A Culture of Caring

Designing hospitals in the global marketplace requires the ability to blend state-of-the-art solutions with a sensitivity to local customs, rituals, and religions.

Growing up in his Iraqi émigré parents’ London home, Mohammed Ayoub learned to speak both English and Arabic from an early age. He also learned to read the unspoken cues that mined the border between his two cultures—sometimes by stumbling onto it. “I remember one time, I accidentally took a glass from a tray with my left hand,” recalls the British-educated architect. “It’s something that wouldn’t even draw notice in England, but that’s just not done in Arab culture. It was so bad that the next time the tray came around, they simply skipped me.”

That youthful faux pas, still discomforting 30 years later, has helped Ayoub develop a cultural sensitivity that he channels into his work with HDR, an architecture and engineering firm with health-care projects in China, India, Saudi Arabia, South Korea, and the United Arab Emirates. “These regions are very eager to adopt the best the West has to offer in technology and design,” says Ayoub, who recently returned from Abu Dhabi where an HDR-designed 2.4-million-square-foot Cleveland Clinic hospital is scheduled to open next year. “But they’re also grounded in their own cultures and histories. It’s our job to observe and reconcile the differences.”

For health-care designers working in far-flung regions, learning to patch the seams that split as West meets East (and Middle East), is as important as calculating volumes, systems, and energy loads. In China, designers need to produce structures that integrate best-in-class Western technologies with time-tested traditional Chinese medicine. In India, developers want new hospitals to conform to the thousand-year-old practice of vastu shastra—the Hindu version of China’s feng shui. In the Islamic world, facility plans must include prayer and ablution rooms, along with gender-specific waiting areas. And plans must be jiggered to ensure that not a single toilet in any facility faces Mecca.

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The Cleveland Clinic Abu Dhabi (CCAD) will offer patients a level of care that equals and in many ways exceeds that available in the West, with cutting-edge technologies, spacious patient rooms, and sweeping lobbies. Its signature feature, a central patient tower, features a double-skin facade that circulates the facility’s mechanical exhaust and reduces the building’s cooling costs by up to 30 percent.

But there are elements in Abu Dhabi—and in hospitals all over the Gulf—that can only be expressed in local argot. Ample use of wood and stone, and a desert palette evoke the peninsula’s arid landscape. Glass panels celebrate light, and commemorate the discovery of that glass in ancient Mesopotamia. There are prayer rooms and waiting rooms, both segregated according to gender. There are dedicated areas in patient rooms for families who—as in nearly all cultures outside the U.S.—often take a prominent role in healing.

While statistics show that family involvement produces better patient outcomes, their presence does make for challenges. “We’ve seen families removing all the furniture out of patient rooms and bringing in a carpet, and then having lunch with the patient on the floor with all the tubes still in him,” says Newton Chase, a former HDR project director for design now serving as senior director of facilities and general services at CCAD. Chase eventually created an alternative family space, leveling all the seating areas, purchasing hospital beds whose side rails could be concealed, and installing interior and exterior window blinds to afford the families their privacy. “There’s a market for a Western imprimatur for health care in this part of the world,” he says. “But there are certain things Western design just can’t accommodate.”

In Saudi Arabia, where HDR is designing two of the five medical cities that the Ministry of Health is building across the kingdom, Ayoub and his team got mired in a tug of war between efficiency and modesty. They also learned that things are not always as they appear, even when designer and client speak the same language. At an early meeting for the King Faisal Medical City, a 1,350-bed complex located in the southern part of the kingdom, HDR discussed the merits of bathroom placement in patient rooms. According to the firm’s evidence-based design team, an outboard placement was the most efficient; setting the bathroom near the patient bed and in clear view of caregivers helps staff monitor the patient and allows them to move more efficiently through the room.

Ayoub, however, wasn’t entirely convinced; he thought an inboard placement was the better choice, particularly in a region where privacy is so highly valued. “If you make an inboard placement, you’ll create a sort of vestibule in the room,” he explains. “It’s a bit more space to cross, but it’s not going to impede staff treatment.”

Last May, in Saudi Arabia, the team presented its findings to their KFMC clients, featuring PowerPoint slides illustrating the clear advantages of outboard bathroom placement. During the presentation their Saudi clients nodded enthusiastically; one even said that an outboard bathroom placement was a clever idea. Given the reception, the team congratulated itself on selling their clients on an important concept. But later, just after the meeting dissolved, one of the directors pulled Ayoub aside to tell him, discreetly, that they’d prefer the added privacy of inboard toilets.

“There are a slew of customs and practices that we need to learn to observe,” says Ayoub, whose Arabic language and cultural fluency are particularly valuable in the Gulf region. “Generally, saying ‘no’ is not accepted. You have to find a delicate way to do it. For the King Faisal project, we were brought in to review their plans. When we presented our study, they knew we were telling them the plans weren’t very good. But we didn’t state that directly. The last thing they want is an arrogant American firm telling them how wrong they are. As a result of our sensitivity, we were hired to design the project.”

Along with modesty and family presence, Gulf hospitals need to acknowledge a deep spirituality among patients, staff, and physicians. For the iconography at the KFMC, Ayoub’s team began with Islam’s eight-pointed star. The figure is derived from the exercise of trying to square a circle, and reflects man’s humility and imperfection before the divine. Over a period of weeks, the team worked with the traditional icon, refining, articulating, and abstracting the figure, rotating its primary angles towards Mecca. Eventually, they derived a geometric graphic element that appears on the hospital facade and in canopies suspended over all the entrances. “To someone outside of the culture it looks simply like a nice pattern,” Ayoub says. “But to someone inside the culture, it’s instantly familiar and comforting.”

Perhaps the most striking differences Ayoub and his colleagues encountered in hospitals around the globe, is in the approach to death. In the United States, hospital morgues are usually small rooms where bodies are prepared for burial out of sight. In Korea, morgues provide large funeral spaces where family and friends can bring flowers, pay respects before a photograph of the deceased, and enjoy a meal in the adjacent banquet hall. In the Arabian Peninsula, they serve as sacred space, where the deceased’s body is washed and wrapped for burial in accordance with Islamic rites. Autopsies, so common in the U.S., are rarely performed, and then only in the case of suspected foul play. “One of my aunts died after she’d finished her university studies,” Ayoub recalls. “She was buried that evening, without any investigation. Here, they would have tried to determine the cause of death. In our tradition, her death was seen as God’s will.”

Modesty and gender divisions are rigidly observed during the traditional Islamic burial ceremony: male relatives wash and wrap male bodies; females prepare female bodies. Not even the bereaved spouse is allowed to see his or her beloved until the rite is finished. Morgues that can accommodate this pre-burial ritual are standard across the Middle East. But they were completely new to American hospital planners. In their initial bid for the CCAD, the HDR team had sketched a U.S.-style morgue. But over the course of several weeks, the team arrived at a deeper understanding. “In Islam, the notion is that even though the body might be dead, the spirit does not rise until the body has been buried,” he says. “During the ritual preparation in the morgue, everyone is aware that there is a spirit in the room. They know they are being seen by something they cannot see. The space you design needs to reflect that.”

Spirit defines and animates health care spaces in all parts of the world—even in the technologically transfixed U.S.—but it does so in wildly different ways. In Beijing, where HDR has master-planned a monumental medical center that, when finished, will cover an area quarter the size of Manhattan, the “wow factor” is almost as important as wellness. “When a person enters a hospital in China, he wants to experience awe,” says Brian Kowalchuk, HDR’s design director. “The architectural grandeur, combined with the presence of traditional medicine, and the presence of researchers on campus, all contribute to a sense of well-being.”

Bordered by Beijing’s Grand Canal (the world’s oldest transportation system) on the west and south, and by the Chao Bai River on the north and east, the 12,000-bed Beijing International Medical Center will celebrate state-of-the-art Western medicine and traditional Chinese medicine in equal measure. The campus will house world-class education and research facilities, yet every entrance—along with at least 90 percent of all patient rooms—will face south according to feng shui dictates. Each of the BIMC’s five internal parks will be dedicated to one of China’s traditional five elements: water, wood, fire, earth, and metal.

“The drivers in China are different from those in the Middle East,” Ayoub says. “They’re not just interested in providing their citizens with top-notch care. They want to show that they can build something that no one else in the world has.”

The transfer of medical design and technology from West to East should improve health care for the residents of Asia and the Middle East, and capture a substantial slice of the lucrative medical tourist traffic—a market that has heated up since the U.S. tightened its visa protocols following the World Trade Center attacks. But many professionals believe there are traditions and practices from these regions the West would do well to consider. “The first hospitals ever built were in this region,” says Dr. Ahmed M. Alnammi, CEO of the King Faisal Medical City-South Region. “And they treated the patient as a human being, as a whole human being living in a specific place and culture. It’s only modern medicine that takes him out of that place. We need to remember that when we build hospitals.”

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