HEALTHCARE ARCHITECTURE: HISTORY, EVOLUTION AND NEW VISIONS Elza Maria Alves Costeira Architect M. Sc PROARQ / FAU / UFRJ; Researcher in the Department of Cultural Heritage of FIOCRUZ; Researcher at the Centre for Urban State of Rio de Janeiro-OUERJ / UERJ *
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In recent decades emerged new concepts for the design of hospitals seeking to bring their spaces the values that make patients feelings like they are in their homes, that is architectural should incorporate to the building’s design the patient's vision and their everyday representations. These concepts also propose the integration of healthcare environments with outer space and incorporate in the areas of diagnosis and treatment a number of assumptions that are considered as promoters of healing. Current research on length of stay and the quality of care-client point to the emphasis of the humanization of these environments in order to alleviate the suffering and anguish during hospitalization, adding family life practices and personalization to spaces, involving teams professionals and families as care partners in offers therapies to achieve the desired cure. However we have to go back in time so that we can understand the importance of Health Environments and Architecture of a trader - Healthcare Architecture - have been established, becoming increasingly critical to the deployment of new centers of excellence in the attention health arising in our country. We can say that the aspect of contemporary hospital is formatted between the seventeenth and eighteenth centuries in Europe. The event cited as crucial to the change of the old hospital structure, with unsanitary facilities, housing hundreds of grouped sick, was the great fire of Hotel-Dieu in Paris in 1772. As this was an institution where many patients were held, it was urgent its reconstruction or replacement. A commission was established to evaluate architectural designs appropriate to the case, conducting studies and researches to find a definitive solution to the hospital. This committee was composed of nine members and was named by the Royal Academy of Sciences, from the efforts of the Baron de Breteuil, the Royal House of Louis XVI. On this occasion had highlighted the works of Doctor Tenon, a French surgeon, which analyzed several hospitals in Europe, not only in order to describe their architecture, but also with a critical eye, functionalist. He published in 1788, five reports gathered in a work name "Memoires sur les hôpitaux of Paris." With the Tenon "project", triumphs pavilion organization, as horizontal hospital space. With the adoption of pavilions thus allowing cross ventilation and an excellent natural lighting, Tenon believed to have solved what was considered the largest producer of unhealthiness in hospitals: the stagnant air and moisture. He also made a series of volumetric studies to establish the relationship between the dimensions of each
pavilion and the number of beds in wards, to ensure optimal minimum volume of air renovated to each patient. Tenon also studied the optimal number of floors for each pavilion, establishing three the optimal number of floors. The technological importance of elements in the consolidation of this profile in the nineteenth century were the development of anesthesia, aseptic practices and the spread of the nursing profession, secular, in this case. Throughout the nineteenth century came also the concern with ventilation and natural lighting in the projects of healthcare buildings, from the so-called "theory of miasma", where the spread of disease was attributed to the effluvia of emanation of matter originating in decomposition. The discovery of the transmission of germs, in 1860, revolutionized the design of hospital projects, isolating the disease and patients in specific pavilions. The work of Louis Pasteur demonstrated the need to combat infection and disease transmission, with the separation of patients and sterilization of medical devices. These principles, isolation of pathologies, lead to a true revolution in healthcare design. The arrangement and the composition of the architecture in multiple pavilions facilitate the development of buildings and integration with your installation space, enabling the creation of hospitals with size of cities blocks, and deployments resembled the small garden cities. At this time the surgery is definitely incorporated to hospitals and, alongside the rise of scientific medicine, the pavilion model and the specific functions of division to the environments of healthcare, we can say that the contemporary hospital profile was born. We highlight also the studies of Florence Nightingale, who, from his experience in the Crimean War (1853-1856), established bases for the construction of Nursing with concepts of ventilation and distribution of patients, lighting and hygiene, which are adopted until today by some institutions. The study of the physical conformation of the wards, called "Nightingale wards”, set a new space model for the healthcare design, with the most striking examples of hospitals designed with this feature. Notes on Matters Affecting published the Health, Efficiency and Hospital Administration of the British Army (1858- Notes on health, efficiency and hospital administration in the British Army). The wards "Nightingale" wards served as a model for the implementation of hospitals for many years, as best healthcare reference, from then to the first decades of the twentieth century, and are still used until the present day, for some concepts and structures designed with horizontal placement. Thereafter, until the twentieth century, the hospitals were greatly incorporating technology into their spaces, requiring in its planning an ever more acute, with facilities, sophisticated building infrastructure and the ever-growing concern in sectorial spaces to separate patients with various diseases and establish tight control flow and circulation to the development of medical activities. The trend of vertical buildings appear as early as the second half of the nineteenth century, with the emergence of "skyscrapers" in Chicago. At the same time,
we observed an increase in the cost of urban land, the shortage of labor nursing, desire to reduce the existing routes in pavilion hospitals and also the issue of inadequacy of the long corridors of movement to the hard climate of North America. The enhancement technologies construction, such as the use of metal structures, is the basis for the establishment of the new typology in healthcare building. The use of lifts, optimized circulation, the use of mechanical ventilation systems and facilities in building infrastructure deployment determine the development of the verticality of the buildings. So the “monoblock” hospital as called rises that later turns into multiple blocks vertical structures, setting the remarkable typology of the twentieth century. Along with the advances in construction technology, we have seen a major change in the health care system and the patient's profile housed in hospitals. These include the continuity of the Lister surgeon (XIX century), subsequently deepened by Ernst von Bergman, the bases for the sterilization of instruments used today. Hospital Surgical Center highlight its importance, while hospitals are now mostly used in patients who did not have resources for home care, used by people with more financial resources. In the period between the two world wars, the hospital was just a one-piece stacking wards "Nightingale". Its typical anatomy designed the underground to the support services, the ground floor for offices and imaging services, the first X-ray services. On the first floor was the administration, the intermediate floors, hospitalization and last floor, the so-called Operating Room. The freestanding hospital model can be seen as a medical symbol of triumph, for his energetic way refers to advances in medical research. This typology modeling various hospital structures of the twentieth century and moves into blocks juxtaposed conformation positioned over a larger base, composed of technical floors. The freestanding hospital works its physical structure, with the rationalization of assistance functions and the compartmentalization of services, disease and complexity of care, implementation of its floors and buildings. During the course of the twentieth century, hospitals reach mixed conformations in physical structures, with plans designed for expansion and the incorporation of new services and users, following the huge development of medical science and the increase in clientele, adding people who, until then not could access to these institutions. History of Public Health in Brazil begins, effectively, in the late nineteenth century and early twentieth century. However we cannot fail to mention the Holy Mercy Homes that are the most typical Brazilian healthcare institutions in the country's establishment as a nation. The Hospitals arrived in Brazil with the coming of the missionaries of the Company of Jesus - known as Jesuits, in the sixteenth century. The first Santa Casa was founded in Santos, in 1543, by the settler Braz Cubas. These hospitals have a major role in healthcare settings in Brazil and have great influence on the care of populations, with its institutions, usually erected in very old buildings,
serving as an object of study and reflection for public health and healthcare environments. The development of the Brazilian hospitals to be confused with the establishment of government healthcare actions throughout our history. We highlight here the initiatives of sanitarist medical-doctor Oswaldo Cruz, seeking the eradication of plague, yellow fever and smallpox, establishing the creation of mosquito coils and mass vaccination of the population, culminating in the "Vaccine Revolt" in Century threshold XX. Actions to provide a network of appropriate assistance for their demand continued after the hygienist reform of Mayor Pereira Passos and doctor Oswaldo Cruz, with the "Reform Pedro Ernesto". In 1930, with the installation of the Provisional Government, delineate the great transformation that his administration brought to the public health services, in Federal District. Pedro Ernesto, M.D., Federal Intervenor at the Federal District formed a team to study the health problems and undertook the construction of several dispensaries and Ready Aid, promoting a major transformation in health issues and medical assistance throughout the Rio de Janeiro. In the field of social welfare, President Getulio Vargas government also introduced important changes. Next to the Retirement and Pension Funds (who came from the 1920s), Institutes of Retirement and Pensions were created, state-controlled bodies responsible for extending social rights to national categories of workers. During the 1930s, were created Retirement and Pension Institutes in various categories like industrialists, commerce, banking, civil servants etc. After 1945, the Institutes of Retirement and Pension expanded their areas, which now include services in the area of food, housing and health. From there begins a period of major public building construction and other specimens with much more complex programs, featuring the so-called Brazilian modern architecture. These architectural structures used the concepts of modernity and points recommended by Le Corbusier, who was three times in Brazil and became a reference for architects at that time, to the shaping of hospital designs. We can cite examples of Brazilian modern hospitals as the Maternity University of São Paulo (1944) by Rino Levi, Porto Alegre Clinical Hospital (1955) by Jorge Machado Moreira or South America Hospital today Hospital da Lagoa (1952) by Oscar Niemeyer . Since the transfer of the federal capital to Brasilia and the creation of the State of Guanabara, began a new administrative stage, bringing a lot of buzz for the health of network management of Rio de Janeiro. On December 28, 1962, is created SUSEME (Superintendência de Serviços Médicos - Sanitary Services Superintendency) by Law No. 279, in order to manage the hospitals of the State of Guanabara. Several hospital works began and unfinished buildings were completed, such as the expansion of the Miguel Couto Hospital, the completion of expansion works at the Hospital Salgado Filho and the emergency room of the Hospital Souza Aguiar. The SUSEME sought cover the problem of the physical structures of the health network, implementing
several health centers, which belong, currently the municipal assistance in various locations of the city of |Rio de Janeiro. From the military coup of 1964, we witnessed in our country, the closing of all employee participation channels in decisions and discussions around the system pension. Against this background, there is a fusion of IAPs- Institutes of Retirement and Pension- (IPASE), through Decree No. 72 of November, 21, 1966 establishing the INPS- National Social Security Institute. In 1968 the government developed the National Plan of Health- PNS- proposing, in short, the free choice of doctor system, the customer, and the medical fees paid by the client-part that exercised the right of choiceand part by Welfare system. In 1974 it approved the action-PPA- Ready Action Planthat, among other things, provides for the bureaucracy and the universalization of visits to clinics and surgical emergencies, through Ordinance No. MPAS 158 of February,18, 1974. The impact this plan in the physical structures of health units is obvious, with institutions experiencing a large increase in demand for services of this nature. The hospital network in Rio de Janeiro, bigger and more costly for their managers, is configured as one of the largest offerings of beds in health facilities, in terms of installed capacity. However, their disjointed physical structure, scrapped and inefficient, comes up against the problems arising from the coexistence of the various levels of government of the city hospitals: the Federal, with units of the security and the Ministry of Health, the State and the City, not forgetting university hospitals, philanthropic and units of the private system. The period between the years 1980 to 1983 was known as the social security crisis. Regardless of the different cyclical and previous crises, resulting from the model of its financing, health could not extend their coverage to rural populations and the criticism of the system and the development of new projects, seeking alternatives. The implementation and the consolidation of a unified health system depended on the new Federal Constitution, adopted and promulgated in 1988. The completion of the molds of the new system- the Unified Health System (SUS) - was established from the so-called Organic Health Law , Law No. 8080 of September, 19, 1990. There are points, irrefutably, the decentralization of healthcare services. Its strongest guidelines, indication of municipalization of healthcare, are in Chapter III, when determining the role of each of the spheres of government to action with the Unified Health System (SUS). The new recommended model has a big impact on the physical layout of healthcare units, requiring a new approach to the architecture of these institutions. The search for a methodology for design and construction of health facilities points to the need for compatibility between medical technology and diagnostic support and therapy present in these structures and the humanization of their environments, promoting the integrity of healthcare to all population segments, as mentioned in the Organic Law of Health.
The much-touted humanization of healthcare environments requires a deep reflection of the architects in the design of hospitals that can provide more than just technological spaces, adding to the concepts of environmental sustainability and comfort structures and employing systems and construction techniques that can provide more readable and environments cozy users. BIBLIOGRAPHY ANTUNES, J. L. Hospital: Instituição e História Social. Letras & Letras. São Paulo, 1991. CAMPOS, E. S. História e evolução dos hospitais. Ministério da Educação e Saúde, Divisão de Organização Hospitalar. Rio de Janeiro, 1944. CARDOSO, V. L. A margem da arquitetura grega e romana e princípios geraes modernos de hygiene hospitalar. Rio de Janeiro, Typographia do Anuário do Brasil, 1927 In SANGLARD, G. e COSTA, R. G. R: Direções e traçados da assistência hospitalar no Rio de Janeiro (1923-31). História, Ciências, Saúde - Manguinhos, vol. 11(1): 107-41, Rio de Janeiro, 2004. CAVALCANTI, L. Quando o Brasil era Moderno: Guia de Arquitetura 1928-1960. Aeroplano. Rio de Janeiro, 2001. COSTA, R. G. R.. Hospital do Andaraí (verbete) IN: PORTO, A. et alli. História da saúde no Rio de Janeiro: instituições e patrimônio arquitetônico – Rio de Janeiro (1808-1958). Fiocruz. Rio de Janeiro, 2008. COSTEIRA, E. M. A. Hospitais de Emergência da Cidade do Rio de Janeiro- uma nova abordagem para a eficiência do ambiente construído. Dissertação (Mestrado). PROARQ/FAU/UFRJ. Rio de Janeiro, 2003. COSTEIRA, E. M. A.. O hospital do futuro: uma nova abordagem para projetos de ambientes de saúde. In SANTOS, M.; BURSZTYN, I. (orgs.). Saúde e Arquitetura- Caminhos para a humanização dos ambientes hospitalares. SENAC Rio, Rio de Janeiro, 2004. KARMAN, J. Manutenção e Segurança Hospitalar Preditivas. IPH. São Paulo, 2011. MIQUELIN, L. C.. Anatomia dos Edifícios Hospitalares. CEDAS, São Paulo, 1992. OLIVEIRA, J. A e TEIXEIRA, S. M. F. (Im) Previdência Social: 60 Anos de História da Previdência no Brasil. Rio de Janeiro, ABRASCO. Vozes, 1985. PEVSNER, N. Historia de las Tipologias Arquitectonicas, Gustavo Gilli, Barcelona, 1980. THOMPSON, J. D. & GOLDIN, G. The Hospital: A Social and Architectural History. Yale University Press. New Haven and London, 1975.
Published at SUSTINERE at http://www.e-publicacoes.uerj.br/index.php/sustinere Jul/Dec 2014
