Editorial: Health Beyond the Hospital
Built in the 1890s, the Royal Victoria Hospital in Montreal is an architectural masterpiece, not because of flying buttresses or dizzying heights or daring cantilevered terraces, but for a reason that is invisible: the way air moves through the building. Constructed in an era plagued by typhoid and other deadly diseases, the design of its "Nightingale wards" effectively encased each patient in a bath of fresh air thanks to an ingenious but hidden ventilation system that enabled the building to "breathe in" fresh air, move it through the wards, and "exhale" the infected air. As Annmarie Adams observes in a recent issue of Harvard Design Magazine, the hospital resembled giant lungs, almost as if it were breathing for the patients within who struggled to catch their breath. These unnoticed pneumatic pathways were "technologies of healing."
Adams, along with her graduate assistant Don Toromanoff, wanted to try to picture the invisible. So they created a computer simulation that illustrated the air movements in the Royal Vic. As they pieced together the evidence, the life-giving circulation of the building came into view. It was an illustration, Adams notes, of a new perspective on buildings offered by literary theorist Steven Connor: we should "think of buildings as articulations of air and of air as the animator of buildings." Connor put it this way:
Air has traditionally been, not the antagonist of the building, but its unobserved complement. Buildings, like utterances, are articulations of the air. No structure that contained no space, had no cavity in it, could qualify as a building. And yet, though buildings include, enclose and admit air, that air is not thought of as belonging to the building.
But as the Royal Vic illustrates, air is integral to the building. While this was an institution built to heal and care, where patients were attended by doctors and nurses, all of that would have been for naught if the very air they breathed was noxious. The architect of the hospital was attentive to the invisible.
There are invisible aspects of healthy social architecture too. Like Adams and Toromanoff's illuminating computer simulation, I hope Comment helps you see what might otherwise go unnoticed—those currents and dynamics of society that are essential but often ignored because they are banal and taken for granted. While headlines focus on spectacles and draw our attention to controversy, the things that make a society tick hum away in the background, in the quiet of life-giving homes and the energy of formative classrooms, even in the sewers and transportation networks that enable us to share life in common. These and a thousand other quotidian realities are nonetheless the oxygen of a healthy society.
Health is one of those key factors, part of the air a society needs to stay alive. Healthy social bodies require citizens who have healthy bodies. A good society will work like the Royal Vic: in a million hidden ways, it gives us fresh air to breathe since physical, bodily health is a baseline for flourishing and prosperity. A healthy society not only sustains but also heals.
But that means health is not just the province of the hospital, or even just the health-care industry. Health is a distributed good that shows the interdependence of society, the partnerships between various spheres. Just as the nurses and doctors and patients at the Royal Victoria Hospital were dependent on the architect, engineers, and plant managers for their medical work, so the health-care industry is dependent on homes, families, churches, and schools to cultivate a healthy citizenry and a healthy society. If we cede all responsibility for health to Medicine, Inc.—which, in many cases, means ceding health to Government & Co.—we only end up sequestering the distributed good of health within a sphere that can't bear its weight. Even if health is a shared public good in which we are all invested, good health also begins at home, the incubator of habits.
As Matthew Loftus argues in this issue, the best thing we can do for a healthy society, and for the health-care industry, is to distribute power and democratize health, returning it in many ways to families, homes, and other subsidiary communities who are closer to those who need care.
Vast sums of money are spent on behalf of patients every day, but the power such money represents usually bypasses the powerless. There is incredible potential both for better health outcomes and more community empowerment, but in order to accomplish these the health-care system must democratize primary care and shift the power from centralized government bureaus and massive health-care institutions to the communities where the sick live. There must also be a commensurate shift in the locus of health-behaviour change from offices and hospitals to homes and streets.
This is thinking about health that takes subsidiarity seriously. But it also reflects Christian thought that takes the body seriously and sees physical wellness as a feature of shalom.
On the other hand, in our conversation with Margaret Somerville in this issue, she rightly cautions that in secular societies, health can become its own sort of idol, turning into the "secular religion" she calls "healthism." "A lot of the individual, communal ... and societal functions that religion used to construct and carry," she comments, "we're now using health care to do." While we often expect too little from health care, we can also go wrong by expecting too much. (A lesson further explored in Todd Billings's review of Being Mortal by Atul Gawande, also in this issue.)
This issue of Comment invites you to consider aspects of health and health care that don't always get our attention. While Christian communities have (rightly) focused on specific hot-button issues in bioethics (abortion, euthanasia, genetic testing, etc.), there has been less attention to the way health-care policy, practice, and technology impinges on systemic factors of justice, flourishing, and the common good. These mundane, unnoticed aspects of health deserve more thoughtful attention from Christians interested in public life. The delivery, distribution, and methodologies of health care have a significant impact on quality of life and human flourishing. These "background" issues of health-care policy and practice overlap with matters of human dignity and our care for those made in the image of God who are especially vulnerable when they are ill. Insofar as Christians should seek the welfare of the city and wellness for our neighbours, we should be invested in national conversations about health-care policy and not just "headline" issues. Christian concern for human dignity will largely be invisible—behind the scenes and at the bedside. But that doesn't mean such labour isn't "public."
A coda to the Royal Vic story is illustrative. Much of Annmarie Adams detective-like unearthing of the ventilation story depended on the correspondence between the architect, Henry Saxon Snell, and the chairman of the board, John Abbott. That second name might ring a bell for Canadians: Abbott, in fact, served as the third prime minister of Canada, in 1891–92. But in 1899 he began a passionate correspondence with Snell about—you guessed it—the ventilation of their new hospital in Montreal. Abbott prevailed in their disagreement, and in many ways shares responsibility for the marvel of the Royal Victoria's life-giving ventilation. Perhaps there are more parallels between Abbott's public life and his HVAC advocacy: both, we could say, were ways of fostering healthy social bodies.