The Third Carer
Ashish Ranpura, MD, PhD
October 2021

Our conception of disease has always shaped our clinical approach. When we thought that disease was a formless evil, we turned to witch doctors and priests to exorcise it. When it was an imbalance of humours, we drank coloured fluids. When we thought it might be malodourous vapours we took in the sea breeze and the mountain air. In the industrial age we imagined jammed-up gears and mis-connected wires and we developed surgical techniques to cut out and rebuild. In the chemical age we imagined a complex interplay between molecules and receptors and popped pharmaceuticals to raise or lower their levels.
Clinical buildings reflect this cultural understanding of disease. They have ranged from dark and secretive apothecaries to bright, metallic temples of hygeine. The architecture of these spaces suggests social hierarchies within the world of health care. Is the healer a ruler or a servant of the sick? Are the ill supplicants or customers?

Today our most articulate conception of disease is the biopsychosocial model. In this framework, illness is the combined effect of a biological vulnerability with a psychological state within a social context. For example, a person who works varying night shifts may be extremely tired with a weakened immune response due to disrupted circadian cycles. When exposed to a cold virus, this person is likely to develop a respiratory infection. If they are then unable to take time off work, their disease may progress. If they are eventually hospitalized with pneumonia, we would miss nearly all of the causative factors predicting disease if we were to focus only on the viral pathogen. In order to treat and prevent disease, we have to see the entire picture.

Clinical buildings today still reflect the monumental scale and gleaming efficiencies of the industrial and chemical eras. Now that we've arrived at the biopsychosocial model of disease, we need a new type of clinical building to support it. This building must function on a personal scale, offering privacy but also community. It must facilitate health interventions that are biomedical as well as those based on diet, exercise and social needs. The building must reflect a change in the way we deliver health care from an intervention at a point in time (a surgery, a prescription) to an ongoing interaction between an individual and a comprehensive care system.

In this sense we can think of the building itself as a third carer, after a patient's family and their medical team. The building will facilitate nurturing interactions and anticipate the needs of its occupants. When the building functions in this way, as an active part of the healing process rather than as a passive stage on which the theatre of medicine is performed, patients will naturally come to associate the building itself with improved health. Just as temples and cathedrals can create a sense of spiritual calm, even without their attendent rituals, so too can this new type of hospital create a sense of wellbeing independent from and in parallel to the practice of health care.

This conditioned response to a designed environment is one of the most powerful tools available to the health care architect. The cultural associations we make with these environments are deep- rooted, and they have a tremendous transformative power both in the literal sense, in that they can alter disease states through placebo- like conditioning, and in the imaginative sense, in that they enable us to envision being well again. We must stop making monuments to those who fund and build hospitals, and return to a time when we built places to heal the sick.