Editorial

Treatment is a collaboration between e-flux Architecture and the Institute for the History and Theory of Architecture (gta), ETH Zürich, featuring contributions by Annmarie Adams and Sally Chivers, Fiona Kenney, David Theodore, Magaly Tornay, and Brittany Utting.

The institution of the hospital has been the dark planet around which many debates of the past two years have orbited, with calls for their protection displacing claims about individual health in national lockdowns. Images of overcrowded Intensive Care Units and sports stadiums converted into field hospitals were visual ciphers for the entire pandemic. What such images and debates occlude, however, is that hospitals are not particularly good at handling infectious diseases. Hospitalization is the last resort for the treatment of an infectious patient, not for the sake of the patient, but for the hospital itself. Putting a contagious person into a complex, highly centralized institution full of sick people is not actually a good idea, from epidemiological and administrative perspectives.

What, then, are hospitals for? It depends on when you ask. The institutions—or rather, the cluster of organizations—that this familiar word denotes have redefined themselves many times over, passing in and out of focus as their determining conditions also change. In contrast to other eras, the twentieth century hospital established its authority above all via improvements in surgery. The triumph of medicine in the first decades of the twentieth century can be understood as the transition from care to cure, with pharmaceuticals as the crucial means, and the hospital as a site only of the most radical intervention. The previous role of the hospital—as a palliative institution—gradually faded away. It is perhaps this very instability in its role that has made the maintenance of familiarity around the term so necessary.

Around the turn of the twentieth century, as the role of the hospital as a palliative institution gradually faded away, the hospital became a germinal site for the architectural avant-garde, the source of many now-familiar innovations from chrome-tubed furniture to mechanical ventilation. In the mid-twentieth century, however, the typology of the hospital was seemingly demoted within architectural discourse, a disappearance so muted that it was barely noted. This was in no small part due to the increasing complexity of hospital design. Compliance with medical standards meant that their design became the preserve of specialist firms and engineers rather than general architects. Even taking into account the notable exception of some extraordinary megastructures, the majority of postwar hospitals became easier to understand as infrastructural projects, rather than as architectural ones.

If the rise of the modern hospital over the course of the twentieth century can be understood as a transition from institutions of care to cure, the reality of medicine in the twenty-first century has been the gradual return of care. Cure implies a solution, a remedy, and restitution, whereas care, is palliative, ongoing, and compensatory. From cancer to psychiatric illnesses, populations today are increasingly beset with illnesses that have no cure. Within medical organizations, the return of care has had a troubling effect on spatial and hierarchical relationships that define the understanding and operation of hospitals. Through the lens of care, the question of how to judge when doctors don’t care enough (or care too much), and where to set the limits of institutions begin to shift in ways that we cannot possibly answer, but that we can trace historical trajectories for.

Of all the fields of institutional medicine, psychiatry and geriatric care present the ethical dilemma of care in its most intractable form—the impossibility of drawing a fixed line between “attending to,” in the sense of solicitude, and “watching over,” in the sense of surveillance. Care, in this sense, can be understood as a particular kind of attention. Unlike mere surveillance, care is not a scalable resource. Care work cannot be done by an app, nor can solicitude be left to devices. And although the capacity for care is, to an astonishing degree, renewable, those who engage in care work can become exhausted, or “numbed,” by the proximity of suffering, specifically when they are no longer able to believe in the symbolic credibility of the institutions in which they serve.

Architecture responds to the inherent contradictions and problematics of medical institutions by presenting itself as a potentially endless sequence of improvements. Substantial developments in computer aided design, building information management, and cloud computing have enabled new degrees of architectural freedom even while complying with complex institutional briefs. For architects, now, hospitals are interesting again. But the identity crisis facing contemporary hospitals is not a problem of design. Rather, it is of the dissolution of the human. Who, or how much of the patient should be admitted to treatment? Who, or how much of the doctor should be called upon to care? What architecture can prescribe here is limited. But architecture can assist us in reading the rapidly evolving spatial relations that result from this antagonistic history of care and cure.