A hospital building can feel timeless. While the halls echo with the sound of ultramodern equipment, basic structural ideas might be familiar to the first practitioners of modern medicine in the 19th century, or to some degree, even the denizens of Europe’s first hospitals in the Middle Ages. Yet each era has left its mark on the way these buildings are built and used—some for the better, some for the worse.

A family tragedy led architect Michael P. Murphy, Jr. to start thinking about hospital designs and where they fall short. Murphy is the founding principal and executive director of MASS Design Group, and one of the authors of The Architecture of Health: Hospital Design and the Construction of Dignity. The new book explores the history and possibilities of hospital design and serves as an accompanying text to the exhibition “Design and Healing: Creative responses to Epidemics,” on view at the Cooper Hewitt, Smithsonian Design Museum in New York City through February 2023.

Q: What was the genesis of The Architecture of Health project?

MURPHY JR: When I was studying architecture at Harvard, my dad got very sick with cancer. One day, I walked out of this studio and realized I hadn’t slept in three days or checked my phone. I had dozens of missed messages—all from my mom. “He’s alive, but he is in the hospital.” All I could think about was losing my father while I was busy, I don’t know, designing some meaningless speculative structure at a Brookline train station.

That began my journey into confronting the design realities of the medical system. I walked into this hospital building and was shocked to see how little the environment had been thought about from the patient’s perspective. The things we were learning as architects, which were so essential to public spaces, had somehow been lost here. And yet hospitals are the most expensive, most well-funded spaces we have, where the most scientifically rigorous thinking takes place. I left that experience thinking, “I’ve got to work in hospital design.”

Q: That’s one premise of the book—that hospitals are meticulously engineered, but not necessarily for the patient. Do you have examples of that?

MURPHY JR:  There are specific things, like blaring lights that are always on or noises that are keeping people awake. There’s furniture designed to be clean, but not really to be sat on. There’s the lack of access to natural air and light, the hallways with no end and no windows. The sum total of these design decisions remind you that you’re an institution first, and place of care only as a distant afterthought.

Hospitals in the United States were also the first buildings to really explore possibility of being what we call “mega structures.” These are structures that take up not just one but many city blocks at once. While this has opened the door to building on specialized wards for, say, children or cancer care, it has also created a backwards way of thinking about access to, let’s say, natural ventilation or fresh air

Q: The idea of breathability is important to you in the book. Why?

MURPHY JR: It makes sense that hospitals were first to seal themselves off from the outside world, where contamination is uncontrolled. This led to an entire built world where the interior is air-conditioned and sealed off. The mega structures compounded this trend. But in addition to feeling claustrophobic for people inside it, this closed off approach isn’t always the best approach to keeping people healthy.

My colleague Jeffrey Mansfield and I started to look at sanatorium hospitals, designed in the 19th century to help with tuberculosis, an airborne disease like COVID-19. We started to see the development of different types of hospital architecture. Very specifically, we saw thin buildings, buildings with cross-ventilation, which could dissipate a threat. We thought there might be a potential there to turn back the clock, a rationale to make a hospital building light and “breathable” again.

Q: Is this what influenced your collective’s work in Rwanda?

MURPHY JR: Yes. We worked on a new hospital with Partners In Health, led by the late Dr. Paul Farmer from Harvard Medical School, and the Rwanda’s Ministry of Health. In the past, multi-drug resistant tuberculosis (MDRTB) was spreading within Rwanda’s hospitals because patients were coming in with one strain of tuberculosis and then infecting one other with different strains. That was happening inside waiting rooms, in the hallways and in every unventilated space.

The solution was to turn the hospital inside out. We put people on the outside, and made them wait outdoors, since the weather is largely temperate there. The rooms were all allowed to have lots of natural ventilation, and we ended up with buildings that could finally breathe.

Q: Are there examples of things going right in hospital architecture?

MURPHY JR: Absolutely. There’s Maggie Centres in the United Kingdom, an independent charity that has set up a specific kind of space for patients who are dealing with cancer. These spaces are on hospital grounds and patients can get treatment and nourishing experiences there without having to wade through the vast institutional landscape of the hospital itself.

There are also inspirations from the past few, hectic years. We were working with Mount Sinai Hospital during the COVID-19 outbreak in April 2020. It was a case study of how nurses and staff reconfigured the space on the fly, while trying to address a health crisis. We found that some of the older, less specialized structures provided more flexibility or adaptability, and that’s exactly what was needed.

Medicine is moving so fast, and frankly medical spaces’ biggest needs may be to adapt to those changes. Right now, when design for buildings, we think of them as 100-year structures. But what if we thought of them as structures that will adapt and change every 10 to 15 years? That kind of flexibility—as well as an openness to rethink fundamental changes like breathability—can pave the way forward. We can start to build hospitals that not only meet the clinicians changing needs, but serve the needs of patients to be in a healing space, to receive that care with ease and dignity.