When the pioneering English nurse Florence Nightingale was sent to Constantinople in 1854 during the Crimean War, she was appalled by the conditions she found in the British field hospital there, which had been built on an open sewer, and whose wounded were dying at a much faster rate than the soldiers on the battlefield.

She introduced new sanitation standards, including clean air, clean water and proper sewers, and quickly reduced the death rate by two thirds. In 1859 she wrote Notes on Hospitals, which is thought to be the first treatise on modern hospital planning. She advocated that hospitals have open wards of limited length and width, high ceilings, natural ventilation through large, operable windows, beds arranged no closer than 3.5-feet apart and surfaces that could be quickly washed and dried.

What Nightingale proved was that the form of a building could lead to much improved outcomes in the health of patients.

Her wisdom resonates today in the exhibition, “Design and Healing: Creative Responses to Epidemics,” on view at the Cooper Hewitt, Smithsonian Design Museum. Organized before the onset of the Covid-19 pandemic by Ellen Lupton, senior curator of contemporary design, in conjunction with the architect Michael Murphy, founder of the MASS Design Group of Boston, the exhibition deepened over time to show how nurses and doctors, designers and artists, engineers and architects, and even regular citizens—like the neighbor who stitched together homemade masks—responded to the crisis with an astounding creativity and resourcefulness.

Collective Data Portrait by Samuel Stubblefield
The multimedia installation Collective Data Portrait by Samuel Stubblefield, commissioned for the show, extracts human biometrics and renders that data as a work of art. Cooper Hewitt, Smithsonian Design Museum. Photo: Matt Flynn © SI

Health Design Thinking, second edition: Creating Products and Services for Better Health

The book explores the special overlap of health care and the creative process, describing the development of such products and services as a credit card–sized device that allows patients to generate their own electrocardiograms; a mask designed to be worn with a hijab; improved emergency room signage; and a map of racial disparities and COVID-19.

It is an exhibition that delivers a refreshing change of spirit from the steady drumbeat over the past two years of pandemic doom and gloom. Despite government and policy failures, the toll on frontline workers, the misinformation campaigns, the supply chain failures and the fast-approaching toll of one million U.S. deaths, both the show and its catalog offer plenty of thoughtful insight into the crucial innovations and real-time inventions that have materialized in the face of desparate need.

A dramatic multimedia installation kicks off the exhibition. The museum-commissioned work Collective Data Portrait by the artist Samuel Stubblefield reveals an unseen beauty that takes place within each human body. The life-size virtual mannequin generates an ambient sound (Stubblefield worked with Grammy Award-winning performers) and a light installation based on the artist’s photographs and films recorded from brainwave data. 

“We wanted to do something at the beginning of the show that expressed community and the beauty of the human body before exploring disease and things that go wrong,” says Lupton. “We wanted a sense of entering a world of calm, and peacefulness, and beauty.”

Clear-fronted mask
A mask helps the deaf or hard of hearing visualize speech and helps enhance conversation among multilingual people, teachers and therapists, who can communicate more easily when their mouths are visible. Rebirth Garments Mask, 2021, Sky Cubacub, Rebirth Garments
Essential Mask Brace
Low-cost surgical masks offered excellent filtration but did not fit tightly enough for the same protection as K95s. The Essential Mask Brace, made of silicone, proved to be affordable and to provide the necessary snug fit. Essential Mask Brace, 2020, Sabrina Paseman, Katherine Paseman, and William Paseman, Fix the Mask

Meant to illustrate how brain waves could be measured, the piece introduces the first section of the show, which is about personal monitoring devices, both for hospitals and for use at home.

“Such devices are a huge part of the future health landscape,” explains Murphy, the architect who leads the MASS Design Group and who specializes in rural hospital design in underdeveloped countries. Stubblefield’s sculpture is about “how we understand the micro interior of our own bodies.”

The array of newly realized medical devices adorning the gallery—manual ventilators, oxygen monitors, portable Covid tests, nasal swabs, zero-waste (recycled material) scrub sets and personal protective gear, including hijab-designed face masks and a homemade mask from a neighborhood collective—exemplifies how necessity is the mother of invention. There is even a plastic sphere that fits over the human head, reminiscent of a 1950s space helmet, but this one, the iSphere crafted in Germany in 2020 by Marco Canevacci and Yena Young, provides face-shielding safety from disease. A clear mask helps people who are deaf visualize speech and a prototype of a low-tech, affordable plastic negative-pressure ventilator from Bangladesh acts as a less-oppressive iron lung.

External Negative Pressure Ventilators
A family in Bangladesh designed and manufactured a negative pressure ventilator, which is gentler on the body than complex hospital ventilators and can be used for home health care. Shaash Negative-Pressure Ventilator, 2021, Karnaphuli Industries Limited

These, and more, are covered in the catalog, Health Design Thinking: Creating Products and Services for Better Health, by Lupton and Bon Ku, director of the Health Design Lab at Jefferson University in Philadelphia. The compendium came out in the spring of 2020 just as the pandemic hit, immediately prompting Lupton and Ku to began work on their second edition, which they labeled “a fieldguide for rapid-response design.”

Perhaps the most surprising takeaway from the show is one of Nightingale’s prescriptions—the curative importance of clean, healthy air.

Historical and contemporary examples of architecture sleekly designed for healing includes Paimo Sanatorium in 1933, which Alvar and Aino Aalto designed in Paimo, Finland, for people suffering from a tuberculosis epidemic. To stop the spread of the disease and to help in the cure, the hospital’s tall, narrow, elegant modern wings and south-facing, open-air terraces, are designed for natural cross ventilation and to allow for patient access to sunlight and open air. The interiors and fixtures were custom designed, including the now-classic Paimo Lounge Chair 41. With its slanted high birch and laminated plywood back that straightens and supports the patient’s vertebrae, the chair helps to facilitate breathing.

Installation View, Plastic Sphere Helmet
The array of newly realized medical devices on view include manual ventilators, personal protective gear, hijab-designed face masks, oxygen monitors, portable Covid tests, nasal swabs, zero-waste (recycled material) scrub sets and even a plastic sphere that fits over the human head, reminiscent of a 1950s space helmet. Cooper Hewitt, Smithsonian Design Museum. Photo: Matt Flynn © SI

Contemporary hospital design projects, especially the work by the MASS Design Group, a 250-person nonprofit enterprise that just won the American Institute of Architects 2022 Firm of the Year Award, are especially compelling. Architect Murphy and his firm partner with local communities abroad to build hospitals in low-income, underdeveloped, pandemic-stricken areas in Rwanda, Haiti and, currently, Bangladesh and Liberia.

In 2008, when Murphy was an architecture student, he volunteered to help Paul Farmer and his organization Partners in Health build a sustainable, low-tech hospital to prevent the spread of tuberculosis and to control outbreaks of cholera, Ebola and coronavirus in Rwanda. “This was a nonprofit organization that didn’t typically have access to the services of designers,” Murphy recalls. “We had to raise the money to work there, which included some of my student loan and a grant from Harvard College. Today we partner with philanthropists who support 20 percent of our architectural practice.”

Paimio Sanitorium Chair
The classic Paimio Lounge Chair 41, designed in Finland, for people suffering from a tuberculosis epidemic, straightens and supports the patient's vertebrae to help facilitate breathing. Aino Aalto, ca. 1932, chair: Alvar Aalto; photograph: Alvar Aalto Foundation

In Rwanda, he learned that hallways are the problem in the transmission of drug-resistant tuberculosis. As patients waited in halls without windows or air flow, their coughing would reinfect one another, promoting drug-resistant variants that they then brought home to their familes.

So Murphy designed buildings with tall ceilings and open wards with beds that faced generous windows, connecting patients with nature and the outdoors. Instead of enclosed hallways, circulation and waiting areas were outside, in covered areas (to protect from rain). He learned to avoid building elevators, sophisticated machinery and air filtration systems because they break down; and in remote areas in underdeveloped countries, they cannot be readily fixed.

Such lessons are described in The Architecture of Health: Hospital Design and the Construction of Dignity, another excellent guide that accompanies the show, by Murphy with Jeffrey Mansfield and the MASS Design Group. The book traces changes in hospital design from antiquity to the present, beginning with what he calls “inherited structures” like chapels retrofitted with beds in the Renaissance. Packed with chronicles (and critiques), it includes a study of Detroit architect Albert Kahn’s “hospital-as-factory” buildings at the University of Michigan, “block hospitals” of the 1950s that occupyied an acre per floor like Bellevue in New York City, and the closed systems of the mega hospitals of today.

During the pandemic, Murphy was asked to work with New York City's Mt. Sinai Hospital.

Gheskio Cholera Treatment Center, Port-au-Prince, Haiti
In 2015, the MASS Design Group created a cholera center in Port-au-Prince, Haiti. The facility is designed to treat 100 patients at a time and is made of materials chosen for their durability, infection-resistant properties and ability to be cleaned extensively with chlorine. GHESKIO Cholera Treatment Center, 2015, MASS Design Group. Photo: © Iwan Baan

In his book he explains how Covid patients in Mt. Sinai had to be moved from its ultra-modern air-sealed wings to a 1930s bed tower with windows that could be opened, retrofitting those spaces with in-room filters.

“We helped doctors create tools to be more spatially aware, to see how disease was transferred,” he says. “We showed how spaces could be reconfigured, using crayons to mark safe and contaminated spaces so the doctors and nurses could understand where they needed to be masked.”

Now he studies how buildings keep us from breathing effectively and how access to breath is modulated by the buildings we are in. Murphy is adamant about what he calls “the right to breathe.”

“The pandemic has prompted a public reckoning with the role of buildings in shaping our health,” he writes in his book. “Recent reporting is waking up to the crisis of breathability in buildings, raising questions about our dependence on mechanical systems and the lack of access to fresh, natural air.”

He continues: “Is it really acceptable that our built surroundings are entirely dependent on ever more complex mechanical systems that pollute the environment and, if they should fail, prevent us from breathing? At our peril we have ignored Nightingale’s prescriptions.”

“Design and Healing: Creative Responses to Epidemics” is on view at the Cooper Hewitt, Smithsonian Design Museum in New York City through February 20, 2023.