Alan Dilani has taken over 100 flights this year. As director general of the International Academy for Design and Health (IADH), he’s a globetrotter, a lecturer, and a consultant in constant demand from Cape Town, South Africa, to Brisbane, Australia, to Trondheim, Norway. Considering the airborne pathogens, circadian-rhythm derangements, and relentless hassles of frequent flying, he by all rights ought to be chronically exhausted or worse. Yet he never takes medications. He sees physicians, but not as a patient. And, according to him, he never gets sick.
His secret is salutogenesis, which is to say a belief that, in order to be healthy, you have to address the root of unhealthiness rather than merely treat the illness.
Dilani is among the global leaders in the movement to incorporate salutogenic strategies into design on multiple levels. Single buildings can accomplish this with natural light, viewsheds, ventilation, nontoxic materials, prominent and welcoming staircases rather than elevators, serene colors, and clear wayfinding signals. Neighborhoods can relieve food deserts, include safe and well-lit sidewalks, and accommodate bicycle paths to make physical activity an easy choice, rather than an out-of-the-way recreational option. Cities can make room for town plazas, unfold according to a simple street grid, and replace congested arterial roadways.
Architects, planners, and public health officials have known about these strategies for a while. But what makes an idea such as salutogenesis useful is that it unifies the elements of smart cities, green communities, and eco-districts. Salutogenesis refines the principles of Smart Growth and New Urbanism; it also contributes to other initiatives, such as the Active Design Guidelines (ADG) developed by five municipal agencies—the New York City departments of Design and Construction, Health and Mental Hygiene, Transportation, City Planning, and the Office of Management and Budget—and AIA New York. For Dilani, salutogenic strategies go beyond hospital healing spaces or community fitness programs to find the foundations of somatic health and disease. And if he’s right, these strategies will revolutionize how architects practice.
In some respects, salutogenesis applies simple common sense to the relationship of environments, bodies, and minds. What makes it a coherent school of thought is its reliance on interdisciplinary research, connecting biomedical knowledge with an explicit mission to place human well-being—not financial imperatives—at the center of creative strategies. But it’s a far cry from feel-good crunchiness or hair-shirt asceticism. Since the benefits it generates include measurable gains in productivity and reductions in expenditures, it also offers clients a persuasive business case. It’s now embedded in national AIA policy through the new America’s Design and Health Initiative, currently producing a body of evidence, a research agenda, and recommendations for architects and officials that are promoted via articles, podcasts, and a recent workshop.
Ray Pentecost, FAIA, president of IADH and vice president and director of healthcare architecture at Clark Nexsen, draws parallels between high-performance, energy-conserving design and design for health. Now that sustainability has expanded from a small subspecialty to what is essentially a professionwide norm, he believes that it’s time for salutogenic design to become the next great wave of theory and practice. “The projects that don’t have it [salutogenic strategies] are going to fall out of favor in the same way that construction for fire safety became more than an option,” he says. When clients understand how much healthier their world could be, “the architects who aren’t doing it won’t stay around,” he says.
Biology, behavior, and built spaces
The underlying biology of stress and relaxation is well understood, says Dr. Esther Sternberg, a medical researcher and author of Healing Spaces: The Science of Place and Well-being (Belknap, 2009). Any kind of stress triggers the hypothalamus (the brain’s stress center), pituitary gland, and adrenal glands to produce a cascade of hormones that aid in short-term fight-or-flight survival reactions. Those hormones also dampen inflammatory immune mechanisms. Stress responses don’t directly make us sick, she reports, but they can weaken our resistance to ever-present pathogens, particularly if they recur enough to become a chronic state.
Relaxation, conversely, triggers the brain’s “reward and anti-pain pathways” by releasing endorphins and dopamine. Since these responses developed over our long evolutionary history, during most of which our ancestors spent immersed in nature, it’s no accident that most of us find natural environments and biomimetic patterns (such as those found in fractal geometry) regenerative. The brain’s functional centers even include what Sternberg calls a “beautiful-view spot,” which University of Southern California neuroscientist Irving Biederman has discovered is rich in endorphin receptors.
That looking at certain spaces and forms might be “giving yourself a shot of endorphins” remains just a hypothesis, Sternberg says, but it is congruent with popular aesthetic experience. The brain also has a site for recognizing buildings, she says, which some evolutionary biologists believe involves our response to mountains and other large navigational cues. And as for the question: Why did such brain areas evolve? “I suppose God is an architect,” she speculates.
Dilani and Pentecost hold that salutogenic design connects these areas of physiological knowledge with the insights of American-Israeli sociologist Aaron Antonovsky, who originally coined the term—an awkward hybrid of Greek and Latin. In his research, Antonovsky identified certain “generalized resistance resources” that foster physical vigor and mental composure by studying the human response to extraordinarily bad conditions, such as concentration camps. People who find their environments manageable, even if those settings are rife with stressors, develop a personal sense of coherence and are better able to sustain health as the World Health Organization defines it: a state of optimal physical, mental, and social well-being; not only the absence of disease and disability.
Antonovsky surmises that because everyone is surrounded by opportunities to be sick, stress is what determines why some people get sick and others never do. “Health is a process,” Dilani says, “composed of psychosocial factors, lifestyle, and experience.”
The rediscovery of agency
For all of biomedical science’s impressive achievements in treating illness, it has not been as successful in promoting wellness. Industrial societies have built some of the most toxic and disturbing environments in human history. And though the United States outspends all other nations on medical care, its obesity, infant mortality, and life-expectancy rates are not excellent. Traditional public-health doctrine views disease as a triangle represented by an agent, a host, and an environment. If you block any point in the triangle (for instance, keeping people away from infectious organisms or out of toxic environments), you can prevent disease from spreading. Dr. Lester Breslow, dean emeritus of the UCLA School of Public Health, has identified three eras in world public-health history: first, from ancient times to the early 20th century, emphasizing communicable diseases such as small pox or malaria; second, the beginning of the 20th century, emphasizing chronic or non-communicable diseases such as obesity or Type II diabetes; and third, more recently, accepting personal responsibility for health.
A pathogen-control approach succeeded spectacularly in the first of Breslow’s phases of public health, when acute infectious conditions were the chief concerns. But the subsequent focus on the pathogenesis of chronic disease has perpetuated “the mind-set that we often get sick because an agent gets to us or something happens to us; that it’s somehow not our fault,” says the IADH’s Pentecost. “This masks the central role that each of us plays in our own health, and that design can play. Public health should enable us to do what it is that we want to do. That means taking personal responsibility, and that’s where salutogenesis can have a great impact. It’s where we say we’re no longer going to settle for design that is simply profitable, or efficient, or sustainable, or programmatically compliant, or any of a dozen other measures of design success; we are going to look for design standards that address and respect public health.”
In 1984, while teaching at Texas A&M University, the evidence-based design expert Roger Ulrich observed that good design could have a quantifiable impact on wellness. Faster post-surgical recovery rates, lower pain-medication requirements, and even better staff interactions with patients could be tied directly to building and interior design decisions. Since then, just as evidence-based medicine has revised traditional practices in healthcare, evidence-based design in medical facilities has led to improvements in patient outcomes, lower rates of iatrogenic injury (or medical error), higher rates of staff satisfaction, and other measures of how environments support healing.
Although some improvements derived from evidence-based design map onto familiar green-design strategies, Pentecost cautions against a general presumption that the validity of these ideas translates automatically across domains. Evidence-based design is a young field with a developing research base, initially derived largely from the hospital sector; its advocates recognize the risk of overpromising, and it has its skeptics. Dilani, for one, views it guardedly, noting that “evidence-based design” is often used merely for marketing, especially in the U.S. “Design is not science; design is creativity,” he comments, noting that the diversity of design solutions in different cultures contrasts with the clear conclusions and implications of evidence-based medicine.
At its most useful, though, the grounding of design in quantifiable results can guide cost-effective architectural and operational decisions. It can also help take the passivity out of the patient role, fostering conditions where patients’ healing capabilities have a better chance to operate.
The human factor and the business case
In his forthcoming book, Sprawling Cities and Our Endangered Public Health (Routledge, 2012), Clemson University architecture professor Stephen F. Verderber, Assoc. AIA, identifies an economic and political “sprawl machine” that has replaced natural ecologies. He argues that it has also replaced vernacular building traditions with cookie-cutter typologies. “Architects have aided and abetted this horizontal growth pattern for 50 years without really thinking very carefully about the health consequences of what they’re doing from a community-health standpoint,” Verderber says. “Architects were developing new building types for suburbia and designing buildings on individual sites without thinking of the systemic implications of what they were doing.”
Verderber’s book offers design guidelines, which he describes as “a synthesis of landscape urbanism and the best principles of New Urbanism [in] a ‘both/and’ proposition” to marshal those contending philosophies in the interests of promoting health and reviving traditional communities.
Clemson’s Architecture and Health concentration has made it a leader in healthcare facility design, but its students also look more broadly at public health concerns. “In the evolution of healthcare architecture in the U.S. in mid 20th century,” says program director David Allison, FAIA, “we migrated towards a line of thinking of an absolute belief in technology.” Hospitals became driven by functional efficiency, he says. “We made very efficient technological factories for delivering healthcare, but up until the last decade or two we left out the human aspect.” Allison often looks to European and Japanese facilities for better examples of investment in designs that bring long-range benefits for an up-front premium. “Part of the problem we have in the U.S. is a separation from understanding the value of capital investment versus long-term operating costs.”
Since the average tenure of upper-level healthcare executives is often shorter than the time it takes to realize many healthcare facility projects, Allison says, their interest in saving money during their tenure trumps an interest in the long-term investment in a 50-year building. It’s a false economy, he explains, because capital expenses account for a relatively small proportion of overall life-cycle “human functional costs” in buildings that operate on a 24-hour, 365-day basis and inherently place their staff, patients, and families in high-stress circumstances. A so-called “salutogenic premium,” akin to familiar green premiums, is hard to estimate until more cases come to attention, Verderber says.
Allison calls attention to the detailed cost–benefit calculations for a hypothetical “Fable Hospital” published by an all-star group of architects and analysts led by Blair L. Sadler of the Institute for Healthcare Improvement and University of California at San Diego. Salutogenic additions to Fable Hospital’s design, which represent $29 million of an overall construction cost of $350 million (roughly an 8 percent premium), bring $10 million in annual savings through lower mortality rates, injury reductions, and shorter lengths of stay. With pay-for-performance Medicare reforms ending reimbursement for care delivered after avoidable adverse events, Allison adds, incentives for improving safety become even higher.
Markku Allison, AIA, (no relation), a resource architect at the AIA Center for the Value of Design and staff lead for America’s Design and Health Initiative, adds that intangibles such as natural light in workplaces yield tangible benefits when their effect on productivity is assessed indirectly through absenteeism rates or test scores.
For some architects, modeling a broad architectural philosophy on public health may ring certain historical bells; for others, it may raise alarms. “Imperfect Health: The Medicalization of Architecture,” an exhibition currently on view at the Canadian Centre for Architecture (CCA) in Montreal, suggests that attempts to solve social and health problems through design have often brought unforeseen consequences. In many cases, tightly sealed windows in 1970s commercial towers conserved energy but contributed to “sick building syndrome.” In other cases, planting trees to give industrial cities Olmsted-style “lungs” also filled the air with allergy-inducing pollen. In the most well-known instance, asbestos was regarded by builders as a flexible, strong, and fireproof “magic mineral” until its association with mesothelioma became apparent in the 1960s.
The show’s curator, Giovanna Borasi, finds architectural prescriptivism a risky proposition. “The moment that architecture is considered a cure,” she says, “we might discover there is another kind of health urgency that becomes more important, and buildings will start to become obsolete.” Borasi, an architect, acknowledges that design can counteract problems such as obesity. But design is a tool that can be wielded in several ways—not all of them beneficial. One of the things that contributed to midcentury sprawl, for instance, was a public desire to move away from urban congestion, communicable-disease hazards, and poor air quality.
Socially purposeful modern architecture and planning addressed some pressing public issues, but the critical backlash against it in the 1970s and 1980s halted a lot of progressive thinking. “Architects just withdrew, except for the energy-crisis questions,” says Kate Schwennsen, FAIA, chair of Clemson’s School of Architecture. “There were some who just thought, ‘We don’t know how to do this, so we’re just going to give up.’ ” Schwennsen supports the development of salutogenic knowledge and practice, but she cautions against making the same mistakes twice.
Salutogenic-design advocates argue that quantifiable data and research can be corrective mechanisms to avoid past mistakes or structures that might become prematurely obsolete. An emphasis on promoting health (rather than merely treating disease), mitigates social segregation, quarantine, and paranoia that recur throughout the CCA exhibition’s darkly fascinating case studies. Think about how many films have appeared in the last 10 years dealing with some kind of “outbreak” or medical mass-hysteria.
But evidence-based design does not have to be overly prescriptive or hamper an architect’s creative freedom. “I don’t believe evidence-based design means you have to design unimaginative boxes with uninteresting spaces,” Pentecost says. “Early skeptics claimed, ‘This is going to kill creative design.’ Nothing could be further from the truth.” Pentecost adds, “Salutogenic strategies can make a complex design more clear, more useful, more workable, and healthier. They are freeing to the designer in many ways.”