells. Without

according to the geographical area,

any check, the disease may keep on

prevalent

progressing, ultimately leading to premature

socio-economic strata. For example, oral

death. They can arise anywhere in the

cancers are common in the Indian sub-con-

body and can affect people from all

tinent, because of higher consumption of

age groups, socio-economic strata, and

chewable forms of tobacco and cervical

race.

cancers are more common in women from

social

cancers

customs,

varies

and

the

lower socio-economic strata because of poor genital hygiene.

Some of the treatments and therapies for curing cancer are: TOBACCO

SUPARI

POLLUTION OCCUPATIONAL HAZARDS

º º Surgery º º Radiation º º Chemotherapy

LIFEST YLE

ALCOHOL

OBESIT Y

BIO-HAZARDS

Figure 2.12 Causes of cancer | by Author

º º Immunotherapy º º Hormone therapy º º Stem cell transplant

Radiation and Chemotherapy can cause several side effects such as: º º Anemia

º º Edema

concentration

fertility problems

º º Appetite loss

º º Fatigue

problems

º º Skin and nail

º º Bleeding and

º º Hair loss

º º Nausea and

changes

bruising

º º Infection and

vomiting

º º Insomnia

º º Constipation

Neutropenia

º º Nerve problems

º º Urinary and

º º Delirium

º º Lymphedema

º º Pain

bladder problems

º º Diarrhea

º º Memory/

º º Sexual and

º º Prostheses

[3]

RE - HUMANIZING HE ALTHC ARE |

60

2.2. 1 ISSUES & NEEDS OF THE PATIENT Every cancer patient’s journey is personal

to inhabit responsive spaces that have

due to their diagnoses as well as lifestyle

the potential to aid the healing process

and family backgrounds. No two patients

and to provide a space that reinforces

undergo the same level of pain and

respect, dignity, and security.

[4]

suffering. In its many forms, cancer can have a catastrophic effect on normalcy and daily life for individuals and families impacted

by

the

disease.

SOCIAL

However,

many cancer patients do share similar treatment

experiences

that

include

PHYSICAL

an array of physical trials, emotional challenges, and spiritual journeys.

It is essential to understand the complete spectrum of journeys that cancer patients

PSYCHOLOGICAL SPIRITUAL

experience, to gain true empathy that informs the design of environments to more efficiently support their fight against cancer. Space can be uniquely designed

61 |

RE - HUMANIZING HE ALTHC ARE

Figure 2.13 Needs of a cancer patient | by Author

PHYSICAL NEEDS

muscle tone, creating limitations in activity and altering familiar daily life.

Most patients receiving invasive treatments such as surgery, chemotherapy,

Furthermore, patients are often burdened

and radiation face the after-effects of

with the financial impact of treatment. This

physical changes and changes in their

additional challenge can increase mental

sense of well-being. These procedures

stress, causing physical fatigue that may

often result in a weak and compromised

influence their ability to heal and even make

immune system. Susceptibility to other

decisions about their treatment.

[5]

diseases can disrupt the healing process, thus, affecting the ability to fight cancer.

To

counter

these

challenges,

some

architectural design features that can be A cancer patient’s newly conditioned

adopted are:

state of normalcy can result in an

º º Barrier-free design

overall feeling of sickness. Treatments

º º Easy and quick access to toilets

and even pain medications for intermit-

º º Private and social spaces for exercise

tent or chronic pain can cause them to

º º Clean, hygienic spaces

feel perpetually nauseous and trigger gastrointestinal issues. This may leave patients vulnerable to uncontrollable accidents, increasing their levels of stress and anxiety.

Changes in physical appearance are a typical result of cancer treatment. Many patients experience hair loss, scars, skin changes, weight loss or gain, sensitivity to smells and temperature, and loss of

Figure 2.14 Coping with the physical changes faced by a cancer patient

RE - HUMANIZING HE ALTHC ARE |

62

PSYCHOLOGICAL NEEDS

of the course and can be a difficult adjustment.

Short-term memory loss or experience of a general fogginess is frequently reported as a side effect of many treatments. Pride and independence are also disrupted. The burden of cancer and the imminent fight can weigh heavy on one’s psyche, leading to sadness and depression.

Figure 2.15 The psyche of a cancer patient

To

face

these

challenges,

patients

In addition to the physical impact, cancer

need to stay positive and find purpose.

treatment can also affect the patients mental

Positive focus, inspiration, and intro-

and psychological makeup. The journey

spection

can be an emotional roller coaster, with

renewed hope, uplifting energy shifts

peaks and valleys of personal progress

and rejoicing at milestones and small

and setbacks. These ups and downs

breakthroughs along the journey.

provide

opportunities

for

[6]

often lead to a general sense of losing control. The dual challenges of battling a

To

counter

these

challenges,

disease that has overtaken their body and

architectural design features that can be

not knowing the outcome of their personal

adopted are:

battle often lead to emotions of fear and

º º Spaces for private counseling and

uncertainty.

group sessions º º A library

Regardless

of

the

catalyst,

mental

º º Yoga and meditation spaces

fatigue is a common issue. A cancer

º º Provision for different levels of

journey can also result in degradation

privacy

of a patient’s dignity. Many patients

º º Pockets of breakout spaces with

struggle with the overall lack of privacy.

connection to nature

Being

º º Pleasing views

exposed,

probed,

prodded,

studied, and examined becomes part

63 |

RE - HUMANIZING HE ALTHC ARE

º º Use of wayfinding strategies

some

SOCIAL & SPIRITUAL NEEDS

reason to fight the fight. This daily battle often spans many months or years. If

Walking the tightrope of cancer treatment

the patient feels supported and stays

requires a safety net of family, friends,

positive, the overall result can enhance

caregivers, and for some individuals, a

their ability to heal.

[7]

spiritual footing. While not all patients believe in a higher power, it is essential for

To

counter

these

challenges,

some

them to find solace during their journey.

architectural design features that can be adopted are:

Support from and connection to others

ยบ ยบ Provision of a prayer room

and/or a higher power can assist them

ยบ ยบ Multiple pockets of social spaces

in finding comfort and give them a

Designing environments for the care and treatment of cancer patients requires a holistic and sustainable approach to design, encompassing empathy, operational knowledge, and creative design thinking. This includes addressing the many complex layers of issues and factors that must be addressed to produce an efficient and responsive cancer care facility. Only by addressing all the needs of the patients can one hope to deliver a holistic healing environment.

RE - HUMANIZING HE ALTHC ARE |

64

2.2. 2 PREVALENT TYPES OF CANCER CARE FACILITIES HOSPITAL

any stage of an illness. Individuals usually receive palliative care at clinics, hospitals,

A hospital is the primary healthcare

or at home by visits from professionals.

[8]

facility for all cancer treatments. It offers medical treatments such as chemotherapy,

The action for palliative care is taken on

radiation, surgery, etc. with the option of

by various government and non-govern-

inpatient and outpatient wards, wherein

ment organizations in India. The current

the patients can either opt to live in the

approach is mainly through associ-

hospital, during their treatment, or visit the

ations of medical helpers, providing

outpatient department (OPD) from time to

home-based aid where a physical model

time for their treatment therapies.

is predominantly absent.

PALLIATIVE CARE CENTER

HOSPICE CARE CENTER

Palliative and hospice care are options for

Hospice is a form of palliative care that

facilitating the provision of care to individ-

seeks to optimize the quality of life at the

uals suffering from chronic diseases.

end of life, while neither hindering nor hastening the dying process.

Palliative care is the treatment of the discomfort, symptoms, and stress of

Individuals who receive hospice care

serious illness, with comfort and quality

refrain

of life as primary goals. It provides relief

their underlying disease. To qualify for

from distressing symptoms including pain,

hospice, an individual usually has six

shortness of breath, nausea, problems with

months or less to live.

from

curative

treatment

for

sleep, anxiety, and side effects of medications. It is available for any age and at

65 |

RE - HUMANIZING HE ALTHC ARE

Hospice caregivers control pain and other

symptoms and provide counseling, family

It is when one gives up all materialistic

support, and many other services. Hospice

pleasures and becomes one with the

can be provided in long-term care facilities,

‘Atman.’ Though it can be attained even

such as nursing homes, at home or in

while living, it is believed that attaining

hospital inpatient wards.

moksha on the death-bed frees one from

[9]

the cycle of life and death and the soul is Hospice care centers in India are seen as

free ever-after.

a last resort for patients whose families these

In order to attain this salvation, people wait

centers are usually run by charitable

to die in this charity-run hostel. It is not a

organizations offering free services.

place where people go to commit suicide.

cannot

afford

caregiving

as

Neither is it a place of mercy killing.

MUKTI BHAVAN

The 12-room hostel consists of a temple

The ‘Mukti Bhavan’ or Salvation House is a hostel in Varanasi, India. Devotees on their death-bed, due to whatever reason, enroll themselves in this hostel to attain ‘Moksha.’

Moksha is the Hindu concept of liberation from the trials and tribulations of life.

and a quarter for its priests. However, the guests are given only two weeks to die. After which they are asked to move on to make way for others. As of 2014, over 14,000 people have made use of the services of this hostel to breathe their last.

[10]

Figure 2.16 Mukti Bhavan

RE - HUMANIZING HE ALTHC ARE |

66

The concept is very similar to the olden days

Most of these patients belong to BPL families

Kashi concept. When older people said

and cannot afford cancer treatment. They

they are going to Kashi, it was assumed

travel great distances to gain the benefit of

they would not return as they would spend

discounted or sometimes free treatment.

the remainder of their lives there and die

Thus, they are unable to provide such high

there in hopes of moksha.

rentals.

[11]

DHARAMSHALA

Some government and private organizations

Patients throng to cities serving as afford-

setting up ‘dharamshalas’ in the proximity of

able cancer care centers in hundreds on a

these hospitals. These temporary lodgings

weekly basis. They seek temporary accom-

are designed to accommodate a maximum

modation in the city during their treatment,

number of people and usually subsist on

which can last from a few weeks to six

the support of sponsors and donors.

have attempted to address this issue by

months or sometimes a couple of years.

These facilities aim to house a maximum Cities are typically cramped, and its facil-

number of people at minimal costs.

ities are saturated due to migration and

Thus, they rarely provide amenities of

other factors. Accommodation in such

any kind. Nursing availability is also

cities can prove to be a costly affair.

compromised in most cases. They endure

Figure 2.17 Shree Gadge Maharaj Dharamshala, Mumbai

67 |

RE - HUMANIZING HE ALTHC ARE

due to social interventions by NGO’s and

medical treatments but instead focus on

financial help from generous donors.

the intangible aspects of healthcare.

CARING CENTER & NGO

These activities are sometimes undertaken by NGO’s who visit other healthcare

Cancer caring centers are rare but an upcoming provide

typology.

These

psychological,

sometimes

physical

centers

social

support

to

and the

patients undergoing cancer treatments or recovering from it, using various therapies and counseling programmes.

They aim at providing a better life to

facilities and provide similar services.

For example, Sanjeevini - Life Beyond Cancer, an NGO based in Mumbai, focuses on providing emotional and nutritional support to patients. UGAM by the Indian Cancer Society offers educational support, participates in creating awareness, raising funds, and counseling activities for cancer patients.

people who are and have been the victims of cancer. They do not engage in

RE - HUMANIZING HE ALTHC ARE |

68

2.2. 3 COMPLEMENTARY THERAPIES

Patients undergoing cancer treatments

strategies, and outcomes measures.

experience

with

Therapeutic experiences can include

tremendous mental trauma. To relieve them

walking, brushing, petting and caring

of these difficulties, various complementary

for an animal, as well as the experience

therapies, along with medical treatment,

of trying to accomplish a given task.

physical

pain

along

[12]

should be undertaken.

Animals such as dogs and cats are loving Complementary therapies do not claim

creatures. They usually open the emotional

to cure cancer but assist in coping

gates for participants. Spending a couple

with the side effects of the medical

of hours every day with them can reflect

treatments. They typically help with

well on the emotional wellbeing.

restoring physical abilities and boosting emotional health.

AROMATHERAPY

ANIMAL-ASSISTED THERAPY

The use of natural oils extracted from plants for relaxation is called aromatherapy. They

Animal-assisted therapy aims at improving

are used during massage, in baths and

a

creams or through diffusers.

participants

functioning

with

social the

and aid

of

emotional domestic

animals.

Aromatherapy can be induced in design with the help of aromatic plants in

Pets allow for a sense of stimulation

gardens and open spaces and by using

that helps nurture a participant’s sense

diffusers in the facility. The aroma thus

of positive well-being. With targeted

circulated triggers the targeted emotions

activities and simply spending time

and produces a positive vibe in the spaces.

with an animal, animal-assisted therapy involves

69 |

specific

therapeutic

RE - HUMANIZING HE ALTHC ARE

goals,

ART THERAPY

HORTICULTURE

Concentration on creating art can help

Horticultural Therapy is a practice that

participants slow down, relax, and process

uses plants and the garden landscape to

their thoughts.

promote well-being for its participants.

The subconscious mind can express

The

feelings through pictures, colors, and

healing has already been established.

shapes that participants might struggle

Horticultural therapy helps in improving

to put into words. By doing so, they may

memory, cognitive abilities, task initia-

begin to gain a better understanding of

tion, language skills, and socialization.

relationship

between

nature

and

their emotions, which can further help to build their confidence.

In physical rehabilitation, horticultural therapy can help strengthen muscles

Feelings can then be discussed in groups

and improve coordination, balance, and

or individual counseling.

endurance. In vocational horticultural therapy settings, participants learn to

COUNSELING

work independently, solve problems, and follow directions.

[13]

More than often patients are in need of professional help to cope with their

MASSAGE THERAPY

emotions and sentiments.

A massage is a form of structured theraThe patients need to let go of their emotional

peutic touch.

stresses and talk freely. Counselors are trained to listen and provide support and

Massage therapy can be used to relax

help. For this, it is essential to provide a

a participants mind and body, relieve

friendly atmosphere, where the patient

tension, and enhance the mood. It also

feels free to talk and not as if he is being

reduces physical pain, fatigue, anxiety,

interrogated or bombarded with advice.

and depression.

RE - HUMANIZING HE ALTHC ARE |

70

MEDITATION

YOGA & EXERCISE

Meditation uses concentration or reflec-

Conventionally,

tion to deeply relax and calm the mind.

treatment for a chronic illness are often

This can help reduce feelings of fear,

instructed by doctors to rest and minimalize

pain, anxiety, and depression.

physical activity. This is appropriate if

people

undergoing

movement causes pain, rapid heart rate Regular meditation practice can help partic-

or shortness of breath. However, newer

ipants feel more in control of themselves

research demonstrates that exercise is

and their lives.

not just safe and possible during cancer treatment, but it also improves physical

MUSIC THERAPY Music connects people to their emotions and is often a satisfactory way to initiate social connections. Music therapy has been found to help reduce pain and discomfort, improve mood and diminish stress, increase the quality of life, and allow participants to better communicate their fears, sadness or other feelings.

[14]

SUPPORT GROUPS

functionality and quality of life.

Excessive rest can lead to loss of body function, muscle weakness, and reduced range of motion. Psychologically, exercise improves self-esteem and lowers the risk of anxiety and depression. Light exercise routines such as yoga or aerobics should be inculcated during and after cancer treatment to regain control over one’s body.

Yoga involves positioning the body in different

ways

and

doing

breathing

exercises. There are various types of Often communicating with people under-

yoga; some use very gentle stretches,

going the same problems can help one

movement, and meditation, others involve

cope better with the problem. Support

more vigorous physical movements and

groups aim to bring people together

dietary changes, for example, t’ai chi.

and enable them to communicate with and help each other.

71 |

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[15]

MIND - Increases gray matter - Cultivates will power - Builds focus and

BODY

- Reduces

Decreases pain -

depression

- Physically modifies Boosts immune system Lowers blood pressure the brain Eases inflammation -

concentration - Eases stress

- Boosts cognitive functions

Reduces heart risk -

& anxiety - Reduces

- Helps sleep

loneliness

- Fosters a

- Cuts emotional

healthy body

reactivity

image

SPIRIT

- Builds self knowledge - Increases compassion - Improves empathy

Figure 2.18 Benefits of meditation | by Author

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72

2.2. 4 A VIEW FROM THE FRONT LINE

BY MAGGIE KESWICK JENCKS Maggie Keswick Jencks, an architect by

REVIEW

profession, was diagnosed with cancer in 1988. Five years after having a mastec-

A view from the front line is Maggie’s

tomy, it returned. She was told, that there

description of living a life with cancer. She

was nothing more to be done, and she only

talks about the various stages of experi-

had a few months to live.

ences starting from diagnosis.

It was during this period that she began

Maggie believes that ‘fear, compounded

to realize several key things which are

by ignorance and false knowledge is a

described in ‘A view from the front line.’

paralysing attack in its own right. The

This description inspired the formula-

myth of cancer kills as surely as the

tion of the Edinburgh Maggie’s Cancer

tumours.’ Having survived the diagnosis

Caring Centre.

by immediate treatment is not the end of cancer. It is just the start point of the many

The

center

would

offer

information,

to come ups and downs.

psychological support, advice on nutrition, exercise, and relaxation therapies. Each

Cancer tends to reoccur and cause fatal

person visiting the center would be

damages in several cases. As it happened

helped to find his or her own best way

with Maggie. The second time was it for

of coping with the disease. There was to

her. With a few months to live and the

be no ‘right way.’

medical opinion of ‘living the remaining days,’ Maggie and her husband Charles

The center was to be a haven, where the

were not yet ready to quit. After signing

range of use would extend from a cup of

up for clinical trials and prolonging the

tea that one could make themselves in a

pain, eventually, she decided to face the

friendly kitchen to attending weekly support

end and quit experimenting with medical

groups led by a clinical psychologist.

remedies.

73 |

RE - HUMANIZING HE ALTHC ARE

[16]

She compares the conventional and

Along with her immune boosting soup

unconventional treatment alternatives

and diet, she was more energetic than

to a parachute jump, where there is no

ever.

guarantee of the parachute opening.

Moreover, even if it does open, a landing

Advice from the director of the Institute

into the thick fog of multiple options with

of Chinese Medicine in London, lead her

no idea what the way home is, leaves the

to exercise which helped her relax and

patient confused and without any directions

boosted her energy. Different therapies

or ability to make decisions. The patients

like reflexology and aromatherapy as

are left to figure their way out themselves.

also pain relief techniques like acupressure

‘How is the patient – utterly unequipped

and

acupuncture

helped

her

overcome her physical problems.

to deal with this barrage of suggestions and faced with doctors who, at worst are

All the different trials and therapies

downright anti any additional therapies

paired with her nutritional and physical

and, at best supportive but sceptical –

choices eventually brought down the

to proceed?’

cancer markers.

Further, the emotional suffering of her

The entire process convinced her of

family due to her pain had physical and

the role played by the mind in cancer

psychological implications for her. At this

treatment. She says that the mental state

point, she decided to educate herself

falls back on the immune system. Michael

about her disease and face it head-on.

Lerner, a knowledgeable and experienced cancer-carer, and the Australian cancer

Starting with a balanced nutritional diet had

survivor Ian Gawlor were both proofs of it.

psychological implications for her. Taking charge of making decisions for herself,

Numerous other studies proved that

helped her regain independency.

therapies

like

support

groups

and

meditation prolonged life and its quality She talks about her time in the hospital when

for cancer patients. Patients who took

she lost 15 kgs but regained it within three

an active interest in their treatments

weeks due to her diet and supplements.

seemed to fare better.

RE - HUMANIZING HE ALTHC ARE |

74

She concludes with ideas to improve

evidence to suggest that patients who eat

the system. Suggesting adjustment

healthily, keep active and take steps to deal

time for cancer patients to accept

with stress and fear, feel fewer symptoms

their illness and a better delivery of

and less pain even in the final stages of

the death sentence by the doctors, as

their disease. Preparing to welcome death

start points, she describes the hospital

healthily and happily is as essential as

environments which seem to say ‘How

dealing with the disease.

you feel is unimportant. You are not of value. Fit in with us, not us with

Carrying Maggie’s ideas for cancer care

you.’

forward, her nurse Laura Lee and husband Charles Jencks laid the foundation for

She suggests change such that patients

Maggie’s Centres. The objective was to

look forward to visiting the hospital and

encourage people who feel frightened and

not dread them. The hospital environ-

anxious about coping with cancer, to feel

ment needs to say ‘Welcome! And

better by developing their sense of confi-

don’t worry. We are here to reassure

dence and resourcefulness.

you, and your treatment will be good and helpful to you.’

The atmosphere in a Maggie’s Centre is more ‘coffee morning’ than ‘cancer

She believes that ignorance breeds fear

ward.’ Due to the success of the Edinburgh

and fear affects the immune system.

Centre, several other centers have been set

Hence, a ready availability of infor-

up across the United Kingdoms and spilled

mation regarding cancer treatments

onto other continents as well.

and

complementary

therapies

is

deficiencies

As both Maggie and her husband were

caused in part by cancer, a crucial

architects, their friends and students,

step in treatment is often skipped by

some of whom were Frank Gehry and Zaha

most due to ignorance.

Hadid, designed a Maggie’s Centre each,

required.

Rectifying

pro bono. WIth world-renowned architects Lastly, it is of utmost importance to

designing Maggie’s Centres, they gained

not lose the joy of living in fear of

fast popularity.

dying. There is a reasonable body of

75 |

RE - HUMANIZING HE ALTHC ARE

The purpose of Maggie’s is to help

it creates spaces which make it easier

people who are feeling as if they have

to be with other people, by creating a

been kicked in the stomach by a cancer

comfortable balance between public

diagnosis, get on with their lives again.

and private, which makes one feel safe

The buildings set the scene for them to do

but at the same time stimulates one’s

just that.

imagination without them even noticing that such a thing is going on, then it has

A building has done a good job if it even

done even more.

[17]

lifts one’s spirits for a brief moment. If

“I mean to keep on marching, down the tail of the statistical curve and on, into the sunset, and then, when eventually I must die, to die as well as possible.”

- Maggie Jencks

RE - HUMANIZING HE ALTHC ARE |

76

2.2. 5 CANCER AND ECONOMICS A diagnosis of cancer often leads to

of land in most cases. This has reper-

catastrophic personal health expenditures.

cussions on the treatment of cancer

Such expenditures can push entire families

making it extremely expensive.

below the poverty line.

Although relatively cheaper than in the People with cancer are 2.65 times more

West, cancer treatment continues to be

likely to declare bankruptcy than people

unaffordable for poor and middle-class

Given that the poorest

Indians, who often do not have health

two-thirds of the population are in much

insurance. Dr. B.S. Ajaikumar, founder

greater need of better health-care provision

and Chairman of the Healthcare Global

than the wealthiest third, increased public

chain of hospitals, declared that “It

investment in health services needs to be a

could cost as low as � 2.5 lakhs for

public policy priority for India.

six months of treatment, with some of

without cancer.

the lowest priced generic drugs in the The expenditures of cancer patients

world, to as high as ` 20 lakhs, with

include

novel drugs and targeted medicines.”

both

direct

medical

and

non-medical costs. The direct costs include buying medicine, hospitalization,

While the incidence of cancer is rising,

pathological tests, medical practitioner

insurance is a big stumbling block. Only

consultancy, travel, and lodging while the

a small fraction of Indians have health

indirect costs are loss of income during

insurance and those who do, rarely have

treatment, premature death, and effect on

critical illness cover. Of the 40 million

the income of other family members, etc.

individual policies sold in 2011, the average

[18]

amount per policy was just �1.9 lakhs. A Doctors estimate that a 100-bed cancer

�10 lakhs policy would mean a �17,000 to

specialty hospital would need an invest-

�50,000 annual premium, depending on

ment of up to 100 cr., excluding the cost

the age of the policyholder.

77 |

RE - HUMANIZING HE ALTHC ARE

[19]

Hence, cancer care treatment and infrastructure for the poor and families living below the poverty line needs to be prioritized. Providing affordable options and

CHEMOTHERAPY �10,000-400,000 REQUIREMENT: AS PRESCRIBED

materializing these options sustainably is

HERCEPTIN �75,000/COURSE REQUIREMENT: UPTO 7 COURSES

the contemporary need.

ERBITUX �100,000/CYCLE REQUIREMENT: 7 CYCLES OR MORE

AVASTIN �100,000/CYCLE REQUIREMENT: 8 CYCLES OR MORE

Figure 2.19 Costs of some cancer treatments and drugs | by Author

“Health cover is very low and is taken by just four to five percent of the people who can afford it. The average cover that most people take is between 1 lakh and 2 lakhs,” - Tapan Singhel, M.D. and CEO, Bajaj Allianz General Insurance Company.

“I had just about Rs 1 lakh when I got my wife to Tata Memorial Hospital for treatment. On the first day itself, I had to shell out Rs 25,000 for various medicines.”

- Suresh Shidke, husband of a blood cancer survivor.

RE - HUMANIZING HE ALTHC ARE |

78

2.2. 6 THE CAREGIVER

The primary caregiver for a patient is the

Constant worrying or concern for the

spouse, partner, parent or an adult child.

patient’s ability to look after themselves

When the family is not around, close

often causes a loss of independence for the

friends, co-workers, or neighbors may fill

patient. The patient’s needs are constant

this role. The caregiver plays a vital role in

and result in a fall in the caregiver’s

the patient’s care. Good, reliable caregiver

independent occupational engagement.

support is crucial to the physical and emotional well-being of the patient.

Along

with

the

emotional

implica-

tions of caring, side-effects of cancer Today, most

cancer treatments

are

medications

and

treatment

options

given in outpatient departments. Thus,

have physical implications for both the

someone needs to take the responsi-

patients and their caregiver. Managing

bility of nursing the patient at all times.

pressure sores and incontinence, cleaning,

As a result, caregivers have many roles.

cooking, traveling to and from appoint-

These roles change as the patient’s

ments, and other needs often result in

needs change during and after cancer

physical exertion and illness. The time

treatment. Caregivers may help feed,

and energy required for taking care of

dress, and bathe the patient. They

the patients’ health problems mean that

arrange schedules, manage insurance

sometimes, they are unable to look after

issues, and provide transportation. They

themselves, resulting in a deterioration of

are legal assistants, financial managers,

their health.

[20]

as well as housekeepers.

Some

considerations

required

for

the

The caregivers are often emotionally or

caregiver in a healthcare programme are:

physically unable or professionally unquali-

º º Respite care

fied to provide the care needed. Also, they

º º Provision of physical and psycholog-

are faced with the emotional impact of

ical therapies

caring which sometimes consumes them

º º Provision of a temporary workplace

psychologically and physically.

79 |

RE - HUMANIZING HE ALTHC ARE

“The facility near Tata hospital is much better off as there are nurses to perform basic emergency procedures and there are medical provisions for the caretakers too.”

-Husband

of

a

patient

at

Shree

Gadge

Maharaj

Dharamshala, Mumbai.

“I had to leave my home and quit my job to come to Mumbai for my 5-year-old grandson’s cancer treatment. We had to live on the streets for a very long time as there was no space in the dharamshala. Now finally we have a room that we share with another family. My wife cooks food while I go to the hospital daily for treatments.

There’s no time to work and earn money. We are running out of our savings also.”

- Grandfather of a pediatric patient.

“This disease has ruined the life of my entire family. They sold everything we had to get me to Mumbai; I don’t know if we will ever go back home.”

- A patient suffering from throat cancer.

RE - HUMANIZING HE ALTHC ARE |

80

2.2. 7 MAPPING AFFORDABLE CANCER TREATMENT

SKIMS

PATEL HOSPITAL

RAJIV GANDHI SUPER SPECIALT Y HOSPITAL

DELHI STATE CANCER INST. AIIMS

S.M.S HOSPITAL CANCER HOSPITAL & RESEARCH INST. THE GUJARAT CANCER & RESEARCH INST. KAILASH CANCER HOSPITAL & RESEARCH CENTER

KAMLA NEHRU MEMORIAL HOSPITAL

PT. JAWAHAR LAL NEHRU MEMORIAL MEDICAL COLLEGE RASHTRASANT TUKDOJI REGIONAL CANCER HOSPITAL

NORTH EAST CANCER HOSPITAL AND RESEARCH INST.

TATA MEDICAL CENTRE

INDIRA GANDHI GOVERNMENT MEDICAL COLLEGE & HOSPITAL

TATA MEMORIAL HOSPITAL

SRI SHANKARA CANCER HOSPITAL & RESEARCH CENTRE MAZUMDAR SHAW MEDICAL CENTER

KIDWAI HOSPITAL CANCER INST. CHRISTIAN MEDICAL COLLEGE

REGIONAL CANCER CENTRE

Figure 2.20 Mapping top public cancer hospitals in India | by Author

81 |

RE - HUMANIZING HE ALTHC ARE

N

NAME & LOCATION

KNOWN FOR

NO. OF B EDS & PATIENTS

SERVICES OFFERED

Delhi State Cancer

Radiation and

95 Beds; 800

250 Patients receive

Institute, Delhi, 2006

Chemotherapy

Patients attended to

Radiation and

offered free of cost

daily in the OPD

Chemotherapy daily

The Gujarat Cancer &

Offers medical

660+50 Beds;

50% Subsidy for

Research Institute,

treatment + palliative

30,000 New patients

general patients and

Gujarat, 1972

care

in the OPD annually

free treatment for B.P.L. patients

TATA Memorial

Leading under the

629 Beds; 67,000

Free treatment for

Hospital, Mumbai,

Rajiv Gandhi Jeevan

Cases registered

70% of its patients

1941

Arogya Yojana for

annually

patients B.P.L. Kidwai Hospital,

40-60% Discounted

429 Beds; 16,000

Lodging and daily

Bengaluru, 1973

cancer medications

Cases registered

meals offered on

annually

basis of sponsorship

Sri Shankara Cancer

Non-profit

360 Beds; 4250

In the last 2 years,

Hospital and

Organization

Cases registered

250 patients

annually

benefited 100% free

Research Centre,

treatment and 600

Bengaluru, 2008

patients received 50% concession Cancer Institute,

Research division +

535 Beds; 15,700

Free treatment for

Chennai, 1954

College of oncologi-

Cases registered

40% of its inpatients

cal sciences +

annually

Division of preventive oncology Free treatment for

200 Beds; 15,000

Regional Cancer

Availability of 20

Centre, Thiruvanan-

Government schemes Cases registered in

thapuram, 1981

and other Non-

2015

Government services

50% and subsidized rates for 25% of its patients

Figure 2.21 Affordable cancer care in India | by Author RE - HUMANIZING HE ALTHC ARE |

82

2.2. 8 MEDICAL MIGRATION FOR CANCER CARE Cancer care options for the well-to-do

patients,

are available in abundance as opposed

ally fully booked. Thus, patients have no

to affordable options for the financially

option but to opt for outpatient services.

disabled.

It falls upon the city’s infrastructure and

The

patients

belonging

to

the latter category face hardships and

[21]

inpatient beds are perpetu-

services to cater to these ‘outpatients.’

difficulties every step of the way from making their way to cities for affordable

Cancer is a costly as well as physically

treatment to survival in those cities

and psychologically wielding disease. With

during their treatment.

the horror of cancer already looming over the patient’s family, an additional factor

Patients who are traveling to a different

of financial burden worsens the situation.

city for affordable cancer treatment end

Thus, providing affordable and beneficial

up spending months in the city. Thus, they

facilities for them needs to be undertaken.

are medical or temporary migrants in the city. These patients sometimes opt for

On analyzing the stated data, it is

outpatient facilities when inpatient beds

evident that the TMH in Mumbai caters

are occupied.

to the largest group of low-income cancer patients. Thus, Mumbai has been

In hospitals such as the Tata Memorial Hospital (TMH) in Mumbai, where the daily load in the oncology OPD is 4,000

83 |

RE - HUMANIZING HE ALTHC ARE

chosen as the site for further study.

RE - HUMANIZING HE ALTHC ARE |

84

M I R A - B H AY A N D E R

THANE JUPITER HOSPITAL

MUMBAI SUBURBAN FORTIS HOSPITAL KOKILABEN DHIRUBHAI AMBANI HOSPITAL

HIRANANDANI HOSPITAL SEVENHILLS HOSPITAL

NAVI MUMBAI

LILAVATI HOSPITAL

SION HOSPITAL

ACTREC

HINDUJA HOSPITAL KEM

JASLOK HOSPITAL SAIFEE HOSPITAL

TATA MEMORIAL HOSPITAL

NAIR HOSPITAL JJ HOSPITAL

MUMBAI CITY

N

PRIVATE HOSPITALS PUBLIC HOSPITALS

Figure 2.22 Top cancer treatment hospitals in Mumbai | by Author

85 |

RE - HUMANIZING HE ALTHC ARE

2 .3 CANCER CARE IN MUMBAI CIT Y As the city of dreams, Mumbai caters to

limited to the benefit of the city dwellers

the needs of all, even in the healthcare

but extends beyond boundaries; offering

sector. With several multi-specialty as well

low-priced and quality cancer care

as cancer specialty private and public

programmes for all in India and also its

hospitals, it caters to all income groups.

neighboring countries.

Especially the renowned inexpensive

Thus, hundreds travel to Mumbai every

cancer treatment provided by the Tata

week with hopes of benefiting from afford-

Memorial Hospital (TMH), which is not

able quality cancer treatment.

‘The Parel hospital (TMH), treats around 67,000 new cancer patients from across the country every year and also attends to 4.5 lakh follow-up cases annually. People from the Middle East and Africa also seek medical attention here.’ - MumbaiMirror, 20 th Oct 2017 RE - HUMANIZING HE ALTHC ARE |

86

BHAK TI VEDANTA HOSPICE

M I R A - B H AY A N D E R

THANE

MUMBAI SUBURBAN

NAVI MUMBAI 12

9

13

SHANTI AVEDNA ASHRAM

7

10

INDIAN CANCER SOCIET Y

6 5

11

8

2 3

1 4

MUMBAI CITY

N

Figure 2.23 Mapping affordable cancer care facilities in Mumbai | by Author

87 |

RE - HUMANIZING HE ALTHC ARE

AT TENDANTS/

NAME & LOCATION

CAPACIT Y

TARIFF

1. St. Jude India ChildCare Centres, ICS, Parel

30 kids

Free accommodation and food

2

Private patients - ₹100 General patients - free

2

2. Nana Palkar Smruti Samiti's (NPSS), Parel

76

PATIENT

3. St. Jude India ChildCare Centres, Ajai Verma Centre, Parel

11 kids

Free accommodation and food

2

4. St. Jude India ChildCare Centres, Cotton Green Campus

165 kids

Free accommodation and food

2

5. St. Jude India ChildCare Centres, Dr. Mhaskar Hospital

8 kids

Free accommodation and food

2

6. The Bombay Mother & Child Welfare Trust, Lower Parel

80

15 Pediatric beds - free

2

7. Shree Gadge Maharaj dharamshala, Dadar

200

Accommodation+dinner - ₹50

2

163

30 patients B.P.L. - free General (4 patients) - ₹130

2

8. Bharat seva sadan, Dadar 9. Dr Ernest Borges Memorial Home, Bandra

Semi-private (2 patients) - ₹225 Private - ₹450 & Deluxe - ₹850 10. St. Jude India ChildCare

41 kids

Free accommodation and food

2

₹100

2

Free accommodation and food

2

Centres,ACTREC 11. Shree Gadge Maharaj dharamshala, Kharghar

80

12. Bharat Sevashram, Navi

95

Mumbai 13. Assam Bhavan, Navi Mumbai 16 (from Assam)

Figure 2.24 Lodgings for cancer patients in Mumbai | by Author RE - HUMANIZING HE ALTHC ARE |

88

2.3. 1 TREATMENT WITHIN MEANS THE TATA MEMORIAL CENTRE,

beds, 37 ICU beds and 25 operation

MUMBAI

theaters. It is renowned for prevention,

The Tata Memorial Hospital (TMH) was commissioned by the Sir Dorabji Tata Trust in 1941. After the transfer of authority to the Department of Atomic Energy in 1962, in its 25th year the Indian Cancer Research Centre, which was established in 1952, and the TMH were merged to form the Tata Memorial Centre.

TMH is one of the best as well as most affordable cancer treatment hospitals in India, accommodating 629 inpatient

Figure 2.25 Growth of the TMH, Mumbai

89 |

RE - HUMANIZING HE ALTHC ARE

treatment,

education,

and

research

for cancer treatment. It is the leading hospital under the Rajiv Gandhi Jeevan Arogya Yojana for patients BPL initiated by the Government of Maharashtra.

The hospital has expanded from 15,363 m 2 to over 53,890 m 2 and continues to do so with the upcoming Women and Children’s hospital and Hydrogen Beam Therapy facility. The Annual Budget which was `5 lakhs in 1941, today runs close to `200 cr.

AV E R AG E 4.5 LAKH FOLLOW-UPS

+

67,000 NEW CASES

+

REFERRALS

2 013 29,000 CASES DIAGNOSED Figure 2.26 Annual patient flow in TMH | by Author

4000

24,500

500

Depending on the financial capacity to

A large chunk of low-income patients

pay for treatment at TMH, patients fall

seeking affordable cancer treatment in

under the following categories:

Mumbai is treated at the TMH. Though

40

1. General Patients (Part paying):

: 60

º º C: Partly charged. (20% for investiga-

infrastructure

such

as

a rehabilitation center at the Indian

AVERAG E tions and consultations and the rest as 4.5 LAKH FOLLOW-UPS per actuals)

supporting

Cancer Society and various lodgings

+

67,000 NEW CASES are established in for the ‘outpatients’

º º NC: Minimal charges for few services; no

the vicinity of the TMH, they are always

2013 the rest as per actuals.

wait-listed as the demand is multiple

investigation or consultation charges and

29,000 CASES DIAGNOSED

+

º º BP (Below poverty): The Rajeev Gandhi

times the availability.

REFERRALS

Jeevan Yojana Scheme provides cashless

While the hospital keeps growing and

quality care to families with an annual 4000 income below 24,500 `1,00,000 for 500 an amount of

widening its programmes, the growth of these supporting facilities is stagnant.

`1,50,000/family/year.

2. Private Patients (Full paying)

40

[22]

: 60 Figure 2.27 Private:General ratio at TMH | by Author RE - HUMANIZING HE ALTHC ARE |

90

INDIAN CANCER SOCIETY

through accommodation, rehabilitation, and survivor support groups.

Mumbai based Indian Cancer Society (ICS)

ยบ ยบ Gathering and collating data through

was established in 1951 as Indiaโ s first

the Population Based Cancer Registry

voluntary, non-profit National Organization

and providing analytic and projected

for awareness, detection, cure, and survi-

reports on the incidence of cancer via the

vorship of those affected by cancer.

Mumbai Registry. ยบ ยบ Providing a medium for the dissemina-

Instead of limiting themselves to a specific

tion of information and research findings

set of functions, ICS is always looking for

to the medical fraternity through the

new ways to lend a helping hand to cancer

Indian Journal of Cancer.

patients throughout India. Approximately 32,000 people have benefited from its

The rehabilitation center at ICS provides

charitable programmes during the years

different

2013-2014.

easy tailoring workshops to dyeing,

programmes

ranging

from

hand weaving, assembly of bags, etc.

The society is entirely dependent on

They

public support for its various activities

enable patients to be socio-economi-

which are:

cally self-reliant. They also manufacture

ยบ ยบ Creating nationwide awareness of

and supply Orthotic and Prosthetic

cancer, its risk factors and preventive

Appliances as a part of the rehabilita-

measures, encouraging regular check-

tion programme.

provide

vocational

training

to

[23]

ups, treatment options, and survivorship. ยบ ยบ Providing for early detection of cancer through cancer detection centers and mobile cancer detection camps across India, especially for the underprivileged. ยบ ยบ Providing funds for the treatment of cancer for poor cancer patients across India ยบ ยบ Providing support during and after treatment to poor cancer patients 91 |

RE - HUMANIZING HE ALTHC ARE

Figure 2.28 Tailoring workshop in the Rehabilitation center at ICS

COMMON ROOM

KITCHEN

ADMIN

ST. JUDE INDIA CHILDCARE

are provided with ration and supplements

CENTRES

on a weekly basis in case they prefer to cook their meals.

St. Jude’s aims at providing free hygienic accommodation to children undergoing cancer treatment from low incomes

TOILETS families with the help of patronages. Along with accommodation, they also provide free nutritional food and emotional support.

RECEPTION St. Jude’s has centers set up in several locations in Mumbai. They cater to 225 kids, i.e., 40% of the need for accommodation of financially challenged children who come to Mumbai, specifically to the

Tata Memorial Centre, for their treatment ROOMS/UNITS NURSERY

A child is allowed two attendants; usually

protocol.

[24]

only the parents are allowed. The families

TOILETS

COMMON ROOM

KITCHEN

1.8M

RECEPTION HIS TOILETS ROOMS/UNITS

1.8M

ADMIN

UNIT

NURSERY

HER TOILETS

Figure 2.29 Typical layout of a St. Jude India ChildCare Centre |

by Author

1.8M

1.8M

UNIT

Figure 2.30 Typical unit layout, St. Jude India ChildCare Centre |

by Author RE - HUMANIZING HE ALTHC ARE |

92

2.3. 2 SHORTCOMINGS OF THE CITY FOR THE ‘OUTPATIENT’ Due to the crunch of space in Mumbai city,

Some government and private organiza-

even though quality affordable healthcare

tions have set up dharamshalas, attempting

options are available, the infrastructure to

to provide stay at minimal or no costs. The

support medical migration is far less than

aim of these lodgings is focused on

required.

accommodating maximum numbers. In their attempt to do so, they compromise on

With the growth of healthcare insti-

the quality of living. Utilizing every inch of

tutes catering to the ‘outpatients,’ the

space leads to disregard for the need of

demand for supporting infrastructure is

amenities and nursing facilities. Despite

over saturated and incessantly growing.

these attempts, the numbers are not

Patients visiting the Tata Memorial Hospital

met, and many are forced to travel to

(TMH) for affordable treatment can barely

Navi Mumbai for cheaper accommoda-

afford two meals a day, let alone accom-

tions or set camp on the streets outside

modations in a high priced real estate area

the hospital.

such as Parel.

Such is the case outside TMH, where

AVAILABILIT Y

patients reside on the footpath despite

+

else to turn to, they live by the roads

their medical conditions. With no one till they get ticked off the waitlist at

710

255

REQUIREMENT

the

dharamshalas.

Individuals

and

organizations have organized the distribution of food and other necessities as a daily routine for the benefit of these ‘outpatients.’ The footpath is abuzz with

4000 PATIENTS IN THE OPD DAILY Figure 2.31 Lodging availability vs. requirement in Mumbai | by Author

93 |

RE - HUMANIZING HE ALTHC ARE

activity and occupied at any point in time, day or night.

Figure 2.32 Daily activities on the TMH footpath; temporary settlements, sleeping by the roadside, waiting for transport, food distribution (from left to right, top to bottom)

“Though the treatment costs are subsidized, there are many other expenses that we need to meet on a day-to-day basis. We often have to visit the doctor twice a month. It is not possible for my family and me to return to our hometown in Bihar and return every time we have to visit the doctor. I am helpless. I have no option but to live on the street.”

-Putun Devi, blood cancer patient from Bihar.

“We have a relative in Vasai, but we cannot travel with a cancer patient in the train. So we chose this footpath.”

-Sushma Tiwari, wife of a throat cancer patient.

RE - HUMANIZING HE ALTHC ARE |

94

2.3. 3 NEEDS OF THE ‘OUTPATIENT’ Patients keep pouring into the Tata Memorial

and shelter. Thus, providing housing, not

Hospital all year round, every year. Despite

just sheltering the patients and their

expansion from time to time, they are

attendants, but also facilitating holistic

unable to satisfy the growing need for

treatment via the design of spaces

affordable cancer care. Along with the

should be given utmost priority.

expansion of the hospital, the snowballing pressure on supporting infrastructure is

A cancer patient faces high levels of

tremendous.

emotional trauma. They require constant motivation and guidance to climb out of the

Addition of another treatment center

cancer pit. This care should be adminis-

will only add on to the already tenacious

tered during as well as after the treatment

issues. Hence, it is essential to first

via a cancer caring institute. This institute

address the existential crisis before

need not provide medical facilities, but

taking any other step towards the

rather facilitate pain relief therapies

provision of treatment.

and support for the social, physical, emotional and spiritual needs of the

The patients face low standards of living due to lack of basic necessity of food

95 |

RE - HUMANIZING HE ALTHC ARE

patients and their family.

RE - HUMANIZING HE ALTHC ARE |

96

97 |

RE - HUMANIZING HE ALTHC ARE

DESIGN INTERVENTION

CHAPTER 03 10 0 DESIGN FUNCTIONS A gist of the intended functions of the proposed programme with related case studies.

A Therapeutic Home for the ‘outpatient’ 101 Providing Care to Cancer patients 103 Need for Sustainability 105 Maggie’s Centres, U.K. 107 Karunashraya, Bengaluru 115 Shree Gadge Maharaj Dharamshala, Mumbai 121 Hope Lodge, U.S.A. 125

130 SITE Site selection and study.

FUNCTIONS, SITE , BRIEF, APPROACH 131 Selection criteria Location + Accessibility + Context 137 Site analysis

142 DERIVING A DESIGN BRIEF Estimating User-ship + Proposed Programme

146 DESIGN APPROACH A conceptual design intent for the proposed project.

Connection with Nature + Domestic Scale + Home-like Environment + Levels of Privacy + Vertical Design

Figure 3.1 Evolution of healthcare wards

99 |

RE - HUMANIZING HE ALTHC ARE

3.1 DESIGN FUNCTIONS The proposed cancer care facility is for

The study executed aims to relook at the

the benefit of the ‘outpatients’ in Mumbai

existing affordable cancer care facilities

city. It is a tool to address the issues of

in India and provide a solution based on

medical migration in Mumbai. Though it

the needs and requirements of not just the

is not a medical institute, it seeks to cater

patients but also their families.

to non-tangible aspects of healthcare via the architectural design of spaces.

The previous studies of therapeutic environments and needs of cancer patients, mainly

The primary aim of this facility is to

the ‘outpatients’ in Mumbai are used to

provide

derive the design functions.

a

healing

environment,

by

means of housing and a break from the unfriendly hospital atmosphere in a caring center.

With the help of positive and negative case studies, a study of the evolution of healthcare architecture, and an understanding of therapeutic spatial design, the proposed brief intends to ‘re-humanize’ healthcare, specifically, cancer care facilities.

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10 0

3.1. 1 A THERAPEUTIC HOME FOR THE ‘OUTPATIENT’ The diagnosis of cancer is a disruptive,

co-morbidities and disease progressions.

life-changing event. Medical migration

They also have a diverse range of prefer-

roots the patients from the warmth of

ences, personalities and family support.

their home only to place them in an unknown and sometimes unwelcoming

Living with the side-effects of the medica-

accommodation during their treatment.

tion, pain and sometimes changes to their physical attributes, lead to troubling

A cancer patient undergoes tremendous

adverse

mental trauma during this treatment and

engagement in communal activities and

requires

his

their emotional well-being. It is essential to

friends and family. This situation is notably

provide a solace for their troubles as per

harder on the ‘outpatients’ who belong to

their preferences; social as well as private.

the

constant

support

of

outcomes

in

terms

of

their

the low-income category and leave their home and family, with limited finance, in

Current lodging facilities are a block of

aspiration of affordable or free treatment.

concrete, with rooms on both sides of

Even though they make their way to

a corridor running through its length.

treatment centers, they typically have to

There is no consideration for recreation

stay in what are often over-crowded and

or even basic medical aid. With the

unhygienic dharamshalas or lodging

patients spending a majority of their time

houses due to their financial limitations.

in this temporary home, it is essential to cater to their healing needs in addition

The patients seeking a home in these lodgings have a diverse range of cancers,

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to those of the basic necessities.

Requirements of a healing residence for cancer patients based on executed studies: º º Rooms &

º º Washing &

º º Workroom/

º º Services &

dormitories

drying areas

computer room

storage

º º Kitchen & dining

º º Nursing room

º º Therapeutic

º º Amenities/

º º Common hall

º º Prayer room

gardens

recreation area

º º TV room

º º Kids playroom/

º º Staff quarters

º º Toilets

nursery

º º Administration

“We are happy to have a roof over our head during these perilous times. If you set your mind to it, you will like everything without asking for more. This is the best we can afford. Hence we are satisfied with whatever little we get.”

- A patient residing in the corridor due to unavailability of a room at the Shree Gadge Maharaj Dharamshala, Mumbai.

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102

3.1. 2 PROVIDING CARE TO CANCER PATIENTS Laura Lee, director of Maggie’s Centres,

sense of independence. A caring center

is of the opinion that, ‘The landscape

primarily offers social support and other

of cancer is changing, because more

therapies to help patients come to terms

people are surviving. Those with a

with their disease.

recurrence live longer. The need for these (caring) centers has never been

Rebuilding towards the routine life for

greater because people are living with

a cancer patient does not begin after

cancer as a part of life.’

the treatment but goes hand in hand with the treatment. It can be used as a

Cancer treatments affect physical, social,

tool to cure the side effects of cancer

and psychological abilities of the patients.

treatment through productive therapies.

Patients tend to rely entirely on their ‘carers’ due to side effects from the treatment and

Healing spaces should not promote the

loss of control over their body. This has

feeling of exclusion, but rather imitate a

psychological impacts too, leading to loss

society that embraces individuals through

of self-confidence.

an environment that fosters measured community

Availability of specialized care helps them to regain these abilities while restoring their

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reintegration.

interaction

and

gradual

Requirements of a caring center for cancer patients based on executed studies: º º Counseling

spaces

therapy

º º Massage room

rooms

º º Support group

º º Art therapies –

º º Social pockets

º º Exercise

sessions

weaving, stitching,

º º Administrative

programmes –

º º Horticulture

painting, crafts

offices

yoga, aerobics

therapy

º º A library

º º Toilets

º º Meditation

º º Animal-assisted

º º Music therapy

“Cancer hijacks your life and drops you into a situation where you have to learn a new language. Having a center within easy reach has been vital in helping me cope.”

- Rani, visitor at Maggie’s London West Centre.

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104

3.1. 3 NEED FOR SUSTAINABILITY As the proposed facility caters to the finan-

generation can be implemented along with

cially challenged, it is set-up and run by a

a power management system.

non-profit organization. Thus, it needs to sustain itself financially.

Consideration for waste management systems to facilitate usage of biowaste to

Though dependent on sponsors and

produce biofertilizer, which can then be

patrons, it can adopt design features

used in horticulture therapies can go a long

that can help to minimize the reliance to

way.

some extent. Implementation of sustainable design features and services can

Water management systems might be

reduce the impact on maintenance costs

incorporated to assure a continuous supply

to a great deal along with generating a

of water without wastage.

clean and green environment.

Use of passive design strategies to In a city like Mumbai, blessed with long

ensure natural lighting and ventilation can

summers, use of solar energy for electricity

reduce power consumption.

105 |

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PRECIPITATION

REDUCED POTABLE WATER CONSUMPTION

EVAPOTRANSPIRATION

WASTEWATER REUSE STORMWATER REUSE

Figure 3.2 Urban Water Management Systems |

by Author

REDUCED WASTEWATER DISCHARGE

STORMWATER TREATMENT

RUNOFF

INFILTRATION NATURAL FACTORS POSSIBLE INTERVENTIONS

BY MAN

ORGANIC WASTE BIOFERTILIZER/ BIOGAS

HAZARDOUS WASTE

INCINERATION DRY/RECYCLABLE WASTE

Figure 3.3 Waste Management Systems | by Author

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106

3.1. 4 MAGGIE’S CENTRES, U.K. “A Maggie’s Centre is a house which is not a home, a collective hospital which is not an institution, a church which is not religious and an art gallery which is not a museum.”

- Charles Jencks, founder of Maggie’s

Maggie’s Centres are a unique typology,

emotional, social, and psychological

an idea envisioned by Margaret Keswick

support. They aim at positive outcomes

Jencks, a terminally ill woman who believed

through the domesticity of spaces in

that cancer treatment environments needed

their centers by creating an informal

good design. Combining spaces to rest

environment for patients to respond

and

positively to the work of caregivers.

reflect,

these

unique

buildings

include gardens, private rooms and gathering areas.

With more than 20 Maggie’s Centres

[1]

spread throughout the United Kingdoms, Maggie’s is a cancer caring organization

most of them designed by world-renowned

that aims at providing comfort to patients.

architects, all centers are designed by a

It is not a palliative care center nor a

set of design features laid out by the

hospice. Neither do they indulge in medical

organization. These features are observed

treatment.

in almost all the centers.

Maggie’s

Centres

Figure 3.4 Maggie’s London West Centre

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provide

Figure 3.5 Maggie’s Manchester Centre

MAGGIE’S ABERDEEN CENTRE Small, domestic scale; like a beacon of hope

Figure 3.6 Design features observed in Maggie’s Centres | by Author

MAGGIE’S MANCHESTER CENTRE Landscape on the sides of the path leading to the center to shed stress.

MAGGIE’S LONDON WEST CENTRE Contrast from a typical healthcare building, creating a kind of curiosity. The centers are bold as well as inviting and safe.

MAGGIE’S LANARKSHIRE CENTRE Constant connection with nature for the user to step out into nature either through a window view, a courtyard, or a garden.

The red striking red wall of Maggie’s London

The ceiling heights and room sizes are

West Centre by Rogers Stirk Harbour +

kept similar to those in a typical house. The

Partners acts as an optimistic, energized,

partition walls fall short of the ceiling as

restorative feature that psychologically

this allows, according to Jencks, ‘spaces

communicates the influence that the

to flow into each other while allowing a

centers intends to envelop a patient

datum of visual privacy.’

into. It creates its own little world in the midst of the busy city life.

The kitchens in all the centers are perceived as the heart of a home where the table

Though small, Maggie’s Centres comprise

is a place to sit and read, talk to other

an intriguing architectural complexity. The

people, and find support from profes-

interior spaces are subdivided in a way as

sional experts. One can walk into Maggie’s

to allow for private as well as communal

at any time, make themselves a cup of tea,

spaces at the same time allowing users

sit down at the kitchen table to think, talk,

to feel part of the whole building.

laugh, cry, or take a quiet moment.

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108

Frank Gehry’s homely center in Dundee

º º Nutritional advice with specialist

looks as if a child made its roof out of

support for managing hair loss and skin

folded foil while Zaha Hadid’s in Fife, with

care.

its shark-like exterior made of sparkling

º º Emotional support/counseling

silicon carbide grit, allows its visitors to

with stress reduction and relaxation

move, in a bold metaphorical way, from

workshops.

darkness to light.

º º Support groups to focus on the

[2]

Maggie’s Centres aim

to build spaces that inspire people to

emotional impact of cancer.

explore the things they can do to help

º º Gardening groups to participate in

themselves to live with, through and

horticultural activities.

beyond cancer in their lives.

º º Courses and talks on exercise, healthy eating, emotional wellbeing, managing

A Maggie’s Centre is a friendly place to

post-treatment challenges, partnering

meet other people as well as a calming

with the medical team, and keeping up

space simply to sit quietly with a cup of

momentum.

tea and reflect. The centers are uplifting

º º Different methods of relaxation

places with professional staff on hand

such as controlling anxious thoughts,

to offer the support people need. The

meditation, creative writing, bereavement

therapies offered at a Maggie’s Centre are:

support, expressive art, and exercise.

Figure 3.7 Maggie’s Lanarkshire Centre - Counseling room

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Figure 3.8 Maggie’s Fife Centre - Kitchen table

[3]

The spatial requirements laid out by

layout space for table(s) for ten people

the organization in its architecture and

with storage space for folding chairs and

landscape design brief are:

yoga mats.

1 Maximum possible natural light.

10 For workshops and sessions, a table to

2 The entrance should be welcoming, with

seat 12 people. It should be private and

a place to hang the coat and leave the ‘brolly.’

not be looked in on.

3 The welcome area as a ‘pause’ space,

11 Sitting/counseling room for up to 12

from which a newcomer can see and

people with a fireplace or stove.

assess what’s going on without the feeling

12 Two small sound-proof and private

of having to jump right in with somewhere

consultation rooms for counseling, with

to sit, preferably with a shelf of books.

windows looking out to grass/trees, or at

4 Office space should be discreet (no

least a bit of sky. One of the rooms should

reception desk) with three main worksta-

accommodate a treatment bed.

tions and six smaller workstations.

13 Two toilets with washbasins and

5 The kitchen should have room for a

mirrors, which should be big enough to

table to seat 12 and a large ‘island’ with

take a chair and a bookshelf and one of

additional seating for two or three people

them must have disabled access. They

and space for setting up food. Space for

must be private enough to cry.

two dishwashers, a large fridge, one and

14 A very small, quiet retreat space to

a half sinks, an oven, and a hob on the

have a rest or a lie-down.

counter.

15 The ability to look out and even step

6 Computer desk for people visiting the

out from as many of the internal spaces

center to access information on cancer online.

as possible even if it is only into a planted

7 Library to find books and information

courtyard. It not only gives a focus to look

on cancer and a space to look at them

out at but also filter privacy in a room with

comfortably. This could be integrated with

glass doors or windows to the outside. The

the ‘pause space’ or be an extension of it.

garden, like the kitchen, should be a space

8 Three sitting rooms which can be shut

for people to share and feel refreshed by.

off from each other or opened up.

16 The interior should not be vulnerable

9 For relaxation groups, t’ai chi, yoga,

from the outside such that people inside

lectures or meetings, a space sufficient to

feel watched or unprotected.

accommodate 12 people lying down and

17 Parking.

[4]

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110

Figure 3.9 Ground floor plan, Maggie’s Manchester

by Foster + Partners

Figure 3.10 Mezzanine floor plan, Maggie’s Manchester

by Foster + Partners

111 |

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112

Inference: The programme and design

for the accomplishment of the design

of the center are carefully tailored as to

and programmes offered. A center like

provide the most appropriate as well

Maggie’s Centre is required in or around

as desirable atmosphere to patients

every hospital offering cancer treatment.

battling cancer. Every aspect and detail of the design and space within the center

Providing a cancer caring center, with a

is controlled and designed with the idea of

similar programme and design features,

providing a home-like, comforting place for

in Mumbai can be the start of a series of

the patients.

caring centers.

The success of these centers speaks

“Maggie’s provided me with a refuge - a sanctuary - part of the real world but somehow detached. The world hadn’t changed but cancer had totally changed who I was and I needed help to learn how to live again.”

- Isobel, visitor

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Figure 3.11 Maggie’s’ Dundee Centre, Maggie’s Aberdeen Centre, Maggie’s Manchester Centre, Maggie’s London West Centre, Maggie’s Lanarkshire Centre, Maggie’s Oxford Centre (from left to right, top to bottom)

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114

3.1. 5 KARUNASHRAYA, BENGALURU irrespective of a patients economic or social backgrounds, in a space that induces healing and peace of mind.

The center is designed with healing as

B E N G A L U R U KARUNASHRAYA

the central concept. It is a haven of lush greenery, birdsong, and peace, in the midst of the hustle and bustle of a metropolitan city.

The activities of the organization are managed by the CEO and a team of four

Palliative & Hospice center Architect: Sanjay Mohe Year: 1999

departmental heads. There are 150 staff members consisting of nurses, consultants and doctors in palliative medicine, social workers, physiotherapists, and occupaB E N G A L U R U

Karunashraya, a joint project by the Indian Cancer Society (Karnataka Chapter) and NO. OF USERS: 225 the RotaryPLOT ClubAREA: of Bangalore 8200M 2 Indiranagar, DENSIT Y: 0.02 provides professional hospice care for advanced stage cancer patients.

The center is run solely on donations

tional and complementary therapists who KARUNASHRAYA

work alongside fundraisers, housekeeping team, catering staff, maintenance workers, administration staff, and a team of more than 60 volunteers who give their time tirelessly in all manner of roles. It is a 75 bedded, fully staffed facility.

and sponsorships by generous entities.

Admission is granted to patients who are not on any active curative treatment.

Karunashraya provides a free service for an active and dignified end to life,

115 |

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NO. OF USERS: 225 PLOT AREA: 8200M 2 DENSIT Y: 0.02

[5]

The facilities provided for in the center are: º º Pain and

º º Kitchen

º º Auditorium

treatment plant

symptom control

º º Daycare

º º Conference

º º Solar water

º º Complementary

º º Laundry room

room

heater and lighting

therapies

º º Prayer hall

º º Administration

º º Open ground

º º Counseling &

º º Meditation room

º º Reception

º º Water bodies &

bereavement

º º Indoor game

º º Morgue

gardens

º º Physiotherapy

space

º º Rainwater

º º Parking

º º General wards &

º º TV room

harvesting system

private rooms

º º Nurse’s quarters

º º Bore-wells

º º Dining hall

º º Charity shop

º º Sewage

The word ‘serene’ acquires a new meaning

natural lighting and ventilation. The

here; every nook and corner is designed to

patients can relax with a view of

invoke calmness and peace in one’s inner

greenery on one side and water on the

self - the greenery, water bodies aglow with

other of their ward.

waterfalls and chirping birds playing in the background music.

The all-around ambiance is kept simple and green without any loud colors for the

The wards are surrounded by water

psychological comfort of the patients.

bodies and greenery. They are designed

The water body plays a pivotal role in

in a way such that all the wards receive

offering serenity.

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116

Figure 3.13 Ground floor plan, Karunashraya | by Author

117 |

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1.

2.

3.

4.

5.

WARDS NURSE’S STATION TOILE TS RECEPTION ADMINISTR ATION

6. DAYC ARE 7. PRIVATE ROOM 8. DOUBLE ROOM 9. MEDITATION ROOM

10.

11.

12.

13.

14.

DRYING ARE A L AUNDRY KITCHEN STAFF DINING PR AYER ROOM

15.

16.

17.

18.

19.

PARLOUR AUDITORIUM MORGUE NURSE QUARTERS PARKING

Figure 3.12 Site plan, Karunashraya | by Author RE - HUMANIZING HE ALTHC ARE |

118

Observations:

Though the center provides for a small

º º Use of natural materials as building

group, it does so up to a standard that has

elements.

not yet been achieved by most institutes

º º Presence of a therapeutic environment.

in India. It is successful in delivering a

º º Catering to all needs – physical, social,

healing atmosphere due to both, its

emotional.

architecture as well as the team running

º º Barrier-free design.

the facility.

º º Horizontally spread out design. º º The water seems murky due to ineffi-

The design incorporates features specially

cient maintenance.

suited to the needs of cancer patients.

The architectural features observed in

Inference: Despite being situated in a

Karunashraya should be incorporated in

metropolitan

every healthcare facility, be it a hospital

city,

Karunashraya

is

an

abode offering the much-required healing

or any other.

environment. Thus, crossing beyond the limitations of a typical urban context.

‘The main attempt through this (water bodies) is to try and capture the feeling of tranquility and sense of calm to soothe the nerves of the patients undergoing excruciating pain. As the built form recedes into the background the vast surface of the water becomes a stage upon which the ever-changing light, breeze, and rain perform and the reflections on the water create a metaphor for reflecting on a life slowly but steadily drawing to a close.’

– Architect’s office

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Figure 3.14 Water bodies and verandas, Karunashraya

“It is like being in a resort, I forget I’m a cancer patient, I’m blessed to spend this valuable time of my life here.”

-Ayesha, resident at Karunashraya.

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120

3.1. 6 SHREE GADGE MAHARAJ DHARAMSHALA, MUMBAI for patients who ‘temporarily migrate’ to the city for affordable cancer treatment.

A group of less than 20 social helpers and hired administrative and maintenance help run this facility.

The facility, a five-storeyed building, is located on a small plot with a mixed-use context surrounding it. Thus, the scope

M U M B A I

for expansion is limited to verticality, which

will

be

exhausted

after

the

ongoing construction of the additional two floors.

SHREE GADGE MAHARAJ DHARAMSHALA

Currently, the Dharamshala accommodates 200 patients with two attendants per M U M B A I

patient.

After NO. OF USERS: 620the expansion, they will be PLOT 900M 2 for another 80 patients. ableAREA: to provide DENSIT Y: 0.6

SHREE GADGE MAHARAJ DHARAMSHALA

Shree Gadge Maharaj Foundation, a charitable trust, runs numerous facilities for the poor and underprivileged in various sectors throughout the country. The Dharamshala in

Dadar, Mumbai was set up with the purpose of providing inexpensive accommodation

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NO. OF USERS: 620 PLOT AREA: 900M 2 DENSIT Y: 0.6

The facilities provided for in the Dharamshala are: º º Reception &

on each floor

tap on each floor

(general + ladies)

administration

º º Children’s

º º Common kitchen

º º 2 Lifts

º º Main kitchen

playroom

on each floor

º º 100 Double

º º Common toilets

º º Drinking water

º º 2 Dormitories

sharing rooms

The residents of this Dharamshala are

double shared room and `40 per person

patients at the Tata Memorial Hospital

for the dormitory. Meals are available at

(TMH). Rooms are granted by a letter of

the mercy of a sponsor or a `5 coupon

recommendation issued by the TMH and a

system. For patients with special dietary

proof of income.

requirements, a ration card is provided to purchase supplements at rates set by

Each patient is allowed two attendants.

the government.

The current tariff is `50 per person for a

45M

DN

ROOM

ROOM

3M

HIS TOILETS

HER TOILETS

+ BATH

+ BATH

20M

PLAYROOM

5M

CHILDREN’S

ROOM

ROOM

ROOM

ROOM

ROOM

ROOM

UP

ROOM

ROOM

ROOM

ROOM

COMMON KITCHEN

ROOM

ROOM

DADASAHEB PHALKE ROAD

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N

Figure 3.15 Schematic first floor plan, Shree Gadge Maharaj Dharamshala, Mumbai | by Author

122

Observations:

º º Schooling sessions after 6 pm, after all

º º People reside in the passages and

the patients are back from the hospital.

convert the common kitchens into dormitories due to unavailability of rooms.

Inference:

Shree

Gadge

Maharaj

º º Even though lifts are present, they do

Dharamshala is an example of a typical

not function, thus, barring movement for

lodging facility available for patients from

the physically disabled.

BPL families. Though it satisfies the

º º No dining hall or common room.

needs of food and shelter, the condi-

º º No amenities.

tions in which the patients live are not

º º No medical aid.

recommendable for patients undergoing

º º Cooking activity in the rooms due to

cancer treatment.

unavailability of common kitchens. º º Water supply is controlled and available

Not only is there a complete absence of

only for a few hours in the day.

the therapeutic or healing environment

º º The building is clean and well maintained

but also a lack of recreational activities,

with renovations conducted by various

medical aid, and privacy.

Lions and Rotaract clubs. º º Every room has a window.

The facility provides merely a roof over the

º º Availability of daily bus service from the

patient’s heads but fails to cater to any other

TMH to the Dharamshala.

needs of the patients or their caregivers.

“I don’t like it here, I miss home and my brother back home” -Deep, patient at TMH from Bangladesh.

“I haven’t had a bath for 3 days because every time I’m off to the hospital with my wife they let out water and we don’t get access to it” - Caregiver and husband to Rukmini, blood cancer patient.

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Figure 3.16 Spaces in Shree Gadge Maharaj Dharamshala; children’s playroom, common kitchen, room, dormitory, people living in the building premises due to unavailability of beds, ongoing construction (from left to right, top to bottom)

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124

NO. OF USERS: 64 PLOT AREA: 3200M 2 DENSIT Y: 0.02

3.1. 7 HOPE LODGE, U.S.A. The Hope Lodge programme by the American Cancer Society is a nationwide network of residential facilities

HOPE LODGE, OMAHA, NEBRASKA

that provides free lodging to cancer patients and their caregivers who travel

Architects: Trivers Architecture

away from home for treatment. There are

Under construction

32 Hope Lodges spread throughout the

Provision for 64 cancer patients

U.S.A. Hope Lodge aims at forming a unique community

of

hope

and

support

by

providing a home away from home in a comfortable, nurturing environment, thus, allowing the patients to focus on getting better.

NO. OF USERS: 64 PLOT AREA: 3200M 2 DENSIT Y: 0.02

It provides temporary residence for adults who are in complete control of their body.

They are referred by social workers from

2

2

the medical centers.

2

2

2

2

2

2

1

2

The lodge provides a shelter while other

2

requirements of food, toiletries, etc. are to be taken care of by the residents for themselves.

The lodges are set up and run on the stands of donations and sponsorships. Appointed

Figure 3.17 Site plan, Hope Lodge, Nebraska | by Author

administrative and maintenance staff and volunteers manage the daily functions.

[6] 2

1

125 |

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2

2

2

2

2

2

2

2

2

3

6

NO. OF USERS: 64 PLOT AREA: 3200M 2 DENSIT Y: 0.02

6

5

NO. OF USERS: 64 PLOT AREA: 3200M 2 DENSIT Y: 0.02

5

3

1 2 3 4 5 6 7

2 2

13

2

2

2

2

2

13 13

12

2

2

2

2 2

2

2

ROOM 8 MEDITATION ROOM 9 CONFERENCE 10 MOVIE ROOM 11 COMMON TOILETS

13 12 13 12

13 13

1

2

11

13

13

13 13

2

2

2

10

11

RECEPTION DINING KITCHEN ADMINISTRATION LIBRARY LIVING ROOM MULTI-PURPOSE

13 13

13 2

11

1

3

Figure 3.18 Ground floor plan, Hope Lodge, Nebraska | by Author

11

4

10

9

8

7

4

1

9

8

7

12

2

13 13

1

13 13 13 13

13 13

2

12

2

12

13

13

13

13 Figure 3.19 Typical floor plan, Hope Lodge, Nebraska | by Author

13 13

13 13

13 13

12 DAY CARE 13 TWIN SHARING

ROOM

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126

Observations:

Inference: Hope Lodge is primarily a motel

º º Segregation of private and public

with a homely, healing atmosphere. They

spaces.

are designed in different cities as per the

º º Provision for various amenities.

needs and requirements of the city in terms

º º No consideration for kids.

of numbers.

º º The kitchen and dining are designed with a similar character as Maggie’s

From the examples of Maggie’s Centres

Centres.

and Hope Lodge, it is evident that

º º Meant for independent patients probably

providing

in the early stages of cancer, who can

possible only on a controlled scale.

look after themselves.

Thus, a design catering to large groups

º º Mass grouping such as dormitories or a

needs to be broken down into multiple

dining mess has been avoided to maintain

small-scale

a domestic scale.

domestic environment.

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domesticity

sections

in

to

design

maintain

is

a

Figure 3.20 Hope Lodge Nebraska, Hope Lodge Phoenix, Kitchen at Boston Hope Lodge, Guestroom in Houston Hope Lodge, Living room in Manhattan Hope Lodge

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128

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3. 2 SITE

I N D I A M A H A R A S H T R A

I N D I A

M A H A R A S H T R A MUMBAI MUMBAI

MAHARASHTRA MAHARASHTRA

N

N

N

N

TATA MEMORIAL HOSPITAL

TATA MEMORIAL HOSPITAL

M U M B A I

The proposed project primarily caters to the

other states, cities and even countries. It

lodging needs of patients from the low-in-

also offers a cancer caring center. Thus,

come group, traveling to the Tata Memorial

the site for the proposed facility is located

Hospital for free/affordable treatment, from

in Mumbai, India.

M U M B A I

F/S WARD

F/S WARD N

F / S

W A R D

N

N

F / S

W A R D

N

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130

MUMBA

HARASHTRA

3.2. 1 SITE CRITERIA LOCATION

therapies can prove to be a strenuous routine. Also, the caring center should be

During cancer patients usually I Ntreatment, D I A undergo radiation therapy multiple times

placed near the Tata Memorial Hospital

N

in a week. Traveling to and fro from

(TMH). Thus, the proposed site is located M A H A R A S H T R A in the vicinity of the TMH which lies in

the accommodation to the hospital,

the F/S ward. MUMBAI

in Mumbai traffic after these rigorous

MAHARASHTRA

TATA MEMORIA HOSPITAL

N

M U M B A I TATA MEMORIAL HOSPITAL

M U M B A I

F/S WARD F/S WARD

N

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N

F / S

W A R D

N

F / S

W

ACCESSIBILITY

a quick route to the hospital in case of emergency.

In order to minimize travel time after treatment procedures, the site should be

Proximity in terms of the highway, railway

located within a 1km radius of the TMH.

stations, and major transport routes is preferable to allow easy availability of public transport systems.

It should be easily accessible to facilitate

DADAR

PAREL ELPHINSTONE

TATA MEMORIAL HOSPITAL

SEWRI

MAJOR ROAD NET WORKS RAILWAY STATIONS

N

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132

PAREL ELPHINSTONE

TATA MEMORIAL HOSPITAL

CONTEXT

To facilitate a maximum number of patients SEWRI with their attendants in the residential

Though located in the heart of the city,

quarters, along with amenities and thera-

the site should be cushioned from the

NET WORKSof land is peutic services, a large chunk

noise, traffic, and pollution of the city

required.

MAJOR ROAD RAILWAY STATIONS

to accomplish the intention of providing a healing environment.

TATA MILLS

TATA MEMORIAL HOSPITAL

HAFFKINE INSTITUTE

Figure 3.21 Site options within a 1 km radius from the TMH | by Author

133 |

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N

N

Haffkine Institute is one of the oldest

Women’s and Children Hospital and a

biomedical

Hydrogen Beam Therapy facility.

research

institutes

in

the

country. It has emerged as a multi-disciplinary Institute engaged in training,

Thus, the proposed plot will practically

research and testing of various aspects of

be a part of the TMH, making it very

infectious diseases.

convenient for the users.

The selected plot is very conveniently

Haffkine Institute has previously engaged

located from the TMH. From the selected

in charitable lending of land within its

plot of Haffkine Institute, 5 acres of land

premises for healthcare benefits. Thus, this

has been reserved for the extension of

site is proposed for locating the healing

the TMH, who are going to utilize it for a

and cancer caring center.

TATA MEMORIAL HOSPITAL

K.E.M. HOSPITAL WADIA HOSPITAL

PROPOSED SITE

HAFFKINE INSTITUTE

TMH EX TENSION

N

Figure 3.22 Site context | by Author

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134

Figure 3.23 Proposed site

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GD ENTRY

AMB

EDK

AR M ARG

HAFFKINE INSTITUTE

PROPOSED SITE

TMH EX TENSION

HAFFKINE INSTITUTE

Figure 3.24 Site plan | by Author

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136

3.2. 2 SITE ANALYSIS Haffkine Institute, Parel

Physiography and Soil Type: The broad physiography feature of the

Latitude: 19-00N

district is broad and flat terrain flanked by

Longitude: 72-50E

north-south trending hill ranges. The hill

Elevation: 18 m

ranges form almost parallel ridges in the eastern and western part of the area.

Climate: The climate of the district is characterized

The soil comprises basalt rock. The soil in

by an oppressive summer, dampness

the district is medium to deep black and

in the atmosphere nearly throughout

reddish soil.

the year and heavy south-west monsoon rainfall from June to September.

Travel time from Tata Memorial Hospital: 8 minutes walking (650m)

Rainfall: The regular annual rainfall over the district

Plot area: 14,515 m 2

varies from about 1800 to 2400 mm. The

Permissible F.S.I.: 5

rainfall gradually increases towards the

Permissible built-up area: 72,575 m 2

north and reaches a maximum of 2382.0 mm.

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Figure 3.25 Annual weather averages, Mumbai RE - HUMANIZING HE ALTHC ARE |

138

Figure 3.26 Sun path diagram, Mumbai; 21st June, 21st September, 21st December, 21st March (left to right, top to bottom)

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Figure 3.27 Wind direction distribution, Mumbai

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140

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3.3 DERIVING A DESIGN BRIEF The proposed programme is broken down into two sections viz. the residence for the ‘outpatient’ and the cancer caring center.

ESTIMATING USER-SHIP

3,749 15

As per the lodging availability and requirement data (figure 2.31), the current facilities satisfy 17.75% of the requirement, if all

19,097 :

78

1,625 :

7

Figure 3.28 Ratio of age groups within the new non-Mumbai cases registered in 2013 in Tata Memorial Hospital | by Author

the OPD patients are assumed to be non-Mumbai residents. It is impossible

Thus, a reverse calculation of permissible

to provide for the remaining 82.25% in

built-up area and the design will lead to

one facility.

the number of users accommodated in the facility.

With each patient being allowed two attendants at the most, the number of people housed in the facility triple, making this a high-density project.

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142

DETAILED PROPOSED PROGRAMME

THE SPACE

AREA REQUIREMENT

1. Welcome area

45 m2

2. Entrance

20 m2

3. Administrative office

50 m2

4. The kitchen

75 m2

architectural brief and Maggie’s Manchester

5. Computer desks

20 m2

Centre.

7. Sitting room

CANCER CARING CENTER The programme and areas for the caring center have been derived from Maggie’s

35 m2 x 3

8. Therapy room

55 m2

It is a proposal for one of the many such

6. Library

40 m2

centers to come. The caring center will

9. Workshop space

30 m2

cater to approximately 120 people at a

10. Counseling room

25 m2

time. The built-up area of 725 m 2 will be

11. Consultation room

15 m 2 x 2

distributed as follows:

12. Toilets

7 m2 x 2

13. Retreat space

15 m2

14. Circulation + decks/open spaces

200 m2

15. Parking 16. Therapeutic gardens

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HEALING RESIDENCE

The second shall be the common usage and administrative section which will

The residential section of the facility is

serve as common amenities for all the

segregated into two sections.

modules. It shall incorporate the following spaces:

The first being a cluster of modules, each

º º Common kitchen

accommodating 90 people which will

º º Common dining/ hall

include all the housing and domestic facil-

º º Administrative offices

ities. This module will be multiplied as

º º Staff living quarters

per the need and design and serves as

º º Common toilets

a scope for future expansion.

º º Children’s playroom º º Counseling rooms

The spaces accommodated in one module

º º Multipurpose space

will be:

º º Meditation space

º º 10 Double sharing rooms + 2 toilets +

º º Amphitheater/social spaces

bath (2 patients + 4 attendants/room)

º º Charity shop

º º 2 Dormitories (4 patients + 8

º º Massage rooms

attendants/dormitory)

º º Therapeutic gardens

º º Ladies dormitory (6 patients and

º º Services

attendants)

º º Parking

º º 1 Set of common toilets (men + women) º º Washing and drying area º º Kitchen º º Dining room º º Living room º º Multipurpose space º º Workspace º º Medical room º º Prayer room º º Terrace garden º º Services and storage

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144

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3.4 DESIGN APPROACH CONNECTION WITH NATURE Based on the research on therapeutic architecture and the impact of nature and environmental factors on the human body and its healing capabilities, the proposed project aims to maintain a strong and constant connect with nature in any possible manner. This connection can be achieved in multiple ways ranging from simple window views to physical presence.

Due to the project being sited in the heart of the city, where the levels of noise and pollution are relatively high, the intended connection with nature may need to occur in an enclosed environment or a space buffered from these disturbing factors.

Figure 3.29 A greenhouse, Rehabilitation Centre Groot Klimmendaal, Farnsworth House (from top to bottom)

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146

DOMESTIC SCALE

HOME-LIKE ENVIRONMENT

Though the proposed project is a high-density housing facility, it aims to achieve a domestic scale within its internal spaces in an attempt to enable the user to connect with them.

Lodge as also research on Evidence-Based Design indicates a faster healing process if the patient is surrounded by a home-like environment.

To achieve this, the facility is broken down into modules. This design feature attempts

The design of Maggie’s Centres and Hope

to

avoid

mass

gatherings

where the user would feel unimportant as one among hundreds, due to the size of the gathering. However, at the same time, it is essential to maintain communal activities on a smaller scale.

Hence, each module will be designed for a group of 90, for it to be economical as well as communal while avoiding the ‘mass’

The presence of a familiar environment adds to the comfort and enables the user to settle right in.

The proposed design aims to achieve this homely atmosphere within the modules to create a more friendly, easy-to-live-in environment by maintaining a similar scale of rooms and spaces as would be in a home.

LEVELS OF PRIVACY

grouping.

Cancer patients experience a constant breach of privacy due to their treatment procedures and loss of control over their body. It is crucial to help them retain some private, intimate moments which may help them to cope with the disease emotionally.

Social spaces are equally necessary to enable the patients and caregivers to maintain a constant communal connect.

Figure 3.30 Habitat 67

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The design of the healing environments

aims to maintain a domestic scale,

will accommodate variations of private

connection with nature and a home-like

and semi-private spaces to enable the

environment.

user to retreat into a private space or enter a social zone whenever he wishes to.

Figure 3.31 Paley Park, Manhattan

VERTICAL DESIGN The proposed project will have a very high footfall along with provisions for future

expansion.

With

the

availability

of a high permissible built-up area and need to accommodate maximum possible numbers, the design may need to formulate vertically.

In spite of this verticality, the project

Figure 3.32 Penda Towers, Toronto, Hotel Golden Holiday, Vietnam

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148

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REFERENCES AND BIBLIOGRAPHY 01

1 Ron Smith & Nicholas Watkin; Ph.D., AIA Academy of Architecture for Health, Therapeutic Environments Forum – Article on Whole Building Design Guide, 22nd September 2016.

2 ibid.

3 Grinde, et al., Biophilia: International Journal of Environmental Research and Public Health, published by Multidisciplinary Digital Publishing Institute, 2009.

4 Ron Smith & Nicholas Watkins; Ph.D., AIA Academy of Architecture for Health, Therapeutic Environments Forum – Article on Whole Building Design Guide, 22nd September 2016.

5 Elza Maria Alves Costeira, Healthcare Architecture: History, Evolution and New Visions, October 2015 – Publication on ResearchGate.

6 UNESCO, World Heritage Centre, World Heritage List, Sanctuary of Asklepios at Epidaurus. (website) 7 Greek National Tourism Organisation, Visit Greece, Sanctuary of Asklepios at Epidaurus. (website) 8 Admin, The History of Hospitals and Wards, Healthcare Design Magazine, 11th March 2010.

9 Heather Burpee, History of Healthcare Architecture, Integrated Design Lab Puget Sound, 2008.

10 ibid.

11 David Keifer; M.D., What is Holistic medicine, WebMD, 05th January 2015.

12 Suzan Walter; M.B.A., Holistic Health, American Holistic Health Association. (website) 13 Betsy Severtsen, Healing Gardens, January 2006 – Publication on ResearchGate.

14 Elizabeth and Nona Evans Restorative Garden, Case studies, Institute for Human centered design. (website) 15 Cleveland Botanical Garden. (website) 16 Elizabeth and Nona Evans Restorative Garden, Case studies, Institute for Human centered design. (website) 17 Yvonne Osei, Exploring Sensory Design in Therapeutic Architecture, Carleton University, Ottawa Ontario, 2014. (Thesis) 18 Hilary Dalke, Lighting and Colour for Hospital Design, A Report on an NHS Estates Funded Research Project, published by The Stationery Office, 2004.

19 Psychologists at the University of British Columbia, 2009.

20 Lindsay Holmes, 11 scents that can do wonders for your living, The Huffington Post, April 2009.

21 Roger S. Ulrich, View through a window may influence recovery from surgery, published by American Association for the Advancement of Science, May 1984.

22 Robert N. Golden; M.D., et al., The efficacy of light therapy in the treatment of mood disorders: A Review and Meta-Analysis of the Evidence, published by The American Journal of Psychiatry, 1st April 2005.

23 Francesco Benedetti, et al., Morning sunlight reduces length of hospitalisations in bipolar depression, Journal of Affective Disorders, published by Elsevier, February 2001.

24 Carla Davis, Shining light on what natural light does for your body, Sustainability, North Carolina State University, March 2014.

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150

02

1 IANS, India’s healthcare sector: A look at the challenges and opportunities faced by the $81.3 billion industry, Firstpost., 12th June 2017.

2 Mohandas K Mallath, et al., Cancer burden and health systems in India 1, The growing burden of cancer in India: epidemiology and social context, published on TATA Memorial Center website, 11th April 2014.

3 TATA Memorial Hospital, What is cancer? (website) 4 Fundamentals of Cancer Center Design: The Patient, Healthcare Design Magazine, 13th January 2014.

5 6 7 ibid.

8 End of Life Washington, End-of-Life Options. (website) 9 ibid.

10 Poulomi Das, This Varanasi hostel lets people check-in to die, Business Insider, India, 23rd August 2016.

11 Rutu Ladage, Mukti Bhavan - The hotel where people check-in to die, India, 11th September 2015.

12 CRC Health, What is animal assisted therapy? (website) 13 American Horticultural Therapy Association, Horticultural Therapy, History and Practice. (website) 14 Alex De Alvarado, et al., Music Therapy Helps People with Cancer, The University of Texas MD Anderson Cancer Center, 14th March 2011.

15 American cancer society, Physical Activity and the Cancer Patient. (website) 16 Foreword, A view from the front line, by Marcia Blakenham, 2007.

17 Maggie’s Centres: Marching on, A view from the front line, Marcia Blakenham, 2007.

18 Prof. Imran Ali, et al., Cancer scenario in India with future perspectives, Cancer Therapy, November 2011.

19 E. Kumar Sharma, Killer costs, Business Today, 17th February 2013.

20 American Cancer society, Caregivers and Family. (website) 21 Dr. Ganesh B., Hospital Based Registry, TATA Memorial Hospital.

22 Tata Memorial Hospital, History. (website) 23 ICS Annual Report, 2013-14.

24 St. Jude India ChildCare Centres, About. (website)

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03

1 Eric Baldwin, The Architecture of Healing: 12 Maggie’s Centres by Gehry, Hadid, Heatherwick and More, Architizer, 26th April 2016.

2 Kate Kellaway, Maggie’s centres: how one woman’s vision is changing cancer treatment, The Guardian, 20th February 2011.

3 Maggie’s evidence based programme, obtained from Maggie’s website.

4 Maggie’s Architecture and Landscape Brief, obtained from Maggie’s website.

5 Karunashraya, Bangalore Hospice Trust, About us. (website) 6 American Cancer Society, Hope Lodge. (website)

DOCUMENTARIES 1 Architecture that’s built to heal - TED talk by Ar. Michael Murphy.

2 Mukti Bhawan (Hotel Salvation), directed by Shubhashish Bhutiani, 2017.

3 Building Hope: The Maggie’s Centres, BBC Documentary, 2016.

THESES 1 Yvonne Osei, Exploring Sensory Design in Therapeutic Architecture, Carleton University, Ottawa Ontario, 2014.

2 Emily Borrett, The Maggie’s Centres: Architecture and Healing, University of Brighton, Interior Architecture, 16 th January 2013.

LITERATURE 1 Innovations in Hospital Architecture, by Stephen Verderber.

2 A view from the front line, by Maggie Keswick Jencks.

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152

LIST OF FIGURES 01

1.1 Art by Tran Nguyen.

1.2 Sketches by Disha Vanzara.

1.3 Street art by Antoine Stevens.

1.4 Illustrated by Author with reference from ‘Innovations in Hospital Architecture,’ by Stephen Verderber.

1.5 - 1.6 Sourced from Google images.

1.7 - 1.10 Sourced from ‘Innovations in Hospital Architecture,’ by Stephen Verderber.

1.11 Illustrated by Author.

1.12 Sketch by Johann Rudolf Rahn.

1.13 - 1.18 Illustrated by Author.

1.19 Illustration by Sunstar Suisse.

1.20 - 1.24 Illustrated by Author.

1.25 Illustration by Omar Youssef, University Of Arizona.

1.26 - 1.28 Illustrated by Author.

1.29 - 1.31 Sourced from Archdaily.

02

2.1 Sourced from Google images.

2.2 - 2.6 Illustrated by Author with reference from India’s healthcare sector: A look at the challenges and opportunities faced by the $81.3 billion industry, Firstpost., 12th June 2017.

2.7 - 2.8 Illustrated by Author with reference from Over 20% of Indians suffer from chronic diseases: report, Livemint, 04th Oct 2016.

2.9 Illustrated by Author with reference from Population Based Cancer Registry report, 2014 by the National Cancer Registry Programme.

2.10 Illustrated by Author with reference from Cancer scenario in India with future perspectives, Cancer Therapy, November 2011.

2.11 Sourced from Google images.

2.12 - 2.13 Illustrated by Author.

2.14 - 2.15 Sourced from Google images.

2.16 Sourced from Mukti Bhavan - The hotel where people check-in to die, India, 11th September 2015.

2.17 Shot by Author.

2.18 Illustrated by Author with reference from LOOK: What Meditation Can Do For Your Mind, Body And Spirit, Healthy Living, The Huffington Post, 16th May 2014.

2.19 Illustrated by Author with reference from Killer costs, Business Today, 17th February 2013.

2.20 Illustrated by Author.

2.21 Illustrated by Author with reference from data obtained from respective hospital websites and newspaper articles.

2.22 - 2.24 Illustrated by Author.

2.25 Sourced from Tata Hospital Handbook.

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RE - HUMANIZING HE ALTHC ARE

2.26 Illustrated by Author with reference from Hospital Based Cancer Registry report of TATA Memorial Hospital, 2013.

2.27 Illustrated by Author with reference from TATA Memorial Hospital, History. (website) 2.28 Shot by Author.

2.29 - 2.30 Illustrated by Author.

2.31 Illustrated by Author with reference from figure 2.24 and Hospital Based Cancer Registry report of TATA Memorial Hospital, 2013.

2.32 Shot by Author.

03

3.1 Sourced from Google images.

3.2 - 3.3 Illustrated by Author.

3.4 Sourced from Maggie’s website.

3.5 Sourced from Archdaily.

3.6 Illustrated by Author.

3.7 - 3.8 Sourced from Maggie’s website.

3.9 - 3.10 Sourced from Archdaily.

3.11 Sourced from Maggie’s website and Archdaily.

3.12 - 3.13 Illustrated by Author.

3.14 Sourced from the official website.

3.15 Illustrated by Author.

3.16 Shot by Author.

3.17 - 3.19 Illustrated by Author.

3.20 Sourced from Google images.

3.21 - 3.22 Illustrated by Author.

3.23 Sourced from Bing maps.

3.24 Illustrated by Author.

3.25 Sourced from weather-and-climate.com.

3.26 Sourced from Andrew Marsh.

3.27 Sourced from Windfinder.

3.28 Illustrated by Author.

3.29 - 3.32 Sourced from Google images.

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154

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