Global lessons in healthcare
Globally, buildings that support the delivery of healthcare services vary broadly by type-ranging from small community outpatient clinics to large acute-care hospitals-and have an equally broad range of owners-including philanthropic nonprofits, corporate entities, and governmental agencies. Healthcare is a significant service economy; while its percentage of the Gross Domestic Product (GDP) varies widely between nations, there is general agreement that the healthcare sector has the capacity to define markets through what it builds and purchases and how it operates.
The industrialized nations of North America and Europe have the most technically evolved hospital infrastructures; however, not surprisingly, the energy intensity of hospital buildings in North America is the highest in the world. The average age of a U.S. hospital is 27 years. And, for the most part, the hospital infrastructure is completely mechanically conditioned. It is characterized by deep floor plate, and non-daylit diagnostic and treatment blocks, with little regard for orientation or passive system design. These buildings operate continuously 365 days per year, with multiple back-ups and redundant mechanical and electrical systems. They've only increased their energy intensity as medical diagnostic equipment with large heat loads continues to enter the marketplace.
In 1996, a comparative study of energy consumption between hospitals in Europe and North America revealed that North American buildings operate at approximately twice the energy intensity of their European counterparts. While the study did not look at system differences, the most important ones are obvious, including the fact that European hospitals require daylight in all occupied spaces, leading to enclosed courtyard planning in lieu of deep floor plates. Nursing units continue to be naturally or passively conditioned, and when mechanical conditioning is installed, the prevalent system is displacement ventilation that introduces air at the floor rather than the ceiling. Not surprisingly, North American design teams are now making pilgrimages to green hospitals in Europe, especially the ultra-low-energy examples in Scandinavia, and are using the lessons learned as a prescription for change.
Rio Negro Hospital in Cali, Columbia, is targeting LEED Gold certification.
There is much to be learned from highly advanced green hospital buildings in other countries. Tools such as the Green Guide for Health Care and LEED for Healthcare integrate into design views and daylight, and places of respite, while also seeking to reduce overall energy demand. This is done while producing effective, high-performance healing environments. Lessons taken from these guides are beginning to take shape in the production of new large-scale acute care hospitals in the developing world, such as Rio Negro Hospital in Cali, Columbia (figure 1), which is targeting LEED Gold; or the University Research Hospital in Changchun, China. In January, the India Green Building Council certified the Kohinoor Hospital near Mumbai as LEED Platinum-the second hospital in the world to receive this rating.
Rio Negro incorporates many green initiatives such as extensive natural ventilation and daylighting, green roof gardens, solar hot water heating, storm water retention, and a high-performance building skin.
At the same time, the vast majority of healthcare delivery in the developing world occurs in extraordinarily low-technology environments-in communities with little infrastructure for potable water delivery, sewage treatment, or reliable grid power. These buildings have lessons for us as well and perhaps define “resilience” and “self-sufficiency” with on-site-based energy and water solutions that those in the developed world can barely imagine. The green building community can learn much from these prevalent healthcare buildings.
Figure 2 shows energy consumption for a typical U.S. hospital (from Target 100); energy consumption for a University Research Hospital in Changchun, China (provided by the hospital to the author); and energy consumption for a typical Chinese hospital in Nanchang, China (provided by the hospital to author). It shows the dramatic difference between new hospital construction and existing hospitals in most of the developing world.
The challenge of infrastructure
Much of the healthcare delivery in the developing world takes place where there are no municipal water or treatment facilities; thus, many hospitals use on-site water-treatment systems for both incoming water and sewage. Because public health infrastructure is either nonexistent or unreliable, many countries require hospitals to install these systems on site. The result is more resilient healthcare delivery and hospitals that can provide healthcare services as well as potable water within their communities. As incidents of extreme weather increase globally, resilient public health infrastructure will become more important to limiting the adverse health outcomes from such events.
Illnesses associated with extreme temperature and precipitation, air pollution, water contamination, and diseases carried by ticks, mosquitoes, and rodents manifest at the community level. Providing potable water to the surrounding community is probably the most important public health benefit they offer due to the disease that is prevented and, consequently, the reduced consumption of medical and natural resources. In 2007, the World Health Organization reported that there are 4 billion cases of diarrheal disease and 1.8 million deaths each year globally from unsafe water and hygiene.
Gaviotas Hospital (figure 3), in Las Gaviotas, Colombia, was a 16-bed, 7,266-sq.-ft. (674-square-meter) solar-powered hospital designed and built by community members and visiting friends between 1982 and 1986. Heralded by a Japanese architectural journal in 1995 as “one of the 30 most important buildings in the world,” the hospital's provision of purified water (using simple solar energy distillation technology) immediately reduced deaths and illnesses that previously plagued the villagers. Though the hospital closed in 1997, the building remains a water distillation plant.
Gaviotas's off-the-grid passive solar hospital building augments its modest energy needs with solar and wind power. Courtesy of Gunter Pauli.
Many hospitals in India, due to increasingly scarce water supplies, feature on-site rainwater collection systems. Likewise, many hospitals forego the use of hot water, except as generated by solar thermal systems. Because newer laundry detergents allow washing with cold water, these simpler, fossil-fuel-free systems serve the requirements of the facilities.
Because of the need to minimize energy costs or infrastructure demands, hospitals in developing countries use mostly mixed-mode or natural ventilation for all of their spaces. In the mixed-mode hospitals, the buildings include a large number of fan coil units, each dedicated to one space. With this arrangement, a large unit is not required to heat or cool spaces that do not absolutely require heating or cooling. The units each condition only a very small space and only the space that absolutely requires conditioning. The units are tightly sized to serve these spaces so they never run at part-load.
What lies ahead
A more transformative vision of “living” and “regenerative” hospital buildings is beginning to coalesce worldwide. Primarily, this vision finds its roots in the connection between buildings and health-the immediate health of building occupants, health of the surrounding community, and health of the larger global community and its natural resources. Practically, it is manifested in a small group of projects glo
bally, such as the proposed Embassy Medical Center in Sri Lanka, which is designed to digest municipal organic waste to power a 1,000-bed hospital. The Living Building Challenge, a framework developed by the Cascadia Region Green Building Council, provides an important baseline for this journey. The Green Guide for Health Care is taking up the challenge of transforming healthcare infrastructure from today's standard practice to zero-energy, toxic-free, zero-waste, water-balanced solutions.
There should not be a belief that delivering high-quality healthcare requires a passport for waste and energy intensity-or that saving lives is somehow outside of broader ecosystems and ecological concerns.
We must, however, pay attention to examples of ways we can provide healthcare that come not only from the most celebrated sources, but also from the most humble. There is much wisdom there. There should not be a belief that delivering high-quality healthcare requires a passport for waste and energy intensity-or that saving lives is somehow outside of broader ecosystems and ecological concerns. Through these public health models and global lessons, hospitals can demonstrate a broad commitment to more-than-high-quality patient care. They can demonstrate a commitment to save lives and improve health without undermining ecosystems or diminishing the world.
Robin Guenther, FAIA, LEED AP, is Principal at Perkins+Will. Walter Vernon, PE, is Principal at M+NLB. Healthcare Design 2010 October;10(10):10-14