The bed in the age of Covid-19

A grid of empty white beds in a dark cavernous space—waiting for bodies. One architecture inside another. A field hospital is set up within days to accommodate 5,500 patients in two convention center halls in Madrid. Buildings designed for temporary events now host an emergency medical architecture, a space for disease. Sick architecture. [Fig 1] And it was not just Madrid, all over the world, from Belgrade to New York, similar spaces were set up during the early days of COVID 19. Neither it was the first time that this has happened, as can be seen in photographs from the 1918 Flu pandemic in the USA showing thousands of beds as a field hospitals in cavernous spaces.

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Le Sanatorium de Paimio, Alvar Aalto, architecte, 1932 © Fondation Alvar Aalto

Beatriz Colomina, historian and theoretician of architecture

July 9, 2022
10 min.
Sick architecture is not simply the architecture of medical emergency. On the contrary, it is the architecture of normality—the way that past health crises are inscribed into the everyday, with each architecture not just carrying the traces of prior diseases, but having been completely shaped by them. Every new disease is hosted within the architecture formed by previous diseases in a kind of archeological nesting of disease. Each medical event activates deep histories of architecture and illness, along with all the associated fears, misunderstandings, prejudices, inequities, and innovations.
In fact, all architecture is sick. Illnesses and architecture are inseparable. It could even be argued that the beginning of architecture is the beginning of disease. As doctor Benjamin Ward Richardson put it when introducing Our Homes and How to Make them Healthy, a compendium of texts by doctors and architects for the 1884 International Health Exhibition in London: "Man, by a knowledge and skill not possessed by the inferior animals, in building cities, villages, houses, for his protection from the external elements, has produced for himself a series of fatal diseases, which are so closely associated with the productions of his knowledge and skill in building as to stand in the position of effect from cause. Man in constructing protections from exposure has constructed conditions of disease[1]."

There is no disease without architecture, and no architecture without disease. Doctors and architects have always been in a kind of dance, often exchanging roles, collaborating, influencing each other, even if not always synchronized  

There is no disease without architecture, and no architecture without disease. Doctors and architects have always been in a kind of dance, often exchanging roles, collaborating, influencing each other, even if not always synchronized. Furniture, rooms, buildings, cities, and are produced by medical emergencies that layer one on top of another over the centuries. We tend to forget very quickly what produce these layers. As soon as the emergency is over we develop amnesia. We act as if each pandemic is the first, as if trying to bury the pain and uncertainty of the past.
And yet it could be argued that the history of cities is the history of disease. The pandemics of the 19th century brought us the infrastructure we still have today in our cities: clean water systems, sewage systems, urban parks, etc.  And they also revolutionized the design of interiors, furniture and buildings.
The relationship between architecture and health is actually an old story that goes back to the very beginning of architectural theory. Vitruvius in the first century BC launched Western architectural theory by insisting that all architects needed to study medicine: “Healthfulness being their chief object.”[2] He devoted a large part of his Ten Books on Architecture to the question of health, giving detailed instructions on how to determine the healthiness of a proposed site for a city by returning to the ancient method of sacrificing an animal that lives there and inspecting its liver to make sure it is “sound and firm.” Likewise for the health of buildings he discusses the theory of the four humors, which was the dominant medical theory of the time. Even more interesting, Vitruvius argues, in reverse, that those who are unwell can be cured more quickly through design, rebuilding the system of those “exhausted by disease” including “consumption,” an old word for tuberculosis. So already in Vitruvius we encounter the idea of architecture for both the prevention and cure of disease. Something that has persisted through the centuries.
In the Renaissance, for example, the very first school of design, the Academia del Disegno in Florence in 1563, founded by Giorgio Vasari, placed itself next to the medical academy and students of design were required to attend dissection in the local hospital Santa Maria Nuova and draw the body for days on end, even as the body putrefied and some students fell ill.
Every subsequent architectural theory added something to this medical paradigm. Cities represent a kind of accumulation of theories of disease from ancient times to the present. One could even argue that disease is the real designer of cities. 
Modern architecture, for example, was produced under emergency conditions. Throughout the nineteenth century and the first half of the twentieth, millions died of tuberculosis every year all over the world. Modern buildings offered a prophylactic defense against this invisible microorganism. All the defining features of modern architecture—white walls, terraces, big windows, detachment from the ground—were presented as both prevention and cure. Yet the medicinal nature of modern architecture and the unimaginable horror it was responding to has been largely forgotten. The image of white buildings whites out the trauma that gave birth to them.
In order to produce the idea of modern architecture as healthy, nineteenth-century architecture was demonized as nervous, unhealthy, and literally filled with disease, especially the bacilli of tuberculosis. Decorative excess was itself treated as an infection. Modernizing architecture was firstly a form of disinfection, a purification of buildings leading to a health-giving environment of light, air, cleanliness, and smooth white surfaces without cracks or crevices where contagion might lurk. Women were advised to leave out petri dishes to see if any bacteria had survived their cleaning routines. The house wife was a bacteriologist and the home her laboratory. 

Every subsequent architectural theory added something to this medical paradigm. Cities represent a kind of accumulation of theories of disease from ancient times to the present. One could even argue that disease is the real designer of cities. 

Architecture has always described in terms of the body, but it is not a healthy body as we usually think about it, particularly with the famous images of athletic male bodies as drawn by Leonardo da Vinci and others, inscribed in geometric systems of proportions. The real body of architecture is a fragile body, prone to sickness or already sick, and in need of support. Architecture is a kind of orthopedic support, a kind of crutch, or artificial skin for this fragile creature.

Take Alvar Aalto and Aino Aalto and their Paimio sanatorium of 1929 in Finland. With its dramatic terraces in the sky, the building even bears an uncanny resemblance, in canonical photographs, to ribs in an X-ray, the primary diagnostic tool for TB. Its clean-lined bedrooms, void of ornament, were designed to minimize surfaces where dust could accumulate Even the intersection of floor and wall beneath the window curved to stop dust build up. The rooms were equipped with furniture and sanitary fittings designed by the architect, including chairs whose back was angled to facilitate breathing and expectoration, sinks designed to reduce splashing and spittoons to minimize sound. Even door handles were carefully designed not to catch the sleeves of the doctor’s white coats.
But the building’s main equipment was the top-floor terrace, seven stories above the forested landscape, where patients were wheeled out for regular doses of fresh air and sun in the specially designed lounge chair by Aino Aalto. [FIG. 5] Eventually, the terrace had to be closed off perhaps because the nurses couldn’t keep up with the number of desperate patients throwing themselves from it every time they turned their backs. Modern architecture as a form of assisted suicide? The discovery and success of streptomycin in 1944 revealed that there was little scientific basis to the air and sun therapy of the sanatorium.Sometimes it even precipitated the end. At Paimio, quite literally.
Tuberculosis made modern architecture modern. It is not that modern architects made modern sanatoria. Rather sanatoria modernized architects. Aalto was a neoclassic architect before his “conversion to functionalism” in the 1927 competition entry for a tuberculosis sanatorium at Kinkomaa, Finland—an unrealized project of horizontal lines and wide terraces for the cure, that anticipates Paimio. For Aalto, the sanatorium was not architecture in the service of medicine but a form of medicine in its own right—a medical instrument: "The main purpose of the building is to function as a medical instrument… The room design is determined by the depleted strength of the patient, reclining in his bed[3]."
Aalto himself had been sick at the time of the competition for the building and claimed that having to lie in bed for an extended period of time had been crucial to his understanding of the problem. Architecture was always conceived for the vertical person but here was a client permanently in the horizontal. [FIG. 6] The whole design of the room and the building had to change accordingly. Light fixtures could not remain in the ceiling irritating the eyes of the occupant lying in bed and for whom the ceiling had all of a sudden acquired maximum importance—a new kind of façade perhaps. The view through the window to the forest outside also had to be calculated from the point of view of the bed. In the terrace the low parapet and thin rail above allowed the eye of the horizontal person to travel far above the forest.
The colors of the room and the building had to be thought in these terms too. Soothing “quiet, dark hues” of blue for the ceiling. The walls in lighter shades. Bright canary yellow in the reception booth by the entrance and in the linoleum of the lobby, staircase and corridors evoked “sunny optimism even in cold, cloudy days.”[4] Psychological factors were also carefully considered: "An extended period of confinement can be extremely depressing for a bed-ridden patient. …A tuberculosis sanatorium is, to all intents and purposes, a house with open windows[5]."
The hospital has to be thought as a new kind of house. And in reverse, the generic house needs to be a sanatorium. Aalto later wrote: "I was able to discover that special physical and psychological reactions by patients provide good pointers of ordinary housing…. To examine how human beings react to forms and constructions, it is useful to use for experimentation especially sensitive persons, such as patients in a sanatorium[6]."
The bodily and psychological sensitivity of the sick person is used to recalibrate architecture. Even the specialized furniture became ordinary every day pieces. If the cantilevered birch wood Paimio chair for example, was designed to open the chest of the patient, allowing them to breathe easier, soon enough that chair became everybody’s chair. Likewise with the rest of the furniture specially designed for Paimio: “The sanatorium needed furniture which should be light, flexible, easy to clean and so on. After extensive experimentation in wood, the flexible system was discovered… to produce furniture which was more suitable for the long and painful life in a sanatorium.”[7] A workshop was set up with a local company to carry the first experiments and in 1935, barely two years after completing Paimio, Alvar and Aino Aalto founded the Finish furniture company Artek, with “the ambition to support and nourish human beings’ physical and psychological wellbeing8]."
The reference point was the seriously ill. Aalto claimed that the architect had to design for the person in the “weakest position.” The tuberculosis patient becomes the model for modern architecture.  In other words, sickness was no longer seen as the exception but as the norm—and varying degrees of sickness define the human condition. The modern subject has multiple ailments, physical and psychological, and architecture is a protective cocoon not just against the weather, and other outside threats, but in modernity, more notably about internal threats: psychological and bodily ailments.
Aalto compared his experiments in Paimio and their application to everyday use to the “exaggerated” forms of analysis that scientists use “in order to obtain clear more visible results,” such as “stained bacteria” for microscope examination.[9] He sees design as a form of medical research with the sanatorium acting as a kind of research lab for modern architecture—a way of testing architecture, looking at what has been hidden, exposing the invisible forces.
The relationship between architecture and the human body is always intimate. With modern architecture this intimacy deepens as the body now includes invisible microbes. Indeed, the real clients of modern architecture are invisible. Sigmund Freud, X-ray, bacteriology and the germ theory of disease all emerged in the same short period of time, and they are all about looking inside, acknowledging the invisible: the unconscious, the skeleton, the microelement of bacterial and the bacillus of TB.

Architecture, likewise, turns itself inside out. The threat is no longer outside but inside in the invisible. The micro scale of the bacteria becomes the base for furniture, houses and cities: the micro and the macro: the bacterium and the city. Cities were suddenly thought to be teeming with unseen occupants that in that sense became the new clients of modern architecture and urbanism.
The architect became a bacteriologist. Architectural itself became bacterial. As Le Corbusier put it, he needed to do “laboratory work,” “isolating his microbe” until it appear in “undisputable clarity.” Those are all his words, then he goes on to say that with this one can make a “diagnosis” and draw up the fundamental principles of modern city planning. Modern architecture goes from microbe to city and back.[10]
Modern architecture lying down is not just the new paradigm of seeing architecture from the point of view of those in the weakest position, the horizontal patient as paradigmatic client, but seeing the human species itself as weak, fragile, vulnerable, and immersed in bacteria. The human is no longer the center of a geometric system, but permanently hospitalized—a complete reversal of Leonardo da Vinci’s visualization of the Vitruvian man or even its reincarnation in modern times in figures such as Le Corbusier’s Modular Man. The clearly defined athletic, vertical, gendered, man gives way to a multiplicity of age, sexuality and physical and mental conditions in multiple combinations and collaborations with other species.  Sickness is not the negative term but the generator of new potentials, the very engine of modernity.

In the book  "Soutenir. Ville architecture et soinpublished by the Pavillon de l'Arsenal in 2022.

Beatriz Colomina
Beatriz Colomina is historian and theoretician of architecture. She is the founding Director of the Program in Media and Modernity at Princeton University, Howard Crosby Butler Professor of the History of Architecture and Director of Graduate Studies at the Escola Técnica Superior de Arquitectura de Barcelona, Universidad Politécnica de Barcelona

1. Benjamin Ward Richardson, “Health in the Home,” introduction to Shirley Forster Murphy (ed.), Our Homes and How to Make them Healthy (London: Cassell & Company, 1883, 5.
2. Vitruvius Pollio, The Ten Books on Architecture, trans. Morris Hicky Morgan (Cambridge, MA: Harvard University Press, 1914), p. 20.
3. Alvar Aalto, in a lecture in Italy describing Paimio, 1956, quoted in Schildt, Alvar Aalto: The Complete Catalogue, pp. 68–69. Text in the Aalto Archives.
4. Karl Fleig and Elissa Aalto, eds., Alvar Aalto: Das Gesamtwerk / L’oeuvre compléte / The Complete Work, vol. 1, 1922–1962 (Basel: Birkhäuser, 1963), p. 39.
5. Ibid.
6. Alvar Aalto, “The Humanizing of Architecture,” Technology Review (November 1940). Also in Architectural Forum, 73 (December 1940), pp. 505–506. Reprinted in Goran Schildt, Aalto in His Own Words (New York: Rizzoli, 1998), pp. 102–106.
7. Aalto, “The Humanizing of Architecture,” in Aalto in His Own Words, p. 104.
8. “The Artek Manifesto,” Artek Company, Helsinki. See also Alvar Aalto, vol. 1, pp. 43 and 66.
9. Aalto, “The Humanizing of Architecture,” in Aalto in His Own Words, p.15.
10. Le Corbusier, Precisions On the Present State of Architecture and Urban Planning, trans. by Edith Schrieber Aujame (Cambridge: MIT Press, 1991), p. 143. Translation of Le Corbusier, Précisions sur en état present d’architecture et de l’urbanisme, (Paris: Crès et Cie, 1930).