HEALTHCARE ARCHITECTURE AS PLACEBO
(Excerpted from Charles Jencks's essay, “Maggie Centres and the Architectural Placebo,” to be published in the forthcoming book The Architecture in Hospitals in November 2005, NAi Publishers, The Netherlands. With permission.)
My own scepticism on architectural determinism dragged on for thirty years. Until one day, because of Maggie Centres, I was invited by BBC Radio to debate with a doctor about the role of architecture in health. To people's surprise, I took the typical doctor's line—“architecture matters for cultural reasons, not because it affected patients that much”—while the doctor took my line—“architecture really does matter for health.” Why? His answer surprised, even shocked, me. “If the architecture of the National Health Service is bad,” he said with a glint, “we don't even show up for work!”
That's pretty good architectural determinism, of a negative kind. Perhaps it might even satisfy scientists, because the absenteeism of doctors, their staying away from bad buildings, can be statistically measured.
Anyway, because I was focused on the patients, I hadn't given much thought to the effect of architecture on the doctors and carers. So I missed the more radical notion that, in the first instance, the carers are more important than the patients because, for the now obvious reasons, if the former are not happy, that will have many negative consequences, both physical and psychological, on the patients. I had to laugh at this new thought—my surprise and change in mind.
As David Spiegel has shown in a famous study of women with breast cancer, group psychotherapy can help patients survive longer. That extension of life may be true because women in these groups help each other socially; they visit each other, co-operate more with doctors, and make better use of medical facilities. That is, their psychological changes soon transform into social and physical ones. It is their mind over matter, because changes in the mind lead to shifts in behaviour.
My argument will be that Maggie Centres, and their architecture, do make a difference in the quality of life and survival rates of patients—though we can't prove this yet—for such reasons as Spiegel's study shows. Furthermore, that the placebo effect also enters into this equation, with The Style Effect, The Cultural Effect and The Carer's Effect. Each Effect is effective, both for the negative reasons that the doctor told me in our BBC radio debate, and for positive reasons. Remember, in bad buildings, doctors and carers often don't show up; with a positive placebo, the patient's belief is important, but it works much better if the doctor strongly believes in its efficacy. On these grounds, we hire good architects, even brand names such as Frank Gehry and Zaha Hadid, because they inspire our carers and the cancer patients, both of them. Good architecture says to the team, “We care, and to show it we have spent extra attention and money on you. Inspiration matters, and can change things. Don't give up.”
But, following this argument, one can see that these Effects may work only for a limited time and under limited conditions. Fresh styles that become endlessly repeated lose their power, just as brands become obsolete when a new, effective one is introduced. Most important of all, it is the interaction between the carers and the patients—the ethos between them, the team spirit engendered—that has to be supported by the architecture. In other words, the potency of architecture is in conjunction with the effective ethos and the team's message, not a strong Effect in itself. Good architecture can make a difference when it underscores the style and approach of an institution.
Put as a theory, I would say that when the style and content of an institution are mutually supporting, then they can produce the Architectural Placebo. This is one idea behind Maggie Centres, as its inception and brief history show.
Maggie Centres are a strange hybrid, a building type that yokes together functions previously divided. Its mixture has elements of a day-care centre and hospice, as well as some functions already being absorbed into large hospitals—for instance, the therapeutic role of art and collective expression. But I think its mixture also typifies the mood of our time, the preference for an urban life of contradictory experience and spontaneous pleasure. When people go to a large hospital today they want the best in technology and applied skill, but they also don't want to be reminded, every minute, of an operation or threat to their life. This contradictory desire results in the great trend of our time toward the hospital that looks, more and more, like a domesticated landscape of heterogeneity. Part urban square, part playpen, part library and bar, it is also bound to be a place for relatives and friends to wait, patiently, and also a place, perhaps, to die and mourn.
Maggie Centres are also radically hybrid, combining at least four building types. First, they are warm, friendly, familiar and domestic—a house that is not a home. Second, with artworks and garden, an expressive architecture that in places goes beyond the expected, they are a museum that is not a museum. Patients who come to them may take risks, and look for support as well as meditation in creative work. Third, some of these people will be asking the ultimate questions—“What is the meaning of my life?”—and so an appropriate space and atmosphere have to be provided for a church that is not a church. Lastly, there are the many complementary therapies on offer, as well as the counseling, in this, the hospital that is not a hospital. If one asks why each Maggie Centre has the semi-open space of a nineteenth-century house, looks in part like an art gallery and church, and functions like a day-care centre, it is fairly transparent. Because, when people face deep questions, they want to come to a place that can take on opposite roles. With the increase in cancer, and the complexity of an aging population, the need will grow.