Architectural Factors for Infection and Disease Control 2022010088, 9781032102665, 9781032102672, 9781003214502

This edited collection explores disease transmission and the ways that the designed environment has promoted or limited

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Architectural Factors for Infection and Disease Control
 2022010088, 9781032102665, 9781032102672, 9781003214502

Table of contents :
Cover
Half Title
Title
Copyright
Dedication
Contents
List of Figures
List of Charts and Tables
Contributor Biographies
Preface
1 Infection and Disease Transmission: Pandemics, Epidemics, and Outbreaks
2 Isolation, Quarantine, Infection Control: Architecture and Planning in Service to Public Health
3 The Social Construction of Airborne Infections
4 Distancing and Colonial Design: Segregated Asylums to Control Leprosy in Suriname
5 Pine Forest and Sunlight: Alvar Aalto’s Paimio Sanitorium
6 Legionnaires’ Disease and Water Systems: History and Prevention
7 Infection Control Through Environmental Design
8 Infection Risk Mitigation Using Pedestrian Dynamics
9 Green Infrastructure for Mosquito Control
10 Emergency Department Design in Response to Pandemics: A Systematic Literature Review
11 Environmental Role of Open Space in Infection and Disease Control
12 Viral and Bacterial Infection Prevention Through Intentional Design
13 Disease Control Within High-Traffic Areas: A Series of Mini-Case Studies
14 Retail Design in a Post-Pandemic World
15 Future Teaching Design for Pandemic Response
16 Architecture Without Prelates, Magistrates, and Admirals: The R3build Pavilion
17 Open Learning Spaces: Redefining School Design in a Post-Pandemic World
18 Toward Culturally Enriched Communities – COVID-19 Implications
19 Mobile Testing Facilities Inspired by Origami Science
Index

Citation preview

ARCHITECTURAL FACTORS FOR INFECTION AND DISEASE CONTROL This edited collection explores disease transmission and the ways that the designed environment has promoted or limited its spread. It discusses the many design factors that can be used for infection and disease control through lenses of history, public health, building technology, design, and education. This book calls on designers to consider the role of the built environment as the primary source of bacterial, viral, and fungal transfers through fomites, ventilation systems, and overcrowding and spatial organization. Through 19 original contributions, it provides an array of perspectives to understand how the designed environment may offer a reprieve from disease. The authors build a historical foundation of infection and disease, using examples ranging from lazarettos to leprosy centers to show how the ability to control infection and disease has long been a concern for humanity. The book goes on to discuss disease propagation, putting forth a variety of ideas to control the transmission of pathogens, including environmental design strategies, pedestrian dynamics, and open space. Its final chapters serve as a prospective way forward, focusing on COVID-19 and the built environment in a post-pandemic world. Written for students and academics of architecture, design, and urban planning, this book ignites creative action on the ways to design our built environment differently and more holistically. Please note that research on COVID-19 has exponentially grown since this volume was written in October 2020. References cited reflect the evolving nature of research studies at that time. AnnaMarie Bliss is a lecturer in Architecture at the University of Illinois at Urbana–Champaign teaching design studios, foundational design principles, history and theory, and research methods for environmental designers. Her scholarship concentrates on health and well-being in design. Dr. Bliss is also the founder and principal of Bliss Historic Preservation and Consulting, a historic preservation architecture firm. Her research and practice projects address the socio-spatial and haptic aspects of preservation design triggering changes in the environmental perception of users and how health sciences play a role in design development. Dr. Bliss has been awarded national and international recognitions for her work including the Alpha Rho Chi Medal of Honor, the P.E.O. Scholar Award, and the King Medal for Excellence and the 2020 Dissertation Award from the Architectural Research Centers Consortium. Dak Kopec is an architectural psychologist and associate professor at the University of Nevada, Las Vegas. Dak has authored several books and is credited with researching, developing, and administering the first low-residency graduate program focused on designs for human health at the Boston Architectural College. He has also served as a visiting professor at the University of Hawaii with a joint position in schools’ architecture and medicine. In 2017, he won IDEC’s Community Service Award for the design of a group home for people with developmental disabilities and earlyonset dementia. Today, Dak is calling on his diverse educational background in health sciences, psychology, and architecture to promote interdisciplinary and person-centered design.

ARCHITECTURAL FACTORS FOR INFECTION AND DISEASE CONTROL

Edited by AnnaMarie Bliss and Dak Kopec

Cover image: Getty Images First published 2023 by Routledge 605 Third Avenue, New York, NY 10158 and by Routledge 4 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN Routledge is an imprint of the Taylor & Francis Group, an informa business © 2023 selection and editorial matter, AnnaMarie Bliss and Dak Kopec; individual chapters, the contributors The right of AnnaMarie Bliss and Dak Kopec to be identified as the authors of the editorial material, and of the authors for their individual chapters, has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. Library of Congress Cataloging-in-Publication Data Names: Bliss, AnnaMarie, editor. | Kopec, Dak, editor. Title: Architectural factors for infection and disease control /edited by AnnaMarie Bliss and Dak Kopec. Description: New York, NY : Routledge, 2023. | Includes bibliographical references. Identifiers: LCCN 2022010088 | ISBN 9781032102665 (hardback) | ISBN 9781032102672 (paperback) | ISBN 9781003214502 (ebook) Subjects: LCSH: Buildings—Health aspects. | Architecture—Health aspects. | Environmental health. | Communicable diseases—Transmission—Prevention. Classification: LCC RA566.6 .A73 2023 | DDC 613/.5—dc23/eng/20220617 LC record available at https://lccn.loc.gov/2022010088 ISBN: 978-1-032-10266-5 (hbk) ISBN: 978-1-032-10267-2 (pbk) ISBN: 978-1-003-21450-2 (ebk) DOI: 10.4324/9781003214502 Typeset in Bembo by Apex CoVantage, LLC

This book is dedicated to human’s best friends – the dogs and cats and other nonhuman friends who have helped us all during our COVID-19 quarantine. A special acknowledgment for our best dog friends Teddie Bliss and Rhydian Kayzar-Kopec.

CONTENTS

List of Figures ix List of Charts and Tables xii Contributor Biographies xiii Prefacexviii   1 Infection and Disease Transmission: Pandemics, Epidemics, and Outbreaks Dak Kopec and Marisela Thompson   2 Isolation, Quarantine, Infection Control: Architecture and Planning in Service to Public Health John Michael Currie   3 The Social Construction of Airborne Infections Jessica Cassyle Carr   4 Distancing and Colonial Design: Segregated Asylums to Control Leprosy in Suriname Stephen Snelders, Henk Menke and Toine Pieters

1

13 30

43

  5 Pine Forest and Sunlight: Alvar Aalto’s Paimio Sanitorium Virginia Cartwright

57

  6 Legionnaires’ Disease and Water Systems: History and Prevention Michelle Brune

65

  7 Infection Control Through Environmental Design Udomiaye Emmanuel, Eze Desy Osondu, and Cheche Kalu

78

viii Contents

  8 Infection Risk Mitigation Using Pedestrian Dynamics Ashok Srinivasan and Sirish Namilae   9 Green Infrastructure for Mosquito Control Phillip Zawarus 10 Emergency Department Design in Response to Pandemics: A Systematic Literature Review Hui Cai and Marzia Chowdhury

93 109

126

11 Environmental Role of Open Space in Infection and Disease Control Maryam Ekhtiari and Neda Akbari

166

12 Viral and Bacterial Infection Prevention Through Intentional Design Debra Harris and Denise N. Williams

177

13 Disease Control Within High-Traffic Areas: A Series of Mini-Case Studies Rose Mary Botti-Salitsky and Lisa Bonnet DePalma

192

14 Retail Design in a Post-Pandemic World Bhakti Sharma

210

15 Future Teaching Design for Pandemic Response AnnaMarie Bliss

221

16 Architecture Without Prelates, Magistrates, and Admirals: The R3build Pavilion Charles Drozynski

231

17 Open Learning Spaces: Redefining School Design in a Post-Pandemic World Yandi Andri Yatmo and Paramita Atmodiwirjo

245

18 Toward Culturally Enriched Communities – COVID-19 Implications Tasoulla Hadjiyanni and Emilie Wambeke

258

19 Mobile Testing Facilities Inspired by Origami Science Ming Hu

273

Index285

FIGURES

1.1 Triage hospital field tent 1.2 Without a point of reference, statisticians can easily inflate or devalue the meaning behind numbers 2.1 Two views Leprosaria in the United States ca. 1900–1917 2.2 Plan and views Lazaretto at Venice, Baltimore Lazzaretto lighthouse, and Staten Island quarantine station ca. 1423–1914 2.3 London fever hospital and Provincial isolation hospital ca. 1848–1915 2.4 Tuberculosis hospitals in the United States ca. 1910–1915 2.5 Monastic hospital at Ewelme, England, ca. 1457–1460 2.6 View and plan of the Narrenturm, Vienna, Austria, ca. 1784 3.1 Sunmount Sanatorium, Santa Fe 3.2 Cottage exterior No. 13 3.3 Presbyterian sanatorium cottages 4.1 Map of Suriname with the capital Paramaribo and the leprosy settlements Batavia and Bethesda 4.2 Schematic map of the leprosy colony Batavia 4.3 Batavia dwellings 4.4 Schematic map of the leprosy colony Bethesda 4.5 Leprosy asylum Bethesda 4.6 Leprosy colony Bethesda 4.7 Bethesda 4.8 Bethesda 6.1 Legionella pneumophila bacteria 6.2 Joseph E. McDade, PhD (left) and Charles C. Shepard, MD, of the Centers for Disease Control and Prevention 7.1 Example of corridor nook earlier proposed and being used by some hospitals 7.2 Corridor width as recommended by the UKDH 7.3 Suggested minimum corridor width 7.4 Example of an open-end corridor 7.5 Example of the courtyard approach

7 8 17 20 22 23 25 25 34 37 38 44 45 47 49 50 51 52 53 66 68 83 84 84 85 85

x Figures



7.6 8.1 8.2 8.3 8.4 8.5 8.6



8.7 8.8 8.9 8.10

9.1 9.2 9.3 9.4 9.5 10.1 10.2 10.3

11.1 11.2 12.1 12.2 12.3 12.4 12.5 12.6 13.1 13.2 13.3 13.4 13.5 13.6 13.7 13.8 14.1 15.1

Coronavirus survival on different surfaces Workflow of pedestrian dynamics for infection risk analysis in the built environment Social force model Two-dimensional (left) lattice and (right) pseudorandom points Histograms for interactions between passengers LBS data for pedestrian densities at different times of the day Schematic of the four layouts considered for modeling airport security checkpoint areas Number of unique contacts for different layouts and processes Variation of secondary infections for different transmission probabilities and layouts Comparison of secondary infections for rope and wall separators Comparison of secondary infections for rope and wall separators when single file is enforced Integrated mosquito control road map Disrupting the mosquito life cycle during the immature stages of development with natural measures Rainwater harvesting design demonstrating direct and preventative measures and general maintenance Rain garden/biorentention design demonstrating direct and preventative measures and general maintenance Bioswale with micro-pools design demonstrating direct and preventative measures and general maintenance The PRISMA flow of the systematic literature review Diagram of an ED prototype with design principles identified from the SLR Adaptable ED layouts using cohort isolation strategies during four stages of pandemics. (a) Diagram of ED during normal operational hours (top left); (b) ED adaptation during early surge (bottom left); (c) ED adaptation during midsurge (top right); (d) full surge plan during peak surge (bottom right) Skyline and topography with wind patterns Three layers of air movement in Bushehr Gram-positive and gram-negative bacteria SARS-CoV-2 UVC robot Nature art for health care Textiles add texture, color, and the perception of warmth and comfort to interiors Surface materials must be easy to maintain, clean, and disinfect Photograph of the grand lobby space at the Northern Light Health System – Eastern Maine Medical Center Diagram with newly proposed design considerations for high-traffic lobby designs Photograph of standard patient room – Virginia Hospital Center Diagram with newly proposed design considerations for patient rooms Photograph of care team work area – Virginia Hospital Center Diagram with newly proposed design consideration for staff high-traffic work spaces Café and public waiting areas Diagram with newly proposed design consideration for cafeterias and public areas Maslow’s hierarchy adapted to retail experiences Redesigning social spaces: A response to COVID-19 by Andi Saban and Prajakta Gharpure

86 94 96 99 101 102 103 104 105 105 106 110 115 118 119 120 128 162

163 170 172 178 180 183 184 185 186 193 196 198 200 202 204 205 208 215 226

Figures  xi

15.2 From pandemic response to typological poesis in catholicism by Taisuke Wakabayashi and Delnaaz Kharadi 15.3 A place to stand: Pandemic response and social justice by Rosalie Howell 15.4 Containing COVID by Jesse Han 16.1 The plan of the R3build Pavilion 16.2 The elevations of the R3build Pavilion 16.3 The R3build Pavilion 16.4 The interior of the R3build Pavilion 17.1 Various degrees of openness for learning spaces 17.2 Learning space qualities offered by different degrees of openness 17.3 Extended learning space 18.1 Without access to indoor–outdoor connections, children in high-rises faced additional challenges 18.2 A boulevard transformed into an exercise area 18.3 Minneapolis’s restaurants used tents in parking lots to abide by health guidelines 18.4 Lake Harriet supports health and well-being 18.5 In Cyprus, the port’s arrival terminal is transformed into a vaccination center 19.1 Basic origami patterns 19.2 Final design of Zipper Tube and Waterbomb combination 19.3 Final design of Miura-Ori–Yoshimura 19.4 Load distribution and testing 19.5 Rendering of testing facility on campus

227 228 229 239 240 241 242 253 254 255 260 261 261 262 266 275 278 279 280 282

CHARTS AND TABLES

1.1 2.1 10.1 10.2 10.3 10.4 10.5 10.6 13.1 13.2 13.3 13.4 13.5 14.1 14.2 17.1 17.2 19.1

Pandemics during the past 20 years Diseases traditionally treated by isolation or quarantine Surge capacity and infection control strategy Articles mentioning strategies against different outbreaks in different countries Level of evidence on surge capacity Level of evidence on infection control strategy Concentrated level of evidence on surge capacity Concentrated level of evidence on infection control strategy Team-generated list of design considerations that have been identified as key elements to be mindful of when designing high-traffic areas in a hospital setting Identified design considerations for high-traffic public lobby Identified design considerations for patient rooms Identified design considerations for care teams’ open working spaces Identified design considerations for café and public waiting area Retail sectors’ infection factors and pandemic guidelines Retail archetypes and experiences as per Stephens and Pine and Gilmore Conflicting aspects of open learning spaces Various degrees of openness for the learning spaces Rating for origami pattern

3 15 129 140 141 145 156 158 195 197 201 203 207 213 218 251 252 276

CONTRIBUTOR BIOGRAPHIES

Editor Biographies AnnaMarie Bliss, PhD

AnnaMarie Bliss is a lecturer in architecture at the University of Illinois at Urbana–Champaign, teaching design studios, foundational design principles, history and theory, and research methods for environmental designers. Her scholarship concentrates on health and well-being in design. Dr. Bliss is also the founder and principal of Bliss Historic Preservation and Consulting, a historic preservation architecture firm. Her research and practice projects address the socio-spatial and haptic aspects of preservation design triggering changes in the environmental perception of users, and how health sciences play a role in design development. Dr. Bliss has been awarded national and international recognitions for her work including the Alpha Rho Chi Medal of Honor, the P.E.O. Scholar Award, and the King Medal for Excellence and the 2020 Dissertation Award from the Architectural Research Centers Consortium. Dak Kopec, PhD HFASID, MCHES

Dak Kopec is an architectural psychologist and an associate professor at the University of Nevada, Las Vegas. Dak has authored several books and is credited with researching, developing, and administering the first low-residency graduate program focused on designs for human health at the Boston Architectural College. He has also served as a visiting professor at the University of Hawaii with a joint position in the schools of architecture and medicine. In 2017 he won IDEC’s Community Service Award for the design of a group home for people with developmental disabilities and early-onset dementia. Today, Dak is calling on his diverse educational background in health sciences, psychology, and architecture to promote interdisciplinary and person-centered design.

Contributor Biographies Neda Akbari, PhD

Neda Akbari received her PhD in microbiology from the Science and Research University in Iran in 2008. She has more than 10 years of experience in microbiology, molecular genetics, and

xiv  Contributor Biographies

biochemistry-based research methods. Dr. Akbari shows demonstrated success in isolating microorganisms and screening and evaluating bacterial enzymes, and gene cloning, expression, and purification. Paramita Atmodiwirjo

Paramita Atmodiwirjo is a professor of architecture at Universitas Indonesia. Her research interests are on the relationship between architecture, interior, and the users’ behaviors and how such relationships should be the basis for designing for users’ well-being. She is the recipient of FuturArc Green Leadership Award 2019 for a project on post-disaster school design. Rose Mary Botti-Salitsky, PhD, FASID, IIDA, NCIDQ

Dr. Botti-Salitsky has been an active voice in the field of interior design for over 30 years as an academic, design professional, author, and advocate. She has written numerous books and papers and presented conferences focusing on promoting well-being of human occupants; their health, safety, and welfare are at the forefront of her research. Michelle Brune, PhD, NCIDQ, EDAC

Michelle Brune is a professor of interior design at Southeast Missouri State University in Cape Girardeau. She also serves as the program coordinator for the Council for Interior Design Accreditation and National Association of Schools of Art and Design accredited interior design program. Brune’s areas of interest include building systems and construction, building codes, and evidencebased design in health care and educational environments. Hui Cai, PhD

Hui Cai is an associate professor, the chair of the Department of Architecture, and the associate director of the Institute of Health and Wellness Design (IHWD) at the University of Kansas. Dr. Cai’s research focuses on using a performance-driven and evidence-based design approach to analyze the relationship between culture, human behavior, and the physical environment, especially in health care settings. Virginia Cartwright

Virginia Cartwright, associate professor emerita, explores light, form, and space through her research and practice, as well as in her teaching on the architecture of Alvar Aalto. Her research areas also include climate-responsive design and daylighting strategies. Since 1998, Cartwright has focused on developing a small architectural practice, which was the recipient of a Meta Design Award in 2003. Jessica Cassyle Carr, MPH, MS

Jessica Cassyle Carr is a writer, editor, and researcher based in Albuquerque, New Mexico. She works at the University of New Mexico College of Population Health, teaching global health and supporting various academic programs. Her research interests include transit equity, the hydropolitics of greenfield development, and health communication through music. Marzia Chowdhury

Marzia Chowdhury is a PhD student at the Department of Architecture at the University of Kansas. Her dissertation topic explores the design strategies of emergency departments in responding to pandemics. Her research combines both quantitative and qualitative methods that include systematic literature review, discrete event simulation, and case studies.

Contributor Biographies  xv

John Michael Currie, FAIA, FRSPH, RIBA

John Currie is a guest lecturer on health care facility planning and patient safety at Clemson University, Johns Hopkins University, and the University of Kansas and has been a featured speaker at numerous professional meetings including the International Hospital Federation. He has 45 years of experience dedicated exclusively to health care facility planning, programming, and design and is responsible for more than 200 health care facilities across the United States and throughout the world. Lisa Bonnet DePalma, IIDA NCIDQ

With over a decade of experience, Lisa Bonnet DePalma, IIDA, works on a range of projects in health science, ambulatory, and acute care settings. Her passion to improve both the patient and end-user experiences in the built environment stems from her stint in hospitality design. Charles Drozynski, PhD

Charles Drozynski is a lecturer working at the University of West England and a part II architect. His research interests include the entanglements of the subvert in society and architecture as well as the development of new technologies that arise from unconventional ideas. Maryam Ekhtiari, PhD

Maryam Ekhtiari is an assistant professor at Shiraz University. Her expertise includes environmental psychology and green architecture. Much of her research focuses on topics ranging from the quality of the integral relationship between human needs, desire, and architecture in all aspects and the relationship between sustainability and historical building. Dr. Ekhtiari is the author of several publications on green infrastructure and design. Tasoulla Hadjiyanni, PhD

Tasoulla Hadjiyanni is Northrop Professor of Interior Design at the University of Minnesota. As a founder of Culturally Enriched Communities, Hadjiyanni advocates for built environments that pave the way for social and racial justice and her award-winning teaching pedagogies have been used to decolonize design education and nurture global citizens. Debra Harris, PhD

Dr. Debra Harris is an associate professor in the College of Health and Human Science at Baylor University and a fellow of the Center for Health Systems & Design at Texas A&M University. Her body of work is focused on factors affecting user experience and outcomes, especially related to health, safety, and cost implications of the built environment. Ming Hu

Ming Hu is an associate professor at the School of Architecture, Planning and Preservation, University of Maryland, USA. Her research activities centers on questions of how, and why, sustainable building design and construction affect energy/resource conservation and environmental and human health to understand how (smart) technologies might be employed to reduce the impact from buildings. Cheche Kalu

Cheche Kalu is a lecturer in Akanu Ibiam Federal Polytechnic, Uwanna. Afikpo, Ebonyi State. Cheche’s research focuses mainly on architectural design and environmental sustainability that aims to solve the numerous problems bedeviling humans.

xvi  Contributor Biographies

Eze Desy Osondu, PhD

Eze Desy Osondu is an academician, administrator, entrepreneur, and consultant architect. He has worked in both private and government establishments, including as a resident architect for China Resources Ltd and as the Abia state chief consultant for Quickwin. Henk Menke, MD

Henk Menke, MD is a dermatologist (retired) and medical historian. He is an independent researcher with a guest appointment at the Freudenthal Institute at the Utrecht University. Menke’s attention is focused on the relationship between colonialism and medicine, and he has published on sexually transmitted diseases, skin bleaching, and leprosy history. Sirish Namilae, PhD

Sirish Namilae is an associate professor of aerospace engineering at Embry-Riddle Aeronautical University in Florida, specializing in particle dynamics and multiscale modeling. His research focuses on multiscale model-based design with applications in public health, transportation, and materials science. His work on infectious disease spread during air travel has generated significant press coverage. Toine Pieters

Toine Pieters is a professor of the history of pharmacy and allied sciences in both the Department of Pharmaceutical Sciences and the Freudenthal Institute and is a senior fellow of the Descartes Institute of the History and Philosophy of the Sciences and the Humanities at Utrecht University, The Netherlands. Toine Pieters has published extensively on the history of pharmacy and allied sciences, medical humanities, digital humanities, and leprosy research. Bhakti Sharma

Bhakti Sharma is an associate professor of interior design at the State University of New York at Buffalo. Sharma’s work focuses on experiential design, branding, and spatial exploration. Her research area in high-end retail design primarily focuses on the marriage of art, fashion, and architecture. Stephen Snelders

Stephen Snelders is a Dutch historian and research fellow at University Utrecht, Faculty of Science, Freudenthal Institute/History and Philosophy of the Sciences, The Netherlands. He has published numerous books and articles on the history of drugs and addiction, tropical medicine and piracy, and human genetics and eugenics. Ashok Srinivasan, PhD

Ashok Srinivasan is the William Nystul Eminent Scholar Chair and Professor. His research focuses on the application of supercomputing to scientific and public health policy applications. He coordinates the VIPRA project, which is funded by the National Science Foundation and the National Institutes of Health. Marisela Thompson, MHID

Marisela Thompson teaches interior architecture and health care design courses in the University of Nevada, Las Vegas School of Architecture. As one of the lead Interior Architecture participants in the Department of Energy’s Solar Decathlon 2017 Competition, she and her team developed creative, innovative, and viable design strategies and concepts to support the daily physical and cognitive

Contributor Biographies  xvii

functioning of active aging adults. Marisela is a passionate advocate of impactful practices of interior design that transform human lives by supporting wellness and health. Udomiaye Emmanuel, PhD

Udomiaye Emmanuel is a senior lecturer at Akanu Ibiam Federal Polytechnic, Uwana, Nigeria. He is a member of the Nigerian Institute of Architects and a fellow of the Nigerian Environment and Safety Management Institute. He has been a researcher in environmental sustainability assessment since 2014, and his current research is concerned with environmental sustainability and occupant’s health interaction. Emilie Wambeke

Emilie Wambeke is a rising senior at the University of Minnesota, studying in the Interior Design program, and working towards her Bachelor of Science in Interior Design. Recently, Wambeke has been working as a research assistant for Dr. Tasoulla Hadjiyanni, where she has worked on collecting research regarding vulnerable populations and design responses to the coronavirus pandemic. Denise N. Williams

Dr. Denise N. Williams is a postdoctoral researcher in the Environmental Forensics and Material Science Laboratory in the College of Health and Human Science at Baylor University and an Adjunct Instructor in the College of Professional Advancement at Mercer University. Her body of work is focused on elucidating the sustainability of human-made materials and on materials’ implications on human and environmental health. Yandi Andri Yatmo

Yandi Andri Yatmo is a professor of architecture at Universitas Indonesia. His current works are primarily on design theories and methods and their relevance to design practice. He is particularly interested in developing research-based design and evidence-based design, including for health and school environment, and has various publications on the relationship between architectural design and health issues. Phillip Zawarus

Professor Zawarus is an assistant professor of the Landscape Architecture program and leads the Landscape Performance Studio and respective seminars specific to urban tree benefits, green infrastructure systems, and ecosystem services as they relate to the Mojave Desert region. His research focuses on desert ecological design related to contemporary stormwater management practices, green infrastructure, and outdoor comfort.

PREFACE

When humanity evolved from hunter-gatherers to an agrarian society, a disease’s ability to infect large groups of people became a reality, and the subsequent fear of contracting a contagious bacterial or viral infection was a routine part of life. Each year thousands of people would contract a bacterial or viral infection. The treatment was often bloodletting by cutting an artery or vein or through a cupping practice that results in the breakage of small blood vessels below the skin or leeches being placed on the body to feed on human blood. Wounds and damage to the body caused by workrelated accidents or inflicted during combat often became infected. The treatment for infections and even sexually transmitted diseases often included mercury-based compounds. Disease conditions thus often resulted in death. As our villages grew into cities and then empires, so did the death count from infectious diseases. The Great Plague (bubonic plague) of 1665 resulted from a bacterial infection caused by a flea bite. These fleas were commonly found on rats, and this infection cost London about one-quarter of its entire population. The Asian and European empires were also responsible for spreading disease, thus expanding regional epidemics to continental pandemics. British, Portuguese, and Spanish conquerors introduced bacterial and viral infections such as the virus that caused smallpox to the Americas and brought a stronger, more virulent version of syphilis back to Europe. An estimated 90% of the Native American populations throughout the northern, central, and southern portions of the continent died due to smallpox. The widespread deaths from this virus are often considered one of the first pandemics because it reached all parts of the globe. In 1796, Jenner created the first vaccine. This vaccine’s widespread use has eradicated smallpox, and vaccines have become the first line of defense against viral infections. A little more than a century later, Fleming developed the first antibiotic, which has been very useful in the fight against leprosy (Hansen’s disease) and the bubonic plague. The proliferation of antibiotics during the 1950s and 1960s and the subsequent rampant overuse have led to new strains of resistant bacterial infections. Tuberculosis, for example, results from a bacterial infection. This disease was projected to be eradicated by the 1980s. However, the bacteria evolved into resistant strains, some of which are now totally resistant. Throughout human history, the most effective method to control the spread of infection has been through social distancing, a compound word that has entered the English language lexicon in

Preface  xix

response to the COVID-19 pandemic that began in 2020. Early hunter-gathering societies would leave the sick behind as the group migrated from place to place. When humans shifted to an agrarian lifestyle, people who contracted a deadly virus or bacterial infection were isolated in their homes or cast out of the village. Later, people were placed in specially constructed buildings called sanatoriums and hospitals. Be it the leper colonies that appeared throughout the world, the outdoor patient areas, tuberculosis sanatoriums, or the recent restrictions on open water features in health care environments to control Legionnaires’ disease, designers of the built environment have been an essential element in the control of disease and infection. During the past two decades, increased populations, global travel, and livestock commodification have increased interspecies’ viral infections. Bird, swine, and camel flus have infected and affected human populations. In 2009–2010, the H1N1 swine flu gripped the world and yielded a relatively milder social reaction than what we saw with the COVID-19 virus. Similarly, West Nile virus, which was once limited to Nigeria, can be found worldwide. The Zika virus, which was first identified in the monkeys of Uganda, resulted in many infants being born with microencephaly within the Americas’ tropical regions. Antibiotic resistance will grow in prevalence, and viruses will continue to mutate and jump species. The pharmaceutical companies will continue to develop vaccines and medications. Product manufacturing companies will also continue to create antibacterial and viral agents, but the probability of another novel virus such as COVID-19 is highly likely. It is the architectural, interior, landscape, product, and urban designers responsible for the elements and configuration of the designed environment. Hence, these professions need to be proactive as the first defense line to prevent the next pandemic. As these respective professions further develop specializations that allow the next generation of designers to gain greater depth of knowledge into areas of expertise, one factor will undouble be the relationship between infections and disease control. This edited publication explores disease transmission and the ways that the designed environment has promoted and prevented the spread and promulgation of disease.

1 INFECTION AND DISEASE TRANSMISSION Pandemics, Epidemics, and Outbreaks Dak Kopec and Marisela Thompson

Introduction The ability to control the spread of infectious diseases has long been a concern for humanity. Prior to the advent of vaccines and antibiotics, infectious diseases such as smallpox and tuberculosis (TB) could devastate populations. Many modernized societies have been spared the deadly effects of pathogens because of the availability of pharmaceuticals. Recognizing, addressing, and containing the presence of a pathogen as quickly as possible is the best way to contain pandemic, epidemic, or even an outbreak. Among the highly infectious diseases include avian influenza (H1N1), drug-resistant TB, Ebola, monkeypox, plague, severe acute respiratory syndrome (SARS), smallpox, and tularemia (Courage, 2014). The threat from a pathogen was highlighted in 2020 with the emergence of the COVID-19 virus. While the COVID-19 virus was unforeseen, the concern for a deadly pandemic has been forecasted for decades. Most pandemics result from the transfer of a pathogen from the normal breathing process. Tiny droplets are produced and become airborne through the normal course of speaking, coughing, or sneezing. These droplets contain the pathogen and can land in another person’s eye and nose and enter their mouth, where it can then be absorbed or be inhaled into the person’s lungs. A second form of transmission comes from the exchange of bodily fluids. The difference between these fluids and the tiny droplets is the quantity and the method of contact. The COVID-19 virus, for example, can linger in the air for several minutes to an hour or more (Centers for Disease Control and Prevention [CDC], 2021). The virus that causes Ebola can survive on dry surfaces for several hours and in body fluids kept at room temperature for several days (CDC, 2021). In the world of public health, there are four important terms when it comes to infection and disease control. These words are outbreak, endemic, epidemic, and pandemic. An outbreak is the higher-than-expected number of cases within a given area. For example, it’s expected to have a certain number of influenza cases within an area and within a given period. When the numbers of these cases spike within the area, an influenza outbreak has occurred, and measures must be taken to prevent the outbreak from becoming an epidemic. Endemics are common outbreaks within specific parts of the world. Endemics can migrate to other parts of the world. West Nile virus, for example, was only endemic to Africa and the Middle East but is now found throughout most of the world (Ronca, Ruff, & Murray, 2021). Epidemics are diseases that affect many people within a DOI: 10.4324/9781003214502-1

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community or region. In the past, epidemics were often caused by bacterial illnesses. Today, most of the epidemics in Western societies relate to chronic health concerns such as asthma, diabetes, and heart disease (Bastian, 2006). A pandemic is defined as a disease or health condition that is prevalent throughout an entire country or the world. Pandemics are more serious than epidemics because they encompass large areas and large numbers of people. A pandemic can arise from a bacterial and/or a viral agent. The Black Death, also known as the plague, was caused by the bacteria Yersinia pestis. This pandemic spanned from 1346 to 1352 and affected Asia, Europe, and North Africa (Britannica, 2021). Many of the bacterial-based pandemics, such as the plague, are controlled with antibiotics. There are no cures for viruses, which make them the primary cause of modern-day pandemics. According to the Microbiology Society (n.d.), the first known antibiotic was arsphenamine discovered by Paul Ehrlich in 1909 and used to treat syphilis. Only a couple of decades later, Alexander Fleming discovered penicillin. The research and development of antibiotics peaked after World War II. Unfortunately, the decades of widespread misused of antibiotics had led to the development of antimicrobial resistance (AMR; Hutchings, Truman, & Wilkinson, 2019). Today, some infections, such as some strains of TB, have become effectively untreatable and have been deemed extremely or totally resistant (Kopec, 2021). When a pandemic occurs, large numbers of people over vast expanses become infected. When we consider that viruses reproduce at a much higher frequency than other more complicated organisms such as mammals, we can begin to understand why they mutate so fast. For example, a single cell that has been infected by a virus can make as many as 100,000 copies of itself. Each of these copies goes on to replicate, which means that the probability of a mutation continues to increase exponentially (Sanjuán et al., 2020). While some mutations will result in a more virulent form of a given virus, many mutations will have little to no effect. For example, there are more than 60 different strains of HIV-1 in the world. HIV-1 and HIV-2 are two main types of the human immunodeficiency virus (HIV), and within each type are different strains. HIV-1 is the most common type of HIV, but a recombinant of HIV is developing from the merging of HIV-1 and HIV-2 in the United States and Europe, where there are high levels of immigration from West Africa (Palm et al., 2014). In addition to human migration patterns, high levels of crowding and population densities have led to overcrowding of livestock, habitat losses, and more people having contact with animals. Since 2000, we have had six different pandemics. The cause of most pandemics is a virus that moves from an animal to people. SARS, Middle East respiratory syndrome (MERS), and now COVID-19 are derivatives of the larger family of coronaviruses. The virus that causes SARS was found in civet cats, which are considered a delicacy in China (Enserink, 2003). While inconclusive, the World Health Organization believes that MERS originated in camels, and there is evidence that pangolins served as the intermediary for the COVID-19 virus. Other, recent pandemics include Ebola and Zika. However, caution must be exercised not to draw oversimplified and generalized conclusions. Frutos et al. (2020) state that the real triggers for pandemics are driven by amplification loops created by humans through land conversion, markets, international trades, mobility, etcetera and that the focus and responsibility for pandemics need to be placed on human activities. Table 1.1 identified the pandemics that have affected the planet in the past 20 years. Throughout the decades, multiple factors have converged to increase the probabilities of a pandemic striking at any time. These factors include human infiltration into areas of the planet not previously explored, increases in human populations allowing for bacterial or viral infections to evolve and mutate faster than before, current livestock farming practices are based on overcrowding and are allowing species-specific viruses to mutate, making interspecies infections more probable, and then there is the widespread overuse of antibiotics within humans and our livestock allowing for bacterial diseases to develop resistance.

Infection and Disease Transmission  3 TABLE 1.1  Pandemics during the past 20 years

Year(s)

Virus

Geography

2002–2003 2009–2010 2012 2013 2015–2016 2019–2022

SARS H1N1 MERS Ebola Zika COVID-19

37 countries Global 22 countries 10 countries 76 countries Global

Drivers of Pandemics Easily spread diseases that can cause high mortality include anthrax, botulism, plague, smallpox, tularemia, and the viral hemorrhagic fevers, such as Ebola (CDC, 2018). These conditions require health care preparation in order to prevent a pandemic. Among the primary drivers of pandemics is overcrowding and overpopulation. According to the online website Worldometer, in 1951, the world’s population was estimated at 2,584,034,261, with density levels being approximately 17 people per kilometer. In 2020, the world’s population was 7,794,798,739 with a population density of 52 people per kilometer. Between 1940 and 2004, which correlate with a significant spike in human populations and population density, more than 300 new infectious diseases emerged (Daszak, 2009). Additional drivers of new pathogens entering the human population are economic development and land use, human demographics and behavior, international travel and commerce, changing ecosystems, human susceptibility, and hospitalizations (Woolhouse & Gaunt, 2009). The ability to travel between large cities in a short time can promote the development of a pandemic. Crowding allows for multiple people to occupy limited space, thereby allowing for the easy transference of airborne pathogens. The incubation period for some of the more common viruses such as the influenza virus is between 1 and 2 days, with the first symptoms being relatively benign. Hence, during the first 72 hours, a person can contract an infectious disease in Tokyo on a Monday, fly to Hong Kong for a meeting on Tuesday, and then be in Singapore by Wednesday. During these three days, the person will have been in airports and in airplanes, which are highly susceptible to crowding. Additionally, Tokyo, Hong Kong, and Singapore are all heavily populated cities with high social densities, which means that the infected person can easily spread the pathogen to numerous other people within a short period. The first line of defense for the proliferation of an infectious disease is social distancing. There are two ways to promote social distancing, and all fall within the scope of practice of the design professional. The first method is the increase personal space allocations within all public spaces. This would mean that maximum occupancy loads for given spaces would need to be reduced. The second is to increase the physical space afforded to people. This means increasing the width of sidewalks and hallways, increasing the total square footage of restaurant dining areas and gyms, and better spatial planning for high-activity areas, such as airports and hotel lobbies.

Disease Transmission Pathogens can transfer from person to person through the air we breathe, directly from person to person through the transfer of bodily fluids, or through contact with an intermediary source. Intermediary objects, also called fomites, occur when a person comes into contact with an object, such as a door handle, that has been contaminated by another infected person. Intermediary organisms, also called vectors are living intermediaries that can transfer pathogens from one person to another.

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TB is caused by a bacterial pathogen and spreads through the air from an infected person who coughs, speaks, or sings. Throughout history, cases of TB have reached epidemic proportions. Some of the earliest treatments included spas or sanitaria, where patients were prescribed rest, fresh air, a rich diet, and carefully supervised exercise (Daniel, 2006). Experts in the 1960s thought the disease could be eradicated because of the diagnostic tools, the availability of therapeutics, and methods for primary and secondary prevention (Cummings, 2007). However, TB remains the top infectious disease worldwide (Bloom et al., 2017). TB has been evolving, and drug-resistant strains have been emerging. MDR (multidrug-resistant) TB has become common throughout India and China, where population densities are very high (Seung, Keshavjee, & Rich, 2015). While still fairly uncommon, XDR (extensively drug-resistant) and TDR (totally drug-resistant) TB has been increasing in overall incidences. Eighty-eight percent of the U.S. cases of antibiotic-resistant TB in 2014 were among foreign-born residents (LaFrance, 2016). The greater risk of contracting TB includes those who belong to low-income populations and live in high-density environments within an urban setting (Arcoverde et al., 2018) where spatial densities tend to be high. Fomites are inanimate objects that can be contaminated by an infectious agent and spread disease. Corona- (including the recent COVID-19) and influenza viruses (including the Spanish flu of 1918) are pathogenic agents that can be transferred from person to person via a fomite or person to person. The COVID-19 virus, for example, can remain active on plastic and stainless-steel surfaces for 2–3 days, up to 24 hours on cardboard, and up to 4 hours on copper (Wein & Bryant, 2020). Factors that influence the viability of a pathogen include temperature, humidity, ventilation, degree of surface texture of the object, and the quantity of the virus. Sneezing and coughing can spread germs onto surfaces either through the droplets released from the sneeze or cough itself or through germs from the sneeze or cough getting onto the hands, which then come into contact with fomites. Transmission via the hands is the most common type of disease spread. The 1918–19 influenza (H1N1) resulted in the deaths of roughly 40 million people worldwide and the 1956–58 influenza (H2N2 virus) pandemic killed nearly 2 million people (Houk, 2020). A significant difference between these two events was the importance of nonpharmacological interventions pertaining to social distancing and isolation. By decreasing social densities and isolating people from others, decreased numbers of people come into contact with the aerosolized transmission of the pathogen as well as potentially contaminated fomites. A pathogen can also be transmitted between humans through an intermediary host called a vector. Mosquitoes, ticks, and fleas are examples of vectors that have been responsible for pandemics such the Black Death, otherwise known as bubonic plague, and more recently the spread of the Zika virus in 2015 to 2016. Vector-based transmissions typically result in epidemics such as dengue fever and chikungunya. However, with global travel, some of these vectorbased diseases have the real potential to rapidly spread to other parts of the globe (Brauer et al., 2016). The Zika virus drew attention from public health officials during the Pacific outbreaks from 2007–2015. In 2015, the virus began spreading throughout the Americas. Zika belongs to a family of viruses that includes dengue, West Nile, and yellow fever and Japanese encephalitis (Musso, Ko, & Baud, 2019). The Black Death resulted from the bacteria that causes plague and was transmitted through the bite of fleas. Plague was such a devastating disease that the corpses of people who died from plague were used as an early form of bioterrorism. Gabriele de’ Mussi in 1348, stated that the plague was transmitted by the Mongols who catapulted diseased cadavers into the besieged city of Caffa, now Feodosia on the Crimean Peninsula. Other accounts of corpses being used for bioterrorism include the Lithuanian troops launching plague-ridden cadavers into the Bohemian city of Carolstein in 1422, and Russians used this technique against the people of Reval (now called Tallinn in Estonia) in 1710 (Barras & Greub, 2014).

Infection and Disease Transmission  5

Pathogens can also pass from person to person through the transfer of bodily fluids such blood, semen, vaginal fluids, and so on. In 1976, the human immunodeficiency virus (HIV) was first discovered in central Africa. HIV is the virus that causes AIDS. Within four years the virus had spread throughout the planet resulting in more than 36 million deaths. Today, there are two predominant strains of HIV, and they are referred to HIV-1 and HIV-2. Worldwide, the majority of HIV infections are HIV-1. While HIV-2 occurs predominantly in West Africa, it has been reported in other countries, including the United States (Peruski et al., 2020). The transmission of HIV and Ebola occurs through the exchange of bodily fluids from injection, absorption through mucus membranes, and possible ingestion of an infected person’s bodily fluids. The 2013–2016 Ebola outbreak in West Africa was unprecedented in scale, being larger than all previous outbreaks combined, with 28,646 reported cases and 11,323 reported deaths (Coltart et al., 2017).

Management of Corpses As designers of the built environment, we design hospitals, morgues, and funeral homes. For this reason, doctors, nurses, mortuary attendants, members of the emergency services, forensic scientists, embalmers, funeral directors, and others may have the occasion to come across a person who has died from a deadly pathogen (Hoffman, Healing, & Mehtar, 2018). Pandemics, epidemics, and outbreaks caused by diseases such as COVID-19, cholera, Ebola, H1N1 influenza, HIV, plague, TB, typhoid fever, etcetera have taken the lives of many people leaving behind corpses that can continue to transmit disease for several days beyond death. The bacteria that cause TB can live in a dead body for up to 36 days (Correia, Steyl, & De Villiers, 2014). The virus responsible for HIV can survive 6–15 days after death, the influenza virus can remain active in the environment for up to 24 hours (Morgan, 2004), and the Ebola virus can survive for up to a week in a dead body. Disease transmission can occur when contaminated sharp objects, such as broken bones or bone fragments, needles, or other tools, might accidentally cause an injury to the person handling the body. Similarly, precautions need to be in order to prevent and control splatter or aerosolized blood that might come from instruments such as power saws used when performing autopsies. Because mucous or ocular secretions can be generated as part of the postmortem process, nonporous surface materials that can be easily cleaned should be used as part of the design process. Caution should be exercised to avoid the transmission of disease from a dead body to a living person. Whether dealing with the recently deceased or with old burials, and regardless of which infectious agents may be present, the risk of infection from human corpses can be greatly reduced by wearing waterproof dressings over existing breaks in the skin and careful cleaning of any injury sustained during a procedure (Hoffman, Healing,  & Mehtar, 2018). Be aware that vector-based diseases from body lice, fleas, and mosquitos can transfer from the corpse to the person handling the body (Hoffman, Healing, & Mehtar, 2018). According to Hoffman, Healing, and Mehtar (2018), postmortem spaces should have adequate ventilation, lighting, running water, and good drainage. The use of high-quality ventilation systems, in addition to a negative-pressure environment, is particularly important when postmortems or autopsies are performed on people who have died from TB. Likewise, nonporous flooring with ample water pressure and good drainage is important when working with the bodies of people who have died from hepatitis B and C or HIV. Places that routinely work with dead bodies should have some form of cleaning and disinfection service or system in place, and the maintenance staff should be aware and knowledgeable of the different systems to ensure continuous and efficient operations. Because the professionals in the space should be wearing personal protective equipment (PPE), a safe place to don (put on) and doff (take off) this equipment is essential along with safe disposal of the equipment. Additionally, there is a need for the safe disposal of single-use gloves and other waste, sufficient sinks and disinfectant areas, and disinfecting washing devices for instruments or autoclaves.

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Chlorine bleaches should be avoided because they damage surfaces or instruments and the reaction between hypochlorite and formaldehyde (which is commonly present in areas where dead bodies are found) can produce a potent bis-chloromethyl ether, which is a known carcinogen. Corpses should be stored in refrigeration systems (González-Fernández et al., 2020). As a rule, it is not necessary to keep bodies in bags. The exception would be bodies leaking blood (such as those from people who have died from hemorrhagic diseases, cholera, etc.) or secreting fluids from open wounds. Those who have died from a hemorrhagic disease should be bagged as soon as possible and should be buried with appropriate precautions (see the later discussion) or cremated. Access to the storage of these corpses should be controlled with adequate security measures (González-Fernández et al., 2020).

Hospitalization Management What makes viruses and bacterial infections so dangerous is their ability to evolve and mutate. Hospitals have become collection points for multiple types of specific diseases and infections. Referred to health care–associated infections (HAIs), these infections include central line–associated bloodstream infections, catheter-associated urinary tract infections, surgical site infections, hospitalacquired pneumonia, ventilator-associated pneumonia, and Clostridium difficile and staphylococcus infections (CDIs) (Boev & Kiss, 2017). HAIs have been linked to MDR infections, and the number one HAI are lung infections that cause pneumonia (Monegro, Muppidi, & Regunath, 2021; Magill et al., 2014). When a pandemic, epidemic, or even outbreak strikes an area resulting in several people requiring the services provided by the local hospital, there is the potential for the patient to concurrently develop an HAI, thereby complicating the health condition of the individual. Castro-Lima et al. (2019) found that there was a higher mortality rate of HIV-infected people who were in critical care units with an HAI. Yearly, 1.7 million people who have had to stay in a hospital develop an HAI and more than 98,000 patients, or one in 17, die from these infections (Haque et al., 2018). Hence, the causal pathogen for the (pandemic, epidemic, or outbreak) places a burden on the health care system, but the probability of, and treatment for an HAI, further burden’s the system. Noting the ability for pathogens to spread within the health care environment, the first biocontainment unit was established at Fort Detrick, Maryland in 1969. These units were referred to as high-level containment care (HLCC) (Cieslak, Herstein, & Kortepeter, 2018) and consisted of a two-bed facility referred to as ‘the slammer.’ A biocontainment unit is an environment that ensures the safety and well-being of patients that may be infected by a highly contagious and extremely pathogenic infectious disease. The Ebola outbreak of 2014 resulted in 56 hospitals in the United States being upgraded for designation by state and federal public health authorities as high-level isolating units (HLIUs). These units are equipped with architectural space planning and HVAC designs; laboratories and other diagnostic equipment; and disposal methods for biomedical waste. These measures have the intended purpose to prevent the further spread of a disease or pathogen. The terms biosafety units (BSUs), biosafety labs (BSLs), and special pathogen treatment centers are designations used to describe an environment that is equipped to safely and effectively contain highly infectious pathogens. The National Institute of Allergy and Infectious Diseases (2018) identifies BSLs as ranging from one to four: BSL-1 contains agents not typically associated with diseases in healthy people. BSL-2 contains agents associated with routine human diseases but not spread through the air. BSL-3 contains agents that can have serious or lethal outcomes on health. BSL-4 contains agents that are lethal and spread throughout the air.

Infection and Disease Transmission  7

There are many factors that differentiate the levels of BSLs. Suffice to say, while a BSL-1 must have laboratory bench and sink, the addition of an autoclave helps promote the unit to a level 2 BSL. A level 3 BSL is where we start to see more environmental demands, such as physical separation from access corridors, self-closing double-doors, interior air directly exhausted and not recirculated, and negative airflow into the patient area. When these requirements are met, and the area can also be isolated, or in a building that can be completely sealed off, with its own dedicated HVAC system that creates a vacuum and contains decontamination systems such as ultraviolet (UV) lights, and HEPA air filtration systems, the unit can be upgraded to a BSL-4. The COVID-19 virus of 2020 can be lethal and is an airborne pathogen that requires BSL-4. However, Western nations that pride themself on advanced practices were reduced to the use of tents during the first days of the COVID-19 outbreak. These knee-jerk temporary shelters demonstrated how ill prepared society is to address the threats from a pandemic, epidemic, and outbreak (see Figure 1.1). Having an HLIU designation means that the hospital must have equipment, infrastructure, and staff training abilities to care for people infected with a highly hazardous communicable disease (HHCD), such as those that can easily spread through the air, or from the transfer of bodily fluids. Prior to 1990, there were only three hospitals in the United States with a level IV biocontainment area. This vast area is larger than all the Middle East, India, China, and Southeast Asia. To put the size of just the continental United States, not including Alaska or Hawaii, into context, consider that roughly 30 European countries fit into the landmass of the lower 48 states (see Figure 1.2). Holt (2014) of the Disaster Accountability Project recommends that each state have at least one level 4 biocontainment unit to be prepared for an epidemic or public health emergency. When developing a biocontainment unit, the Centers for Disease Control and Prevention (2015) have identified several fundamental principles to keep in mind. The first is the ability to isolate. An ideal setting would be in a stand-alone building where those entering and exiting the building are

FIGURE 1.1 Triage

hospital field tent for the first aid, a mobile medical unit for patients infected with coronavirus

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FIGURE 1.2 Without

a point of reference, statisticians can easily inflate or devalue the meaning behind numbers. When compared geographically to Europe, we can see that the United States is severely unprepared for pandemics. The assertion was realized during the 2020 COVID-19 pandemic.

restricted to the people of significance to the patients and employees. A second principle pertains to the admission of patients and the removal of the deceased. A third principle pertains to the facility. The air handling systems must be able to convert individual spaces from positive to negative pressure to prevent contaminated particulates from entering noncontaminated areas. Also, there needs to be a direct exhaust system with HEPA air filtration capacities to support MERV 13 air filters that can capture infectious particulates as small as 0.1 microns, with vents placed away from public areas. Transporting a patient to the biocontainment unit must be carefully considered to reduce transfer time, control contamination, and ensure the safety of individuals that are interacting with the patient. Consider that the back of an ambulance is a small, confined area. Once a patient with an infectious disease has arrived at a hospital, getting the patient to a secure area without the possibility of further contamination must be part of the infection and disease control process. Direct access to a secure area from an ambulance bay is the ideal. In some cases, a patient might be air-lifted to the hospital. Depending on the location of the helipad, the patient may need to ride in an elevator. In this case, the elevator should be designated only for vertical transportation of highly infectious patients, health care workers riding with the patient should be wearing PPE, and the elevator car doors should remain open when not in use. When designing a biocontainment unit be aware that a graduated vacuum air handling system will need to be specified to create negative pressure that is tracked by multiple pressure monitors. The goal of this system is to prevent contaminated air from a patient room to flow into hallways and the main circulation area and then to prevent possible contamination from leaving the containment area and entering the main portion of the hospital. There are multiple spaces that need to be considered by the designer. The first includes a locker room with showers. Here the health care workers can store their clothing while they wear disposable scrubs that will be disinfected and incinerated after their shift. From the locker rooms should

Infection and Disease Transmission  9

be a main circulation area with a nursing station. This is where health care providers can perform nonpatient contact work such as paperwork. This area, along with all other spaces in the secured area, should be designed with nonporous smooth materials that can be easily cleaned, and the use of UV lights in areas where dust or other particulates might gather is also important. A second space should allow for the disposal of solid waste such as patient trays, bedding, PPE, dressings etcetera. Solid waste should first be autoclaved and then incinerated. Be aware that a biocontainment unit can generate between 30–50 bags of waste per day. This number will increase with the number of patients. Ideally, there will either be a lab located within the secure space, or at least directly adjacent to this space. This lab should be able to perform routine tests such as blood counts, routine chemistries, blood gas measurements, urine analysis, and tests for a variety of infectious agents. Close to the lab should be a secured biosafety cabinet where blood, tissue, and other specimens can be kept for processing. Prior to entering a patient room, a health care worker should first pass through an anteroom, which is a smaller room that serves as a buffer between the patient area and the hallway or adjacent main circulation area. The anteroom should contain a hands-free sink as well as PPE and a shower for emergency decontamination. The anteroom is where health care workers can don (put on) and doff (take off) PPE. Donning and doffing PPE is typically a two-person job so that space must be large enough for two people to comfortable move while wearing their PPE. Anterooms require a minimum of six total air changes per hour (Centers for Disease Control and Prevention, 2019). The next important space is the patient rooms which should outfitted with adjustable beds, IV stands, and ample surfaces for monitors. Also, be aware that liquid waste will need to be disinfected and then flushed down the toilets. Patient rooms should have the strongest negative pressure and allow for a minimum of 20 air changes per hour. This air will need to pass through HEPA-filtered system prior to being expelled. When planning the construction of a hospital that will contain a biocontainment unit, the architect should consider the regions prevailing wind patterns as part of the space planning and ventilation exhaust.

Summary The ability to mitigate the spread of disease depends on the capability to adequately recognize, address, and contain pathogens as quickly as possible. Bacteria and viruses are commonly spread throughout populations through three occurrences: inhalation, absorption, and the exchange of bodily fluids. The probability of absorption is increased through two intermediary sources, fomites and vectors. Fomites increase exposure through surface contact with inanimate objects on which bacteria and viruses can live for varied periods. Vectors provide opportunities for transmission through exposure to mosquitos or ticks that carry the pathogen. Bacteria-based pandemics are addressed with antibiotics. Viral spreads are the primary cause of modern pandemics due to the resistance to medicinal intervention. Human population factors such as population migration, density, and misuse of antibiotics currently reduce the effectiveness of addressing the containment of bacterial and viral pandemics. The increased risk factors for the spread of disease indicate the need for adequate health care preparation to reduce high mortality rates. Common drivers for the spread of infection and disease include overcrowding and the ease of travel between cities within a short time. Two critical interventions are conceptualized from social distancing. The first intervention is the increase in personal space allocation within public spaces. The second is providing larger physical space in designed environments.

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Designs of hospitals, morgues, and funeral homes are critical environments for the mitigation of disease transmission. Each of the three environment types should address proper ventilation and lighting levels, the utilization of pressurized environments, and access to adequate water and drainage systems. These environments should organizationally identify locations for the donning and removal of PPE, designate areas for the safe disposal of PPE, and provide adequate conditions for the storage and disposal of corpses. Physical interactions with corpses increase the chance of transmission by increasing exposure to infected deceased individuals. A range of individuals from emergency responders and criminal investigators to medical personal interact with corpses. Steps should be taken to reduce unnecessary exposure, and care should be taken to minimize the risk of accidental transference of bodily fluids that can occur during the inspection, dissection, and movement of the corpses. Hospitals serve as a collection point for diseases and infections due to their purpose within communities. As epicenters for exposure to bacterial and viral infections, the design of these environments must respond and address disease containment and infection prevention. Hospitalization management includes the development and utilization of high-level isolating units and biocontainment units. These specialized units are designated biocontainment safety levels to describe the management and how the physical design should address the containment of infectious agents. The safety designations require the critical analysis and integration of hospital management, ­ventilation and pressurization of air, physical organization, and physical design considerations. Design considerations include understanding the requirements for a staff locker room, areas for waste ­disposal, the laboratory for specimen and sample analysis, anterooms, and patient rooms.

References Arcoverde, M., Berra, T.Z., Alves, L.S., Santos, D., Belchior, A.S., Ramos, A., Arroyo, L.H., Assis, I.S., Alves, J.D., Queiroz, A., Yamamura, M., Palha, P.F., Neto, F.C., Silva-Sobrinho, R.A., Nihei, O.K., & Arcêncio, R.A. (2018). How do social-economic differences in urban areas affect TB mortality in a city in the triborder region of Brazil, Paraguay and Argentina. BMC Public Health, 18(1), 795. Barras, V., & Greub, G. (2014). History of biological warfare and bioterrorism. Clinical Microbiology and Infection, 20(6), 497–502. Bastian, J. (2006). A modern epidemic. EMBO Reports, 7(12), 1201. https://doi.org/10.1038/sj.embor.7400866 Bloom, B.R., Atun, R., Cohen, T., Dye, C., Fraser, H., Gomez, G.B., Knight, G., Murray, M., Nardell, E., Rubin, E., Salomon, J., Vassall, A., Golchenkov, G., White, R., Wilson, D., & Yadav, P. (2017). TB. In: Holmes, K. K. et al., editors. Major Infectious Diseases, 3rd edition. Washington, DC: The International Bank for Reconstruction and Development, The World Bank. Boev, C., & Kiss, E. (2017). Hospital-acquired infections: Current trends and prevention. Critical Care Nursing Clinics of North America, 29(1), 51–65. https://doi.org/10.1016/j.cnc.2016.09.012 Brauer, F., Castillo-Chavez, C., Mubayi, A.,  & Towers, S. (2016). Some models for epidemics of vectortransmitted diseases. Infectious Disease Modelling, 1(1), 79–87. https://doi.org/10.1016/j.idm.2016.08.001 Britannica T Editors of Encyclopedia. (2021, August 27). Black Death: Encyclopedia Britannica. www.britannica. com/event/Black-Death Castro-Lima, V., Borges, I.C., Joelsons, D., Sales, V., Guimaraes, T., Ho, Y.L., Costa, S.F.,  & Moura, M. (2019). Impact of human immunodeficiency virus infection on mortality of patients who acquired healthcare associated-infection in critical care unit. Medicine, 98(23), e15801. https://doi.org/10.1097/ MD.0000000000015801 Centers for Disease Control. (2015, January 28). Interim Guidance for Preparing Ebola Treatment Centers. www. cdc.gov/vhf/ebola/healthcare-us/preparing/treatment-centers.html Centers for Disease Control and Prevention. (2018). Bioterrorism Agents/Diseases. https://emergency.cdc.gov/ agent/agentlist-category.asp. Centers for Disease Control and Prevention. (2019). CDC’s Guidelines for Environmental Infection Control. https:// www.cdc.gov/infectioncontrol/pdf/guidelines/environmentalguidelinesP.pdf on February 11, 2021. Centers for Disease Control and Prevention. (2021). Ebola (Ebola Virus Disease). https://www.cdc.gov/vhf/ ebola/transmission/index.html.

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Cieslak, T.J., Herstein, J.J., & Kortepeter, M.G. (2018). Communicable diseases and emerging pathogens: The past, present, and future of high-level containment care. Bioemergency Planning: A Guide for Healthcare Facilities, 1–19. Coltart, C.E., Lindsey, B., Ghinai, I., Johnson, A.M., & Heymann, D.L. (2017). The Ebola outbreak, 2013– 2016: Old lessons for new epidemics. Philosophical Transactions of the Royal Society of London: Series B, Biological Sciences, 372(1721). https://doi.org/10.1098/rstb.2016.0297 Correia, J.C., Steyl, J.L., & De Villiers, H.C. (2014). Assessing the survival of mycobacterium TB in unembalmed and embalmed human remains. Clinical Anatomy (New York, N.Y.), 27(3), 304–307. https://doi. org/10.1002/ca.22355 Courage, K.H. (2014, October 24). Inside the 4 U.S. biocontainment hospitals that are stopping Ebola. Scientific American. www.scientificamerican.com/article/inside-the-4-u-s-biocontainment-hospitals-that-arestopping-ebola-video/ Cummings, K.J. (2007). TB control: Challenges of an ancient and ongoing epidemic. Public Health Reports (Washington, DC, 1974), 122(5), 683–692. Daniel, T.M. (2006). The history of TB. Respiratory Medicine, 100(11), 1862–1870. Daszak, D. (2009). Can we predict future trends in disease emergence? In: The Institute of Medicine (US) Forum on Microbial Threats: Microbial Evolution and Co-Adaptation: A Tribute to the Life and Scientific Legacies of Joshua Lederberg. Workshop Summary at Infectious Disease Emergence: Past, Present, and Future. Washington, DC: National Academies Press. Enserink, M. (2003). Clues to the animal origins of SARS. Science, 300(5624), 1351. Frutos, R., Serra-Cobo, J., Chen, T., & Devaux, C.A. (2020). COVID-19: Time to exonerate the pangolin from the transmission of SARS-CoV-2 to humans. Infection, Genetics and Evolution: Journal of Molecular Epidemiology and Evolutionary Genetics in Infectious Diseases, 84, 104493. González-Fernández, J., Ibáñez-Bernáldez, M., Martínez-Tejedor, J.A., Alama-Carrizo, S., Sánchez-Ugena, F.,  & Montero-Juanes, J.M. (2020). Management of corpses during the COVID-19 pandemic in Spain [Gestión de los cadáveres durante la pandemia por COVID-19 en España]. Spanish Journal of Legal Medicine, 46(3), 109–118. https://doi.org/10.1016/j.remle.2020.05.001 Haque, M., Sartelli, M., McKimm, J., & Abu Bakar, M. (2018). Health care-associated infections – an overview. Infection and Drug Resistance, 11, 2321–2333. https://doi.org/10.2147/IDR.S177247 Hoffman, P.N., Healing, T.D., & Mehtar, S. (eds.). (2018). Guide to Infection Control in the Healthcare Setting: The Infection Hazards of Human Cadavers. International Society for Infectious Diseases. https://isid.org/guide/ infectionprevention/infection-hazards-of-human-cadavers/ Holt, K.M. (2014). Bio-containment Units in the U.S.: How Many We Have and Plans for Building More. Disaster Accountability Project. http://www.disasteraccountability.org/blog2/bio-containment-units-u-s-many-plans-building/ Houk, R. (2020, July  6). A  history of pandemics in the past 100  years. Johnson City Press. www.johnsoncitypress.com/living/a-history-of-pandemics-in-the-past-100-years/article2e8b4c2f-dbe2-5c15-b3f2a52be6925a5c.html Hutchings, M.I., Truman, A.W., & Wilkinson, B. (2019). Antibiotics: Past, present and future, Current Opinion in Microbiology, 51, 72–80. Kopec, D. (2021). Person Centered Health Care Design. London: Routledge. LaFrance, A. (2016, August  3). The danger of ignoring TB. The Atlantic. www.theatlantic.com/health/ archive/2016/08/TB-doomsday-scenario/494108/ Magill, S.S., Edwards, J.R., Bamberg, W., Beldavs, Z.G., Dumyati, G., Kainer, M.A., Lynfield, R., Maloney, M., McAllister-Hollod, L., Nadle, J., Ray, S.M., Thompson, D.L., Wilson, L.E., Fridkin, S.K., & Emerging Infections Program Healthcare-Associated Infections and Antimicrobial Use Prevalence Survey Team. (2014). Multistate point-prevalence survey of health care-associated infections. The New England Journal of Medicine, 370(13), 1198–1208. https://doi.org/10.1056/NEJMoa1306801 Microbiology Society. (n.d.). The History of Antibiotics. https://microbiologysociety.org/members-outreachresources/outreach-resources/antibiotics-unearthed/antibiotics-and-antibiotic-resistance/the-history-ofantibiotics.html Monegro, A.F., Muppidi, V.,  & Regunath, H. (2021). Hospital acquired infections. In: StatPearls [Internet]. Treasure Island, FL: StatPearls Publishing. Morgan, O. (2004). Infectious disease risk of dead bodies following natural disasters. Revista Panamericana de Salud Pública, 15(5), 307–312. Musso, D., Ko, A.I., & Baud, D. (2019). Zika virus infection – after the pandemic. New England Journal of Medicine, 381, 1444–1457.

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National Institute of Allergy and Infectious Disease. (Last reviewed 2018). The Need for Biosafety Labs. https:// www.niaid.nih.gov/research/biosafety-labs-needed. Palm, A.A., Esbjörnsson, J., Månsson, F., Kvist, A., Isberg, P.E., Biague, A., da Silva, Z.J., Jansson, M., Norrgren, H., & Medstrand, P. (2014). Faster progression to AIDS and AIDS-related death among seroincident individuals infected with recombinant HIV-1 A3/CRF02_AG compared with sub-subtype A3. Journal of Infectious Diseases, 209(5), 721–728. Peruski, A.H., Wesolowski, L.G., Delaney, K.P., Chavez, P.R., Owen, S.M., Granade, T.C., Sullivan, V., Switzer, W.M., Dong, X., Brooks, J.T., & Joyce, M.P. (2020). Trends in HIV-2 diagnoses and use of the HIV-1/ HIV-2 differentiation test – United States, 2010–2017. MMWR: Morbidity and Mortality Weekly Report, 69(3), 63–66. https://doi.org/10.15585/mmwr.mm6903a2 Ronca, S.E., Ruff, J.C., & Murray, K.O. (2021). A 20-year historical review of West Nile virus since its initial emergence in North America: Has West Nile virus become a neglected tropical disease? PLoS Neglected Tropical Diseases, 15(5), e0009190. https://doi.org/10.1371/journal.pntd.0009190 Sanjuán, R., Nebot, M.R., Chirico, N., Mansky, L.M., & Belshaw, R. (2020). Viral mutation rates. Journal of Virology, 84(19), 9733–9748. Seung, K.J., Keshavjee, S., & Rich, M.L. (2015). Multidrug-resistant TB and extensively drug-resistant TB. Cold Spring Harbor Perspectives in Medicine, 5(9), a017863. https://doi.org/10.1101/cshperspect.a017863 Wein, H., & Bryant, E. (eds.). (2020). Study suggests new coronavirus may remain on surfaces for days. NIH Research Matters. www.nih.gov/news-events/nih-research-matters/study-suggests-new-coronavirus-mayremain-surfaces-days#:~:text=Scientists%20found%20that%20SARS%2D,to%20protect%20against%20 infection Woolhouse, M., & Gaunt, E. (2009). Ecological origins of novel human pathogens. In: The Institute of Medicine (US) Forum on Microbial Threats: Microbial Evolution and Co-Adaptation: A Tribute to the Life and Scientific Legacies of Joshua Lederberg. Workshop Summary at Infectious Disease Emergence: Past, Present, and Future. Washington, DC: National Academies Press.

2 ISOLATION, QUARANTINE, INFECTION CONTROL Architecture and Planning in Service to Public Health John Michael Currie

Introduction – Isolation There are probably no institutions which confer greater blessings upon humanity than those which provide for the reception and maintenance of incurable cases. – Henry C. Burdett, Help in Sickness (1885)

Isolation is a very old type of intervention meant to control the transmission of disease. It was practiced thousands of years ago by isolating people who may have communicable diseases or were judged unclean according to the Mosaic books of both the Torah and the Bible. In the book of Leviticus, chapter 13 (Leviticus is the third book of both the Bible’s Old Testament and the Torah), requirements are listed for evaluating ill people and isolation – presumably in leper colonies. What was identified as the leprosy of biblical times may not have been only leprosy (what we know as Hansen’s disease today) but possibly included other skin diseases. The main practice is to separate (isolate) those people in the village who are obviously ill with disease from the healthy population. Twenty-five hundred years ago, when the final text of the Torah is widely agreed to have been published, the religious leaders of a village did not understand the chain of infection in disease transmission, but they did know the effect, and they designated a separate physical place for the diseased to be housed (Barker, 1995). Two terms are important to this discussion. They are related but not interchangeable. The first term is isolation. In various forms and practices, isolation means physically separating obviously ill persons from others in the community or family, providing some level of care for them, and holding them in isolation until they no longer exhibit symptoms – presumably no longer capable of passing on the disease. We find an example of lifelong isolation with leprosy (Strange and Bashford, 2003). The second of these terms is quarantine. This is a somewhat newer term than isolation. It means to separate people and physical goods in a facility apart from the community who may have come in contact with disease – especially epidemic disease – and holding them for a specific period waiting for symptoms to be present or for no sign of disease to be present at which time they would be released from quarantine.

DOI: 10.4324/9781003214502-2

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Quarantine as a public health practice dates to the 14th century when the Black Death (or bubonic plague as it is known to some, but it was also looked at as a virus) affected most of Europe, including Italy and nearby Mediterranean ports. The word quarantine has evolved from Italian quarantena, which means a 40-day period. Travelers, ship’s crews, and merchandise making up the cargo that had potentially been exposed to disease in other ports were kept in quarantine for a specified period to prove that they were not infected. In 1377, the seaport in Dubrovnik (then Ragusa), issued a “trentina” – which is taken from the Italian word for 30, trenta. It was in Ragusa (Dubrovnik today) that the first law to enforce the act of quarantine was implemented. Ships traveling from areas known to have high rates of plague or other diseases were required to stay offshore, not in a building, for 30 days before being allowed to dock. Anyone onboard who did not exhibit symptoms at the end of the waiting period plus the cargo was judged unlikely to spread the infection and so was allowed to disembark (An Untainted Englishman, 1767). Some ports or towns would create a “cordon sanitaire,” as a quarantine measure (Hays, 2009). This was a physical barrier (rope or fencing) that could only be crossed with permission. This practice persisted into the late 19th and early 20th centuries. When plague emerged in San Francisco, (1900–1904), the predominantly Chinese section of the city was quarantined by encircling it with a rope and armed guards to ensure that people did not pass through without specific permission. A “cordon sanitaire” was also used to control an outbreak of bubonic plague in 1899–1900 in Honolulu’s Chinatown. Multiple blocks of that city were literally cordoned off. One can guess the logic behind targeting these particular ethnic communities. Quarantine is still a useful practice today albeit modified for current conditions. During the severe acute respiratory syndrome (SARS) epidemic in 2003, the City of Toronto quarantined individuals who may have encountered the disease by confining them to their homes (or, in some cases, their places of work) until no symptoms presented and it was certain that they were not infected. This measure was effective in controlling SARS because individuals infected with SARS were not infectious until they began to exhibit symptoms. While not a strict definition of the 40-day quarantine, the concept is the same (Bashford, 2016).

The Beginnings of Infection Control in Medical Settings Hospital design and construction undertaken before 1850 included open wards for inpatients. Consequently, cross-infection among those patients was common, and mortality rates were high. Florence Nightingale’s observations from the Crimean War led her to advocate smaller pavilion-type wards (fewer patients with more space between beds) joined by open-air corridors. Nightingale emphasized the importance of aseptic nursing practice, wound care, and a clean patient environment. These ideas were called “fever nursing”. These practices – both nursing and design – were quite different from time-honored popular concepts of disease at the time. Fever nursing implied disease transmission by contact with body substances rather than solely the environment or miasma (Nightingale, 1863). The germ theory of infection was accepted (although not universally) in hospitals in the late 1800s, partly due to the work of Joseph Lister and Louis Pasteur. Conditions for patients began to improve as overcrowding decreased, and antisepsis and aseptic techniques increased. Communicable disease hospitals (e.g., fever hospitals in the UK) were established using individual and group isolation practices. Physician Jacques-Joseph Grancher in Paris advocated using the theory of communicability (an early acknowledgment of the germ theory) by physical contact rather than airborne spread or noxious odors for most diseases. Grancher allowed patients with communicable diseases to be housed in open wards but with separation among patients by wire-mesh screens. These screens nominally separated patients but perhaps, more important, encouraged staff members to don gowns and wash their hands. Early in the 20th century, hospitals began following stricter isolation procedures of

Isolation, Quarantine, Infection Control  15 TABLE 2.1  Diseases traditionally treated by isolation or quarantine

Bacterial Disease

Viral Disease

Plague Leprosy Syphilis Typhus Cholera Typhoid Tuberculosis

Smallpox Measles Yellow fever Dengue Rabies Polio Influenza Ebola SARS COVID-19

Source: Adapted from Murderous Contagions by Mary Dobson (2015).

patients with conditions deemed to be easily communicated in a completely private room using separate utensils and disinfectants (Rosenberg, 1992). A wide variety of bacterial and viral diseases are now treated using some form of isolation or quarantine. As knowledge and science-based medical practice evolved the techniques of isolation (and, to a certain extent, quarantine) continued their usefulness for infection control for individual patients, for populations at-risk and for communities. A growing list of serious diseases make use of isolation for treatment. In the early 20th century, physician Charles V. Chapin of Providence Rhode Island City Hospital used individual isolation cubicles (hard side walls) for patients with communicable diseases and documented that fumigation (to eliminate arthropod vectors) had little effect on controlling the spread of infection. Chapin’s work was very important in emphasizing the roles of persons and physical contact rather than things as spreaders of disease and helped contribute to the end the miasma theory of disease. Staphylococcus aureus was identified as a widely occurring hospital-acquired pathogen since the 1930s, and it continues to be a serious problem today. The rise of S. aureus and subsequent mutations prompted the development of professional infection-control programs in US hospitals. In 1968, the American Hospital Association published the first edition of the Infection Control Manual, which presented a simple barrier precautions scheme for patients diagnosed with or suspected of communicable diseases, listing the need for gloves, gowns, masks, hand hygiene, and visitor screening. As hospital practice matured so did the concept of the building and its inherent systems contributing to infection control. The basic building layout to separate clean from soiled, sophisticated isolation environments, ventilation and filtration, products and surfaces selected for sanitary application all combined to provide a more hygienic environment for patients, families, and staff (Pearson, 1913; Venzmer, 1972)

Leprosy and Isolation for Life Right up until modern times, its unfortunate victims were treated as outcasts, or worse. – Paterson (2017) The word leprosy became recognized around 383 ce when Jerome (now Saint Jerome) translated the Hebrew word sara’at and the Greek word lepra into the Latin word leprosy while translating the whole Bible into Latin (producing the Vulgate version). For hundreds of years, this translation was regarded as conclusively establishing leprosy as the first disease subjected to isolation by religious leadership and is the earliest recorded example of isolation requirements used as a disease control

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practice. See the book of Leviticus chapter 13 for the Laws of Cleanness or the corresponding book of Leviticus in the Torah stating that the individual should live alone and away from the camp and temple area for specific periods of time (Barker, 1984). A leper colony, sometimes also called lazarette, leprosarium, or lazar house, was used to isolate people with leprosy in accordance with the biblical text. The term lazaretto, which is derived from the name of the biblical figure Saint Lazarus, can be used to refer to isolation sites for a number of disease control purposes, which were at some time also “colonies”, or places where lepers were sent. Many lazarettes were operated by monastic houses. During the Middle Ages, there were social and medical implications for the individual. Lepers were forbidden to enter inns, churches, mills, and bakeries; touch healthy people; or eat with them. Lepers were subjected to stringent regulations. They were excluded from the church by a funeral mass and symbolic burial. It is estimated that there were as many as 19,000 leper houses (named variously) in Europe in the 12th century. Lepers who were not confined to one of these asylums often traveled around alone and were forced to wear special clothing (usually torn and soiled) and to carry a wooden clapper to warn of their approach. The building leper houses or leper colonies (founded as a mitigative response to the risk of infection) at Metz, Maestricht (in the 7th century), St. Gall (in the 8th century), and Canterbury (in the 11th century) gives evidence of widely spread disease in western Europe during the Middle Ages. Unfortunately, most leprosy facilities or sites are not well documented, and they have attracted little archaeological interest as excavation sites. Not much is known about the size of these establishments or the methods used to diagnose and treat leprosy. In 1790, unused land known as Voorzorg was designated by the Dutch colony of Suriname as a site to treat leprosy. However, in 1823, the government ruled that the leper colony at Voorzorg had to be abandoned because of its close vicinity to working plantations and the nearest town, Paramaribo. The interned lepers were transported forcefully to a remote abandoned plantation located on the Coppename River, which was judged to be sufficiently far away from Paramaribo. Moving these people was not an easy task clearly showing that this was not a move intended to improve care but rather to safeguard the uninfected population. The leprous slaves resisted to the very end, even though their villages and huts were set on fire (Menke, Snelders, and Pieters, 2011). In the mid-1800s, leprosy was explained by three anti-contagionist schools of thought: hereditarian, sanitarian, and dietarian. Most of the strongly and widely stated medical debate was by Norwegian and British researchers. Around the world, leprosy was dealt with by isolation and confinement. Renowned leprosy expert G. Milroy was a Scottish physician and influential adviser to the British government on leprosy. He criticized Suriname as an example of a country addressing leprosy in a barbaric way: “They [the leprosy patients] are treated as outcasts, being expelled and rigorously excluded (for the rest of their lives) from society” (Menke et al., 2011). Bergen, Norway, had the largest concentration of leprosy patients in Europe, and between 1850 and 1900, Bergen had three hospitals for leprosy patients. Bergen’s last two patients died in 1946 and the hospital closed (International Leprosy Association). Europeans’ interest in dealing with leprosy cases in Hawaii began early in the 19th century. When Hansen’s disease (leprosy) was introduced to the Hawaiian Islands, then king Kamehameha V banished leprosy patients to the remote Kalaupapa peninsula on the north shore of the island Molokai. The Hawaiian parliament introduced formal legislation attempting to control the spread of leprosy in 1865. Kalaupapa peninsula was set aside for the first contingent of people who arrived in 1866. Leprosy policies in late 19th-century Hawaii seem to have reflected racial moves to disempower Hawaiians beginning with early missionary assessments of the causes of disease and depopulation among Hawaiians and became intense as European and US commercial interests needed control of land for the growing plantation industry. The isolation of “lepers” to the Kalaupapa peninsula occurred at the same time that White business interests were steadily taking over the Hawaiian government, culminating in the overthrow of the legitimate reign of Queen Lili‘uokalani in 1893. By

Isolation, Quarantine, Infection Control  17

FIGURE 2.1 Two views Leprosaria in the United States ca. 1900–1917. Confinement for Hansen’s Disease

patients and families amounted to a life sentence separated from society Source: Author’s collection.

that time, more than 8,000 people, mostly Hawaiians, had died at Kalaupapa after spending most of their lives in isolation there. Kalaupapa once served as a prison but is today home for the few remaining former patients, who are now cured but had been forced to live their lives in isolation and now have chosen to remain. The legislation requiring lifetime involuntary confinement continued until 1969. People with leprosy only began to be treated as outpatients during the 1970s and 1980s, even though G.

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Armauer Hansen, MD, discovered the bacterium that causes the disease in 1874 (International Leprosy Association). The images of the leprosy colony show us that these facilities were designed and constructed principally as communities or villages not as health care facilities. The purpose of the Molokai colony was isolation and confinement (International Leprosy Association). In 1917, many years after Hawaii first began sending patients to Kalaupapa on Molokai, the US government federalized the Louisiana Leper Home at Carville. The center continued under the administration of the Daughters of Charity of St. Vincent De Paul nuns. Patients from outside of Louisiana arrived in Carville beginning in 1921. Until 1950, all cases of leprosy required mandatory stays at Carville by law, effectively these requirements amounted to imprisonment. The Daughters of Charity administrators oversaw improvements to the site, including building living quarters, food service facilities, and medical clinics. Louisiana sold the Home in 1920 to the US government following Senate-sponsored legislation to create a “National Leprosarium”. In 1921, the US Public Health Service (USPHS) took over Carville and the hospital was renamed US Marine Hospital 66, also known as the National Leprosarium of the United States. In the years before an effective treatment was found, the US government isolated leprosy from the general population via a policy of confining and segregating patients. From 1894 to 1999, the National Leprosarium (now known as the Gillis W. Long Hansen’s Disease Center) was the only inpatient hospital in the US dedicated to the treatment of Hansen’s disease (note that Molokai was only isolation). Carville, Louisiana has since been a home for 4,500 victims of Hansen’s disease once believed to be highly contagious (Daughters of Charity Archives). The Carville Center sponsored research that eventually led to the successful medical treatment of the disease in the 1940s. Beginning in 1933, a laboratory began at Carville (originally started by the Daughters of Charity) whose research found a successful sulfa drug treatment in the 1940s. In 1971, researchers discovered that a multidrug therapy effectively treated Hansen’s disease (rifampin along with a multidrug therapy). In the early 1980s, Hansen’s disease officially became an outpatient diagnosis. In 1986, the Carville facility was renamed the Gillis W. Long Hansen’s Disease Center. Carville is clearly using architectural isolation techniques vary reminiscent of the Pavilion Plan Hospital concept seen in Europe as far back as the late Renaissance and in the US. The pavilions here are living quarters. Clinics and community facilities are clustered in the center of the site development (Daughters of Charity Archives, n.d.).

Lazaretto The lazaretto has been with us for centuries as a way to control the passage of disease from one community to another. A lazaretto (or sometimes called a lazaret) comes to us from the Italian language and generally refers to a quarantine station for maritime commerce and travelers. Lazarettos can be hulks of large naval craft placed permanently at anchor, isolated islands, or cordoned-off buildings within the port. In some lazarettos, postal items and other cargo were also disinfected by fumigation (Cawthorne, 1768). This type of quarantine practice was still being done as late as 1936 around the world. Another use of a like word can refer to a leper colony administered by a Christian religious order, which was sometimes called a lazar house, after the parable of Lazarus the beggar. Lazarettos were common throughout Europe and much of the rest of the world. One of the earliest examples is in Dubrovnik, Croatia. These were constructed and operated generally by government entities, although they have their roots in Christian monastic orders. The most urgent use of the lazaretto was intended to control the plague or Black Death from entering the port. In 1789, John Howard a social reporter, reformer, and gentleman traveler toured Europe to report on the lazarettos still in use. His work, Prisons and Lazarettos, contains personal observations and detailed floor plans of the sites he visited. He also proposes a “New plan” for an ideal lazaretto (Howard, 1791).

Isolation, Quarantine, Infection Control  19

Malta In 1592, a lazaretto consisting of wooden huts was built on Manoel Island in Malta during a major plague epidemic. It was demolished in 1593 after the worst of the disease passed. In 1643, Grandmaster of the Knights of Malta Giovanni Lascaris built a permanent lazzaretto on the island to control the periodic influx of plague and cholera on board visiting ships. The facility was progressively improved over time and was enlarged during the British governorship of Sir Henry Bouverie in 1837 and 1838. The facility, which still exists, was officially closed in 1929. In the Malta lazaretto, it is clear that ships could approach and there are two distinct forms – one for the quarantined goods and one with a more open façade to house the passengers and crew.

Corfu and Zaknthos Lazaretto Island (formerly known as Aghios Dimitrios) is located two nautical miles northeast of the Greek island of Corfu. In the early 16th century, when Corfu was under Venetian rule, a monastery was established on Lazaretto Island for the prevention and containment of diseases but not necessarily quarantine of ships. Later that century, the island was renamed Lazaretto, referring to the leprosarium that had been established there. In 1798, during the French rule of Corfu, the islet housed a military hospital. In 1814, during the British occupation, the leprosarium was renovated and went into operation for that purpose once again. After the Ionian islands were united with Greece (1864), the leprosarium only operated when needed. Lazaretto Islet survives off the coast of Corfu and another on Zakynthos.

Venice and Ancona The first lazaretto was established by Venice in 1423 on Santa Maria di Nazareth (also called “Lazaretum”, today “Lazzaretto Vecchio”), an island in the Venetian lagoon, is Lazzaretto Nuovo, also in the lagoon. Pope Clement XII commissioned the architect Luigi Vanvitelli to design and build the Lazzaretto of Ancona at the south end of the Ancona harbor. One can see at Ancona in this present-day photograph a more deliberate expression of confinement in the Architecture of the Lazaretto – almost prison-like with enclosing walls and a single entrance approached by a bridge. This facility certainly lives up to the strict concept of quarantine (Howard, 1791; Cipolla, 1981).

Marseilles The lazaretto at Marseilles located on the promontory of L’Isle de Pommegue was the largest of its kind serving the commerce in the Mediterranean and protecting the communities of France. Here again we see planners taking advantage of a small island to be used for quarantine at the approach to the harbor. According to the Penny Illustrated News in an 1849 report, this lazaretto operated as one of the best in Europe, along with those in Livorno, Genoa, and Malta.

Great Britain The first English quarantine regulations, adopted in 1663, required the confinement (in the Thames estuary) of ships with suspected plague-infected passengers or crew. According to Edward Hasted in 1798, two large so-called hospital ships (which were also sometimes called lazarettos), which were the surviving hulks of 44 Royal Navy gunships were permanently moored in Halstow Creek in Kent – an inlet from the River Medway and the River Thames.

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FIGURE 2.2 Plan

and views Lazaretto at Venice, Baltimore Lazzaretto lighthouse, and Staten Island quarantine station ca. 1423–1914. Lazarettos founded to control the spread of disease by quarantine. This practice was worldwide.

Source: Author’s collection.

The hospital ships monitored for ships coming to England, which stayed in the creek under quarantine to guard the country from the incursion of infectious diseases, including the plague. Fidra is an uninhabited island in the Firth of Forth in eastern Scotland. There are ruins of an old chapel on the island that were used as a lazaretto for the sick. It was dedicated in 1165 to St. Nicholas and falls within the monastic tradition of care for the sick – especially those afflicted with leprosy (Rawcliffe, 2009).

United States In the United States, numerous lazarettos were built and operated as quarantine stations at principal ports. African slaves brought to Savannah, Georgia, had to wait for clearance at a quarantine station established in 1767 on Tybee Island, which the slave ships approached by way of Lazaretto Creek. Baltimore, Maryland, maintained a Quarantine Station and later a US Marine Hospital Service Hospital. There were multiple locations and design layouts, but the final choice was at the main access to the Baltimore harbor. The quarantine station known as Lazaretto Lighthouse formed a

Isolation, Quarantine, Infection Control  21

part of a Cordon Sanitaire that blockaded the city in times of epidemic disease risk from foreign ships entering the harbor. The Baltimore lazaretto no longer exists, but the place name persists on current-day maps. The Philadelphia lazaretto situated on the Delaware River dockside was built in 1799 as a response to the 1793 yellow fever outbreak. This structure has a clear residential quality to it (Hansebooks, 1888). The Columbia River Quarantine Station near Knappton, Washington, located across the river from Astoria, Oregon, also has a remaining example of a government-built lazaretto constructed in 1912 by the US Marine Hospital Service. Funds and authority for the lazaretto were voted in US Congress in 1897 “to prevent the invasion of pestilential disease”, which, according to the bill, included cholera, smallpox, and plague. New York Environs was the site of multiple quarantine facilities. The term lazaretto was starting to be overtaken by the title Quarantine Station. The volume of shipping and passenger traffic drove large quarantine facilities such as Ellis Island. Lesser known were stations such as Rosebank Staten Island Quarantine Station. This facility served a smaller volume of traffic. For about a century, beginning in 1873, Rosebank was the site of a quarantine hospital located on Bay Street. The hospital was given to the US government in 1921 and was renamed as the USPHS Quarantine Station (Rosen, 2015).

Pesthouses, Fever Hospitals, Sanatoria, and Isolation Hospitals The pesthouse is the institutional descendant of the lazaretto. From the lazarettos, we learned the effectiveness of the practice of isolation and quarantine. At this time, medicine still favored the miasma theory of disease, so isolation was a preferred public health measure. These buildings went by many names. A pesthouse, plague house, fever hospital, or fever shed referred to a building used for people with infectious that were easily transmitted to others – diseases such as tuberculosis, cholera, smallpox, or typhus. Many such facilities were built around the world. Often used for forcible quarantine, many towns and cities established one or more pesthouses located next to a graveyard and a waste pond nearby for infectious waste disposal. A  fever hospital or isolation hospital was purpose-built to house and, to some extent, treat infectious disease patients diagnosed with illnesses such as scarlet fever and smallpox. Their purpose is to treat affected people while isolating them from the general population. This is not quarantine but isolation away from the general population of the community (Risse, 1999). Early examples of this building type in England included the Liverpool Fever Hospital built in 1801 and the London Fever Hospital built in 1802 (later moved to a different site in 1848). The London Fever Hospital originally contained only 15 beds when built in 1802 in Gray’s Inn Road. The hospital was moved in 1815 to the west wing of the London Smallpox Hospital and expanded to 120 beds. The Northern Railway bought the original site to build the Kings Cross railway station. The money received from the sale allowed the charity to commission a new Hospital on a 4-acre site on Liverpool Road, Islington, with 200 beds. Public health practice continued to mature as a force for reform in patient care and in research into the causes of disease. There emerged a clear indication that isolation combined with thoughtful and humane care practices delivered good results – patients recovered and transmission in the community subsided. At the end of the 19th century, we see the growing acceptance of the germ theory even if the specific infectious agents were not fully understood (Nightingale, 1863; Gaynes, 2011). Many such hospitals were created in England (Figure 2.3) as laws were passed at the end of the 19th century, making infectious disease reportable to health authorities and public health officers could ensure that the patients were isolated. During the 20th century, as disease process became better understood, immunization and antibiotics reduced the devastation of these diseases. Starting

22  John Michael Currie

FIGURE 2.3 London

fever hospital and Provincial isolation hospital ca. 1848–1915. Specialty hospitals strictly for those with contagious disease – Follows Nightingale’s fever nursing practice

Source: Author’s collection.

with the London Smallpox Hospital built in 1741, there were eventually more than 1,200 such hospitals in the UK during the 19th century.

Tuberculosis Sanatoria Tuberculosis (TB) was once called the “White Plague” or the “Captain of Death”. TB is a highly contagious pulmonary disease caused by the bacterium Mycobacterium tuberculosis. It can be breathed in or swallowed with food. This agent was first identified and characterized by Robert Koch in 1882. This disease can advance to more serious forms, such as miliary TB, known colloquially as galloping consumption, which occurs when infection crosses into the bloodstream and spreads throughout the body. No specific antibacterial drug was developed until 1946 (McNeill, 1894). Sanatorium is a word that comes from Latin meaning “health-giving”. TB sanatoria (or sanatoriums) were created based on a regime of rest and separation from the community. Fresh air and rest were considered the critical steps in curing TB, and windows were kept wide open year-round. Nourishing food was plentiful, and patients were expected to eat well to build their strength. The first American sanatorium was established by Dr. Edward L. Trudeau. His Adirondack Cottage Sanatorium opened in Saranac Lake, New York, in 1885. The major idea of the sanatoria movement was isolating infected patients to stop the spread of the disease in the community. Saranac

Isolation, Quarantine, Infection Control  23

FIGURE 2.4 Tuberculosis

hospitals in the United States ca. 1910–1915. No medical intervention was available for TB beyond long stays separated from their communities and families until Waksman’s Streptomycin discovery in 1943.

Source: Author’s collection.

was composed of a group of residential-style cottages and low-rise structures arranged in a villagelike setting, which gained the name “cure cottages” (Strange and Bashford, 2003). The Firland Sanatorium, which was Seattle’s municipal tuberculosis hospital, opened in 1911, as part of a major public health move in the fight against what was Seattle’s leading cause of death. The sanatorium was one of the few government facilities (usually local authority) developed to have a distinctly residential feel as if the patients were guests, not inmates. Firland was located on a large site north of the Seattle city line. Comparing the contemporary alternative at Lima, Ohio, established by the city one sees a much more institutional design and one clearly founded on the concept of confinement. As was common at this time, patients were required to undergo 3 to 5  years of hospitalization for treatment (see Figure 2.4).

Isolation Hospital The isolation hospital was another facility-based attempt to carry out a public health solution to infectious disease (Carrington, 1911). These projects tended to be low-rise buildings with a limited capacity principally focused on separating the patients from the community. Occasionally these sites became known as contagious hospitals, which would erase any doubt as to their purpose. The mayor of Lowell, Massachusetts, declared in the Lowell Sun, November 14, 1917, that Lowell’s Contagious Hospital was “one of the greatest civic improvements in the history of our city”. The Lowell facility was aimed at controlling TB. It is an interesting and sad coincidence that 20 miles away at Fort Devens, Massachusetts, less than a year later, there was one of the worst early outbreaks of pandemic influenza that would go on to destroy millions of lives worldwide. In the UK, similar efforts had been taken to isolate the undesirable diseases of cholera, smallpox, and scarlet fever. Diseases such as these were deadly, and there were no known treatments in early 20th-century medicine (Graham-Smith and Purvis, 1922).

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The Letchworth and Hitchin Isolation Hospital was finally opened in 1915 after 10  years of design and construction efforts, including a nationwide design competition by the Hitchin Joint Hospital Board consisting of representatives of Hitchin Urban District Council, Hitchin Rural District Council, and, from 1919, representatives of Letchworth Urban District Council – hence the name Hitchin Joint Isolation Hospital. One can see in the published plan these hospitals were made up of linear structures containing 2-bed to 3-bed wards that were generally separated by sex of the patient, not necessarily the diagnosis. The narrow plans allowed for excellent cross ventilation and natural light. Also clear in the drawing is planning for the separation of beds with plenty of clearance for moveable screens, which was the practice at the time.

Alvar Aalto and the Paimio Sanatorium Aalto was selected by design competition to design the Paimio Sanatorium. This building was a creative representation that design can contribute to healthy treatment and good outcomes. That was Aalto’s claim when he stated that the realized building was a “medical instrument” – contributing to the healing process. Paimio is undeniably important in the history of architecture and therapeutic environments, but it still relied on isolation from society as its primary public health contribution. Paimio stands tall among the 16 sanatoria funded and built by the Finnish national government in the 1930s.

Almshouses, Bede Houses, and Monastic Charity Charity for and duty to those suffering in the world is a very human urge and is not limited to a single religious or civic group. There are examples of seclusion and comfort provided to those in need in the architecture of many times and places. And the shared root word of hospitality and hospital has been pointed out in many writings. Author Guenter Risse describes the interweaving of the secular and the religious hostels and infirmaries in his excellent work on the history of hospitals (Risse, 1999). From this, we see centuries of development in the architecture of sheltering. Examples of almshouses and other housing for the poor provided privacy and security in isolation from the broader community (see Figure 2.5). One can see the visitor accommodations in single or family rooms at the cloistered church in the English village of Ewelme. This series of connected structures was built around 1457–1460. The almshouse is a rough square with rooms for 13 individuals around a central courtyard. In some sources, this part of the property is called an almshouse, and in others, it is labeled the hospital and is directly connected to the church and adjacent school (Dollman, 1858). Monastery examples of similar lodgings, often referred to as infirmary spaces, are clearly shown on the drawings of many sites such as Cluny and St Gall. Almshouse, hospital, and Bede house are often used interchangeably. If the principal purpose of these sites was care for the sick, then infirmary was the proper term. The Hospital of St Cross and Almshouse of Noble Poverty is the oldest almshouse in England. It is located in Winchester and was founded as a charity between 1132 and 1136. It was designed to house 13 in rooms around a cloistered courtyard. It operates to this day as a charity and almshouse (Godfrey, 1955).

Isolation and Confinement in Mental Health Mental illness has been a crisis throughout history for families, communities, religion, and medicine. Mental illness often demonstrates no symptoms or signs beyond the patient’s behavior. There were many explanations and theories offered – most of them wrong. But an overwhelming response to this illness was to seclude and confine the patient. The Fools Tower or Narrenturm in Vienna at the University Hospital was built in 1784 as Europe’s first purpose-built asylum for the mentally ill. It is

Isolation, Quarantine, Infection Control  25

FIGURE 2.5 Monastic

hospital at Ewelme, England, ca. 1457–1460. Religious orders and wealthy families provided shelter and care for the poor and for homeless patients.

Source: Author’s collection.

FIGURE 2.6 View and plan of the Narrenturm, Vienna, Austria, ca. 1784. Confinement for the mentally

ill consisted primarily of holding patients in prison-like settings until the reforms of the late 18th century through early 20th century circa 1784. Source: Author’s collection.

intended for the long-term confinement of patients. There is little visual evidence of a therapeutic setting for care seen here (see Figure 2.6). Ideas evolved in Europe and the US and care progressed from mere confinement to actual treatment. Notable among the reformers are John Conolly, who was an English psychiatrist. In 1839, he became the resident physician at the Middlesex County Asylum. This was where he introduced the principle of nonrestraint into the treatment of the insane. This practice and his book, The Treatment of the Insane without Mechanical Restraints, led to nonrestraint becoming accepted practice throughout England (Conolly, 1856).

26  John Michael Currie

William Tuke was an 18th-century English Quaker and the founder of the Retreat at York in 1796, a significant new form of mental health asylum in which older, barbaric so-called treatments for mental illness were abandoned and more humane practices instituted – an approach that became known as moral treatment (Porter, 2011). Thomas Story Kirkbride was a psychiatrist from Philadelphia, Pennsylvania, and the superintendent of the Pennsylvania Hospital for the Insane. He developed requirements of asylum design based on the moral treatment philosophy and the belief that the physical environment of care (both built and natural) can have an effect on the behavior of patients. Kirkbride authored a significant book laying out his principles for the construction and administration of hospitals for the insane titled On the Construction, Organization, and General Arrangements of Hospitals for the Insane. His recommended building layout (the Kirkbride Plan) was intended to have a curative effect. The idea of institutionalization was a central part of Kirkbride’s philosophy for effectively treating the insane. Kirkbride’s work was widely adopted (not without debate in medical circles). and more than 70 Kirkbride Plan hospitals for the insane were built throughout the US and Canada between 1845 and 1910 (Kirkbride, 1854; Tomes, 1994). Holloway Sanatorium for Mental Disease was an institution in England for the treatment of those suffering temporary mental illness. This example is offered as a contrast to the strict warehousing of patients to keep them away from society. Holloway is at the other end of the spectrum – it is a pleasant trip away so that patients can be treated and gently recover then returned to the community. The sanatorium was the result of a design competition and was realized in the “high Victorian” style. Opened in 1885, Holloway was widely famous for innovative therapies such as massage and gymnasium exercise. However, controversial restraint methods were also employed.

Contagionists, Sanitarians, the Public Health Service, and the Institution of Isolation: Theories on How Disease Is Caused and Spread The miasma or miasmatic theory of disease was popular for several centuries. It originated and was made popular starting in the Middle Ages. This miasmatic theory states that diseases were transmitted and caused by the presence of a malodorous, poisonous vapor, referred to as miasma, in the air breathed by people in the community (Bray, 1996). For centuries prior to the wide acceptance of germ theory, health officials, researchers/scientists, doctors, and influential writers had explained the incidence and prevalence disease without understanding the role of disease-causing microorganisms (Berridge, Gorsky, and Mold, 2011). Modern germ theory was developed by research in the last half of the 19th century. This theory establishes that most diseases are associated with specific microorganisms (Gaynes, 2011).

Various Public Health Belief Systems The constant disagreements among those styled as contagionists and anti-contagionists over how the communication of infectious diseases worked played a major role in 19th- and early 20th-century public health and medical practices. The contagionist view was that diseases could be spread by infected items and perhaps other individuals – an early acknowledgment of the germ theory. The opposing view endorsed the venerable miasmatic theory (Delacy, 2017). The sanitary movement was launched in European countries in the 1820s. Sanitarianism aimed to reduce environmental pollution to improve human health. These reformers maintained the idea that disease was dependent on environmental factors, such as impure air and water supply (Duffy, 1992). The term filth diseases was first used in print in 1858 by English doctor Charles Murchison. Murchison identified a class of conditions, mostly caused by infectious pathogens, that were associated with unhygienic and squalid living conditions. This phrase became popular with various social reformers and the growing public health and sanitarian movement. It was not so much critical as

Isolation, Quarantine, Infection Control  27

accusatory, assigning the cause for these diseases to the physical living conditions rather than to some moral failing among the people forced to live there. In Victorian England, professionals in the emerging field of epidemiology were developing field-based, observational methods that defined the professional nature of the discipline and its theories and practices, leaving behind the outdated arguments of the miasma theory.

The American Public Health Association A significant origin event of the American Public Health Association was a series of four national conferences called the “Quarantine and Sanitary Conventions” held from 1857 to 1860. The final meeting of this group of scientists and engineers took place in 1860 in Boston, Massachusetts. This was the year when Abraham Lincoln was elected as president and that South Carolina seceded from the US, which started the US Civil War. One can gauge the accuracy and slow adoption of knowledge of disease process by the fact that a committee of these conventions was formed to study the “Nature and Sources of Miasmata”. Also of note was a smaller committee titled “Architecture, Etc.” (Board of Councilmen, 1859). Twelve years later, the American Public Health Association was formed (Duffy, 1993).

US Marine Hospital Service, Maritime Quarantine Division, and the USPHS An act of Congress was signed into law by President John Adams in 1798 that, in part, created the authority for a tax that merchant seamen pay to support the proposed network of US Marine Hospitals. This was an early example of prepaid health insurance in US history, and the law was amended a year later to include all members of the US Navy. Following the new law in 1801, the first US Marine Hospital built, owned, and operated by the federal government was located at Washington Point, Virginia. In the ensuing years, additional Marine Hospitals were established in the port cities of Boston, Massachusetts; Portland, Maine; Newport, Rhode Island; New Orleans, Louisiana; Mobile, Alabama; Charleston, South Carolina, and Washington, D.C. (Centers for Disease Control and Prevention, 1918; Cofer, 1910). In 1878, major epidemic diseases, such as smallpox and yellow fever, around the world caused Congress to pass the National Quarantine Act, which was intended to provide a central authority in disease prevention and transmission in the US. The task of controlling diseases using quarantine and disinfection, as well as carrying out what limited immunization programs available from the science of the day, was given to the Marine Hospital Service. In the following year, the National Board of Health was created by Congress. This National Board of Health was responsible for preserving and improving public health and for conducting research working with the Marine Hospital Service. It had the power to quarantine goods and people, principally at the ports of entry. Ten years later in 1889, Congress passed an act establishing the United States Public Health Service and its commissioned corps – making it a part of the Marine Hospital Service. The Marine Hospital Service expanded to be called the Public Health and Marine Hospital Service to reflect growing responsibilities in 1902 and in 1912, the name of the Public Health and Marine Hospital Service was shortened to the Public Health Service (PHS). Congressional action in the following few years broadened the powers of the PHS through investigations into human disease (such as TB, hookworm, malaria, and leprosy), sanitation in urban areas, safe water supplies, and sewage disposal.

The Great Flu Pandemic In 1918, with no concrete germ theory, no identification of the cause of influenza, no vaccine to protect against influenza, and no drugs to treat secondary bacterial infections that can be associated with influenza infections, control efforts worldwide were limited to nonpharmaceutical

28  John Michael Currie

interventions such as isolation, quarantine, good personal hygiene, the use of disinfectants, and limitations of public gatherings. Most of these actions were applied unevenly from region to region. USPHS did not respond to the developing influenza pandemic, at least initially, in a forceful manner. The US Surgeon General at the time, Rupert Blue, issued a series of precautions to safeguard against the “flu” on September 13, declaring that “in most cases, a person taken with ‘Spanish influenza’ [sic] feels sick rather suddenly. He feels weak, has pains in his eyes, head, or back, abdomen, etc., and may be sore all over.” Such warnings were typical for recurring influenza season, but the 1918 strain, which was an H1N1 avian strain, proved to be something entirely different from prior experience (The Navy Department Library). In a single week in October 1918, 4,500 people died from influenza in Philadelphia and 3,200 died in Chicago. As the death toll continued to increase, Surgeon General Blue, working with the War Department, created a network of emergency treatment and isolation facilities. Throughout the pandemic, PHS appointed USPHS officers solely for influenza duty and employed 1,085 doctors and 703 nurses to work alongside the military medical departments. The PHS’s involvement in fighting influenza may have saved many lives. It certainly rallied state, local, and national health organizations in a single effort. The power of the pandemic demonstrated to USPHS officials, including Surgeon General Blue, of the need for a single, focused public health agency to handle efforts in quarantining, isolating, preventing, and eradicating disease including the research that should accompany these efforts (The Navy Department Library). The First World War claimed the lives of 16 million people. The 1918 influenza epidemic killed an estimated 50 million people. Within just a few months, influenza killed more people than any other illness in history. While the disease influenza caused a far greater number of deaths, the effects of the pandemic and USPHS’s efforts were overshadowed by international news of World War I. From the late 1890s through the war years of the 1940s, several discoveries and refinements introduced antibiotics and antimicrobials to medicine. From the development of a chemical called arsphenamine by Paul Erlich in 1909, which proved to be an effective treatment for syphilis, to Alexander Fleming’s accidental discovery of penicillin in 1928 to Selman Waksman giving us streptomycin in 1946, modern medicine has been able to treat using pharmaceutical specifics rather than simply isolate for the control of infectious disease.

References Barker, K. (Ed). (1984). The NIV Study Bible. Grand Rapids, MI: Zondervan Publishing House. Bashford, A. (Ed). (2016). Quarantine. London, UK: Palgrave. Berridge, V., Gorsky, M. & Mold, A. (2011). Public Health in History. New York, NY: Open University Press. Board of Councilmen. (1859). Proceedings and Debates of the Third National Quarantine and Sanitary Convention (New York). New York, NY: Edmund Jones and Company. Bray, R. (1996). Armies of Pestilence: The Impact of Disease on History. New York, NY: Barnes & Noble, Inc. Burdett, H. (1885). Help in Sickness. London. Kegan Paul, Trench & Co. Carrington, T. (1911). Tuberculosis Hospital and Sanatorium Construction. New York, NY: National Association for the Study and Prevention of Tuberculosis (US). Cawthorne, J. (1768). The Immediate Necessity of Building a Lazzaretto for a Regular Quarantine, After the Italian Manner, to Avoid the Plague, and to Preserve Private Property from the Plunderers of Wrecks Upon the British Coast: A Practice as Dangerous in Its Consequences, as It Is Barbarous in the Execution. London, UK: Reproduction from British Library. Centers for Disease Control and Prevention, National Center for Immunization and Respiratory Diseases (NCIRD). (1918). Pandemic (H1N1 Virus). www.cdc.gov/flu/pandemic-resources/1918-pandemic-h1n1. html. Accessed 2 July 2021. Cipolla, C. (1981). Fighting the Plague in Seventeenth Century Italy. Madison, WI: The University of Wisconsin Press. Cofer, L. (1910). Public Health Bulletin No. 34: Maritime Quarantine. Washington, DC: Washington Government Printing Office. Conolly, J. (1856). The Treatment of the Insane Without Mechanical Restraints. London: Smith, Elder & Co.

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Daughters of Charity Archives. (n.d). Daughters of Charity Archives. Province of St. Louise, Emmitsburg, MD: Charity Archives. DeLacy, M. (2017). Contagionism Catches On: Medical Ideology in Britain, 1730–1800. Cham, Switzerland: Palgrave Macmillan. Dobson, M. (2015). Murderous Contagion: A Human History of Disease. London, UK: Quercus Editions Ltd. Dollman, F. (1858). Examples of Ancient Domestic Architecture Illustrating the Hospitals, Bede Houses, Schools Almshouses, etc. of the Middle Ages in England. London: Bell and Daldy. Duffy, J. (1992). The Sanitarians: A History of American Public Health. Oxfordshire, UK: Marston Book Services Limited. Duffy, J. (1993). From Humors to Medical Science: A  History of American Medicine. Chicago, IL: University of Illinois Press. Gaynes, R. (2011). Germ Theory: Medical Pioneers in Infectious Diseases. Washington, DC: ASM Press. Godfrey, W. (1955). The English Almshouse. London, UK: Faber and Faber Ltd. Graham-Smith, G. & Purvis, J. (Eds.). (1922). Isolation Hospitals. Cambridge, UK: Cambridge University Press. Hansebooks (Ed). (1888). Annual Report of the Supervising Surgeon-General of the Marine Hospital Services of the United States for the Fiscal Year 1888. Government Printing Office (a replica). Hasted, E. (1798). The History and Topographical Survey of the County of Kent, 2nd ed., vol. 4. Canterbury, 45–191. Hays, J. (2009). The Burdens of Disease: Epidemics and Human Response in Western History. New Brunswick, NJ: Rutgers University Press. Howard, J. (1791). Prisons and Lazarettos: Volume Two. An Account of the Principal Lazarettos in Europe. London: Johnson Dilly and Cadell Patterson Smith. International Leprosy Association. History of Leprosy. https://leprosyhistory.org/geographical_region/site/ hawaii. Accessed 15 July 2021. Kirkbride, T. (1854). On the Construction, Organization, and General Arrangements of Hospitals for the Insane. Philadelphia: Lindsay & Blakiston. McNeill, R. (1894). The Prevention of Epidemics and the Construction and Management of Isolation Hospitals. London, UK: R. & R. Clark. Menke, H., Snelders, S. & Pieters, T. (2011). Leprosy control and contagionism in suriname. Academic Journal of Suriname, 2, 168–175. www.adekusjournal.sr/adekusjournal/data/documentbestand/Artikel_Lepra_Menke.pdf. The Navy Department Library. A Forgotten Enemy: PHS’s [Public Health Service] Fight Against the 1918 Influenza Pandemic. www.history.navy.mil/research/library/online-reading-room/title-list-alphabetically/i/influenza/aforgotten-enemy-phss-public-health-service-fight-against-the-1918-influenza-pandemic.html. Accessed 2 July 2021. Nightingale, F. (1863). Notes on Hospitals. London: Longman, Green, Longman, Roberts, and Green. Paterson, T. (2017). Holidaying Among the Lepers, 24 June. www.cowichanvalleycitizen.com/home/t-w-paterson-holidaying-among-the-lepers/. Accessed 8 July 2021. Pearson, S. (1913). The State Provision of Sanatoriums. Cambridge, UK: The University Press. Porter, R.  & Wright, D. (Eds). (2011). The Confinement of the Insane: International Perspectives, 1800–1965. Cambridge, UK: Cambridge University Press. Rawcliffe, C. (2009). Leprosy in Medieval England. Woodbridge, Suffolk, UK: The Boydell Press. Risse, G. (1999). Mending Bodies, Saving Souls: A History of Hospitals. New York, NY: Oxford University Press. Rosen, G. (2015). A History of Public Health. Baltimore, MD: Johns Hopkins University Press. Rosenberg, C. (1992). Explaining Epidemics and Other Studies in the History of Medicine. Cambridge, UK: Cambridge University Press. Strange, C. & Bashford, A. (Eds). (2003). Isolation: Places and Practices of Exclusion. Abingdon, Oxon, UK: Routledge. Tomes, N. (1994). The Art of Asylum-Keeping: Thomas Story Kirkbride and the Origins of American Psychiatry. Philadelphia: University of Pennsylvania Press. An Untainted Englishman. (1767). The Nature of a Quarantine: With Important Remarks on the East-India Company’s Affairs. London, UK: Reproduction from British Library. Venzmer, G. (1972). 5000 Years of Medicine. New York, NY: Taplinger Publishing Company.

3 THE SOCIAL CONSTRUCTION OF AIRBORNE INFECTIONS Jessica Cassyle Carr

Introduction Mycobacterium tuberculosis is old, but its exact age has long been the subject of debate. The pathogen spreads through the air via the coughing, sneezing, speaking, singing, or laughing of a person with an active infection, and is transmitted into the lungs of those with whom they share close, poorly ventilated quarters. The disease it causes, tuberculosis (TB), is primarily respiratory but can also affect the organs and the skeleton. Archeological evidence found on human bones from the Andes Mountains of South America dates its presence there to at least 700 ce, possibly 290 ce (Nelson et al., 2020). Around the Yangtze River in China, TB appears as far back as 3900 bce (Okazaki et al., 2019). In Central Europe, it is as old as 5400 bce and, in the Eastern Mediterranean, as old as 6200 bce (Hershkovitz et  al., 2015). Some biomolecular research even suggests that the pathogen may have circulated in human populations within Africa for much longer – at least 70,000 years by some measures (Buzic & Giuffra, 2020), and as long as 2.8 million years by others (Gutierrez et al., 2005). Regardless of its possible Paleolithic origins, a volume of evidence etched on skeletons from the Neolithic Revolution highlights the social nature of the disease. During this period, beginning around 10,000 bce, the permanent settlements of agricultural societies arose as some prehistoric cultures gradually transitioned away from hunting and gathering. It is estimated that the world’s population rose to 4 million at this time after enduring at 1 million since the emergence of Homo sapiens (Roser, Ritchie, & Ortiz-Ospina, 2013). The denser communal living spaces of urban life subsequently created opportune conditions for the spread of disease. Meanwhile, trade and migration carried TB and other pathogens around the globe. Social constructionism is a theory of knowledge wherein the world, even that which seems entirely biological, is shaped and defined by humans. The etiologies of airborne infections tend to stem from the organization of interior environments and the way that people are made to arrange themselves within them.

Airborne Transmission Infectious diseases spread in various ways. Some travel through vectors like insects, for example, malaria, trachoma, Lyme disease, and bubonic plague. Others are ingested through contaminated DOI: 10.4324/9781003214502-3

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food or water, for example, cholera, dysentery, giardia, and norovirus. Still others involve direct person-to-person contact, for example, syphilis, hepatitis B and C, and staph infection. Many pathogens transmit through multiple modes. For instance, trachoma is an eye infection caused by the bacteria Chlamydia trachomatis. It spreads through direct person-to-person contact and indirect contact with fomites (inanimate objects that are contaminated with pathogens) but is also vectorborne because it is carried by flies. Another example is staph infection, a disease caused by the staphylococcus bacteria which expresses itself in many different ways including skin infections, food poisoning, and toxic shock syndrome. It is also transmitted through direct person-to-person contact and indirect contact with fomites. Some evidence suggests that Staphylococcus aureus – the antimicrobial resistant form of staph known as methicillin-resistant Staphylococcus aureus (MRSA) – can be transmitted through airborne droplets (Kozajda, Jeżak, & Kapsa, 2019). Pathogens, and diseases they cause, are complex, and understanding their mode(s) of transmission is essential in determining how to reduce risk. Pathogens capable of airborne transmission are those that travel within aerosolized particles small enough to linger in the air for extended periods. This mode is considered indirect person-toperson transmission. While many pathogens can travel through the air, true airborne transmission is delineated by particle size, which is dependent on several factors: the size of the pathogen, the material that carries the pathogen, and the pressure when projected into the air. Particle size is also determined by environmental factors including humidity, temperature, sunshine, and airflow. Larger droplets remain in the air for minutes at most before being overcome by the force of gravity and falling onto surfaces or onto the ground. Droplets tend to transmit in a spray, which is why this mode of transmission is sometimes referred to as spray-borne or droplet-spray. Droplets can infect people in close proximity through deposition on mucous membranes like the nostrils, lips, or eyes. By contrast, finer droplets dry quickly, forming into what is known as droplet nuclei. By virtue of a smaller size, droplet nuclei can stay suspended in the air for hours, travel farther distances, and cause infection through inhalation. Traditionally, the latter phenomenon is considered airborne transmission. As is true for TB, pathogens that are considered airborne spread through the coughing, sneezing, speaking, singing, or laughing of a person with an active infection. Airborne particles, like smoke, float in the air and are transmitted into the lungs of those with whom they share close, poorly ventilated quarters. Not all respiratory infections in humans are caused by airborne pathogens, but airborne pathogens almost exclusively cause infections of the respiratory system, which includes the sinuses, nose, throat, and lungs. Generally, symptoms include sneezing, coughing, sore throat, congestion, and, in more serious cases, chest pain and difficulty breathing. Identifying a respiratory pathogen’s primary mode of transmission – large droplets that fall (spray-borne) or floating droplet nuclei (airborne) – is important because the control measures differ for the two. Preventing large-droplet transmission requires social distancing and avoiding direct contact with an infected person both inside and outside, physical barriers and masks within a certain distance, cough etiquette, and surface sterilization. Preventing airborne transmission requires indoor mask wearing at all times, minimizing time spent indoors and in crowds, air filtration, and ventilation. Droplet transmission is not mitigated by air filtration or ventilation. Only a handful of pathogens are universally recognized as capable of airborne transmission. These include TB, chickenpox, and measles. There is also strong evidence for the airborne transmission of influenza and the coronaviruses that emerged in the 21st century including severe acute respiratory syndrome (SARS), Middle East respiratory syndrome (MERS), and COVID-19 (SARS-CoV-2), as well as respiratory syncytial virus (RSV) and human rhinovirus (Wang et  al., 2021). The emergence of COVID-19 magnified the lack of consensus around the mode of transmission, which, due to a poor understanding of various mechanisms of these pathogens, was a point of contention before the global pandemic (Tellier, Li, Cowling, & Tang, 2019).

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Burden of Disease Ameliorating TB’s impact on humanity is a top priority in global health. Today, the World Health Organization (WHO) estimates that a quarter of the global population is infected with latent mycobacterium TB, and of those infected, 5 to 10 percent develop active TB. Despite the disease being preventable and mostly curable, it kills nearly 1.5 million people worldwide annually, according to the WHO (2021). Other long-standing pathogens circulating in the human population, such as polio, tetanus, and measles, have been significantly reduced in prevalence (Centers for Disease Control and Prevention [CDC], n.d.a). Another pathogen – smallpox, which became the first vaccinepreventable disease in the late 18th century (and was preventable via inoculation as long ago as 1000 ce in China) – was completely eradicated by 1980 (Niederhuber, 2014). Despite the ongoing efforts of scientists, there is still no reliable vaccine for TB. The distribution of a disease is based on a variety of factors including time, place, the health of the host, and the pathogen’s characteristics such as mode of transmission and how readily it reproduces itself and spreads. In one year, a person with active tuberculosis can infect 5 to 15 others through close contacts. As TB is a social disease, as well as a disease of poverty, more than 95 percent of TB cases occur in nations with developing economies. The disease takes hold more easily as a result of a compromised immune system, the primary risk factors being undernutrition, diabetes, alcohol use disorders, and smoking (WHO, 2020). Those living with a heavy burden of disease – the cumulative consequences of illness within a community – are more susceptible to becoming sick with TB. TB once required a four-month hospital stay, but new drugs introduced in the mid-20th century allowed patients to undergo treatment at home. Drugs still take months, if not years, to complete, and inappropriate use of the treatment is an issue. This includes issues of drug quality, patient compliance (completing a prescribed treatment regimen), and correct prescription by clinicians. New bacterial strains which are resistant to treatment with first-line anti-TB medications pose a serious threat to global health security. While treatable with second-line medications, it is expensive and toxic and can take up to two years to treat multidrug-resistant TB (MDR-TB). Just 57 percent of MDR-TB has proved curable worldwide. In the past few decades, because it disproportionately impacts people with compromised immune systems, TB has also become a risk for people living with HIV. They are 18 times more likely to become sick with the disease. In 2019, nearly 70 percent of TB patients worldwide were coinfected with HIV/AIDS (WHO, 2020). Due to its ongoing prevalence, it is important for global health practitioners to test, identify, and treat TB cases, which saves millions of lives each year. Until the emergence of COVID-19, TB was the world’s leading cause of mortality from an infectious disease. As COVID-19 diluted resources within health care systems beginning in 2020, fewer patients received treatment for TB and fewer cases were detected. According to Stop TB Partnership, a collective of 1,700 partners that operates through the United Nations, progress toward reducing the disease’s burden was reversed by more than a decade as a result of the disruptions posed by the COVID-19 pandemic (2021). Consequently, TB cases and deaths are expected to escalate.

The Prevention Paradox In 1990, New York City was suffering from the effects of more than two decades of systematic disinvestment in TB control and social services. During the fall of that year, Leo Maker was the pseudonym used in a sensational, racist, and classist personification of New York City’s rising TB rates (Colgrove, 2011). According to the New York Post, the movements of one unhoused middle-aged Black man – panhandling on public transit, taking day labor, buying drugs, and sleeping in parks, as the paper recounted – represented a “contamination” threat posed by lower classes on the city’s more fortunate inhabitants. Maker also represented the all-too-common urge to understand the spread of disease through scapegoating and through the reduction to a “patient zero” (Barnes, 2010).

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For many reasons, this sort of individual framing of disease and the prevention thereof is contrary to the ethos of public health. One of these reasons is outlined in Geoffry Rose’s classic paper, “Sick Individuals and Sick Populations.” Rose writes about an individual and population prevention dichotomy, otherwise known as Rose’s Theorem: “A large number of people at a small risk may give rise to more cases of disease than the small number who are at a high risk” (1985). This concept is underlined by the River Story, a public health parable about “upstream” and “downstream” approaches. Rather than rescue people from a river downstream in perpetuity, practitioners must go upstream to fix the problem that causes the people to fall into the river in the first place. More technically, there are three levels of prevention – primary, secondary, and tertiary. Tertiary prevention involves treating and keeping an individual who already has a disease as comfortable as possible (downstream). Secondary prevention involves screening and early treatment of individuals at risk of developing a disease (midstream). Primary prevention involves intervening before the onset of disease (upstream). Although used less frequently, primordial prevention describes interventions designed to prevent wider disease incidence, mainly through social and environmental factors that can be altered via policy channels (even farther upstream). Within this conceptual framework, the built environment exists mostly on the primary or primordial prevention levels. The upstream approach to disease prevention is not always easily understood by the medical establishment or the public, which, as in the case of Leo Maker, tend to view health through the lens of the individual. Further complicating the matter is the prevention paradox. “A preventive measure which brings much benefit to the population offers little to each participating individual,” Rose (1985) explained. This is not to say that tertiary- and secondary-level interventions are not an essential component of prevention. Clearly, clinical services are a necessary component of a functioning society, and public health practitioners often design multilevel interventions to prevent the spread of disease. The problem described by the prevention paradox is that the efficacy of primarylevel interventions is often invisible. Rose points to seat belts and vaccines as examples of measures that effectively prevent morbidity and mortality on a large scale but offer few tangible benefits to members of the public who participate in the interventions. The efficacy of environmental design as a means of primary- or primordial-level prevention is equally, if not even more invisible. That is not to say that those in the business of prevention are unaware of the impact of environmental design. The built environment – along with economic stability, education, food, community/social context, and the health care system – also dwells within a fundamental public health framework known as the social determinants of health. Built environment social determinants of health include the places where people live their lives: housing, schools, offices, prisons, recreational venues, and public spaces. These places are considered societal-level pathways of disease, both causal and preventative, because they create the circumstances of daily life and, in turn, health outcomes over time. The built environment is reflected in the UN’s Sustainable Development Goals as well, including Goal 11: Sustainable Cities and Communities. This goal aims to improve health outcomes by increasing peoples’ access to public spaces and transport, implement national urban policies, and improve conditions for the more than one billion people worldwide who live in informal settlements or urban slums (2020). In 1993, a few years after the New York Post’s dubious Leo Maker stories, the WHO declared TB a global health emergency (WHO, 1994). A legitimate causal pathway in the 1990s resurgence of TB, like so many health outcomes in the population-level context, was disinvestment in tuberculosis control and social services (Colgrove, 2011). Ultimately, people had fallen into the river because of policy choices.

Urban Transition While each pathogen is unique, home and work conditions are a major factor in the spread of all airborne respiratory infections, including TB, influenza, measles, chickenpox, and the coronaviruses that emerged in the 21st century (i.e., SARS, MERS, COVID-19; Ather, Mirza, & Edemekong, 2021).

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In the Western world, TB reached its apex in prevalence during the Industrial Revolution, after people migrated from rural communities to seek work in dense cities (Figure 3.1). Between the 17th and 19th centuries, tuberculosis caused 25 percent of all deaths in Europe (CDC, n.d.b) but began to decline with improvements to nutrition and urban environments in the early 20th century. Because TB is transmitted through airborne droplets, it thrives in buildings that are crowded, poorly ventilated, and dark and disproportionately affects populations living in substandard housing. It is also an occupational hazard, and at its height, it tended to afflict those who worked in confined spaces, and spaces polluted with particulate matter. This included miners, factory workers, printers, bakers, and laundresses. Policy regulations concerning working conditions (shorter hours, better environmental conditions), the mitigation of slum housing conditions, the introduction of sanitation and hygiene standards (cleaning up sewage and providing clean water) – along with better access to food and subsequent reduction in malnourishment – had a synergistic effect of reducing the burden of disease in communities leading to reduced prevalence of TB (Bynum, 2012). The world’s population has risen at a nearly vertical trajectory since 1800, when there were approximately 990 million people, a sum that took hundreds of thousands of years for humankind to reach. By 2050, the population is expected to grow to 9.7 billion. Corresponding to this rapid multiplication of the species is a shift in geological epochs, from the Holocene to the human-influenced Anthropocene. In the second decade of this century, more than half of the world’s population lives in urban areas. By 2050, an estimated two thirds of the world’s population – roughly 6.5 billion people – are projected to inhabit densely populated cities (WHO, n.d.). This shift from rural to urban living is known as urban transition, and it is a key demographic feature of 21st-century health. As a result, the physical characteristics of urban neighborhoods, which are already significant causal and preventative pathways for both infectious and chronic disease, will be even more significant in determining global health outcomes. Another demographic consideration is climate migration, or

FIGURE 3.1 Sunmount

Sanatorium, Santa Fe

Sunmount Sanatorium in Santa Fe offered wealthy tuberculosis patients an opportunity to convalesce in cottages ventilated with clean, high desert air. Source: Katherine Stinson Pictorial Collection, Center for Southwest Research, University Libraries, University of New Mexico.

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the displacement of people worldwide due to the effects of climate change. According to researchers at the World Bank, as many as 216 million people could be displaced by 2050 (Clement et al., 2021). While cities have the potential to provide better access to services like education and health care for more people, they can also act as Petri dishes for the spread of disease, including airborne infections. This is evident in TB data from the Neolithic Revolution, the Industrial Revolution, and more modern pandemics.

Housing Home can be thought of as a site of security in that it is constant, it is the spatial context where ordinary activities of existence take place, it is a source of control for the individual, and it is a refuge from the outside world (Dupuis & Thorns, 1998). Housing, on the other hand, is a territory of ideological contests concerning what the property is expected to provide. Increasingly, housing is treated as a source of wealth, both corporate and personal, yet international human rights treaties recognize housing as a social good. This includes the Universal Declaration of Human Rights (UDHR), adopted by UN member states in 1948. Per the UDHR, housing should provide more than merely “four walls and a roof.” More broadly, the right to adequate housing means “the right to live somewhere in security, peace and dignity.” This is defined by the following elements: security of tenure; availability of services, materials, facilities, and infrastructure; affordability; habitability; accessibility; location; and cultural adequacy (Office of the United Nations High Commissioner for Human Rights, n.d.). The realization of additional human rights, including the right to health, the right to privacy, the right to work, the right to vote, and others are contingent on access to adequate housing. Unfortunately, the UDHR is a voluntary, aspirational announcement of principles and not a legally binding document. The United Nations estimates that globally 1.6 billion people live in inadequate housing and that 100 million people are experiencing street homelessness. Subsequently, about a quarter of all urban dwellers live in conditions that undermine their health (2020). Part of the incongruence between the aspirations of international human rights treaties and the reality of global living conditions lies in the financialization of housing. This refers to the scenario in which, in the wake of the 2008 financial collapse, housing is increasingly treated as a commodity by the financial sector and becomes divorced from its social function of supporting the health and well-being of people and communities. Home prices, rather than being based on incomes, are based on what a convoluted global housing market can bear, leading to increasing inequality. The rise in housing prices excludes many middle- and low-income households from access to homeownership and rentals, drives households to peri-urban fringes where fewer services exist, compels households to take on debt, and, in developing economies, leads to forced evictions and displacement in the interest of development (Farha, 2017). The spread of airborne infections depends on the prevalence of infection within a population and the frequency of contact between people who have active infections and those who are susceptible to becoming sick. This contact is much more likely to occur in crowded conditions with shared airspace, especially in closed spaces with limited ventilation (Lienhardt, 2001). For the quarter of urban dwellers living at the margins of society, a lack of adequate housing poses a risk of exposure to airborne infections. In low-income settings in Montreal, Canada, which has a very low rate of TB, residential density, taller buildings, and households with more people per room were associated with more TB cases compared to the rest of the population (Wanyeki et al., 2006). In South Africa, which has one of the world’s highest TB rates, many households – nearly all of them Black – have endured forced evictions from developed urban areas to underdeveloped peri-urban fringes that lack services. While damaging to the social fabric of communities, another result of these removals are longer commutes on public transit to reach employment, increasing the risk of exposure to TB and other airborne infections (Richardson et al., 2016). Living in an informal settlement or slum,

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places that are frequently the sites of overcrowding, is associated with an increased risk of exposure to airborne infections and an increased risk of mental illness (Weimann & Oni, 2019). Meanwhile, homeless shelters also elevate the risk of exposure to airborne infections due to overcrowding and a lack of ventilation (Moffa et al., 2019).

Prisons More than 11 million people, at a rate of 145 per 100,000, are held in prisons worldwide. Since 2000, the world’s prison population has risen by 24 percent. The United States, which incarcerates more people than any other country, holds 2.1 million people in prison, a rate of 655 per 100,000 population (Walmsley, 2018). Prisons are sites of human rights violations – overcrowding, abuse, violence, lack of health care, and, subsequently, risks to public health. Due to the closed setting, and because health care is not prioritized, prisoners experience increased burdens of disease. Prisoners are disproportionately affected by drug addiction and mental illness – an estimated 25 percent of prisoners in the United States have a serious mental illness (Hirschtritt & Binder, 2017), as well as infectious diseases like HIV, viral hepatitis, and MRSA. Prisons are also high-risk sites for outbreaks of airborne infections, including TB, influenza, chickenpox, measles, and COVID-19 (Beaudry et al., 2020), while a large body of evidence suggests that, worldwide, both latent and active TB is significantly more prevalent in prison settings (Grenzel et al., 2018; Kawatsu, Uchimura, Izumi, & Ohkado, 2016; Vinkeles et al., 2013). Prisons are considered reservoirs that facilitate TB transmission into communities through visitors, prison workers, and released inmates. Crowding and a lack of natural or mechanical ventilation are the key environmental elements that cause the spread of airborne infections within these settings (Grenzel et al., 2018). Recommendations for mitigation of infectious disease in prisons include prioritizing prison health care, including testing and treatment, while – especially in the case of TB – decreasing the prison population is stressed (Basu, Stuckler, & McKee, 2011; Ndeffo-Mbah et al., 2018). Decreasing the prison population may also help reduce the homelessness–incarceration cycle. A history of incarceration is strongly associated with the risk of becoming homeless (Nilsson, Nordentoft, & Hjorthøj, 2019), while people experiencing homelessness are more likely to become involved with the justice system and enter incarceration than the general population (Greenberg & Rosenheck, 2008).

Natural Ventilation TB sanatoriums built during the late 18th and early 20th centuries reflected a social approach to treating the disease. In lieu of antibiotics and chemotherapy, living standards were improved. Patients, isolated from the general public, were prescribed fresh air, sunlight, healthy food, and rest (Ortblad, Salomon, Bärnighausen,  & Atun, 2015). To maximize access to fresh air, sanatoriums were designed with natural ventilation in mind and often contained patient rooms with rows of windows, or cottages with screened-in porches. Otherwise, these facilities created rooftop verandas, terraces, and lawns where patients, or “lungers,” lay recumbent in the fresh air and sun (Figure 3.2). Primarily an option for wealthier sufferers of the disease, treatment at sanatoriums was not available to poor populations with disproportionate burdens of TB. Whether by choice or occupational obligation, in the 21st century most people spend most of their time indoors. Americans, for instance, according to the U.S. Environmental Protection Agency (EPA), spend an average of 90% of their time inside. Concentrations of indoor air pollutants are contingent on a building or room’s air exchange rate. In the case of biological pollutants like airborne pathogens, whether the infectious agents concentrate in the air of a room is also contingent on how crowded a space is, how contagious the people in it are, and how long they linger. For this reason, source control via masks and social distancing is a key element in the prevention of airborne

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FIGURE 3.2 Cottage

exterior No. 13

Dwellings at TB sanatoriums built in the late 18th and early 20th centuries offered ample natural ventilation. Shown here is a row of cottages with screened-in porches at Valmora Industrial Sanatorium in Northern New Mexico. Source: Carl H. Gellenthien Collection of the Valmora Industrial Sanatorium Records (HHC 239, Series IV: Photographs 1910–1988, PH048–028). New Mexico Health Historical Collection, Health Sciences Library and Informatics Center, University of New Mexico, Albuquerque, NM. Special Credit Line: Photograph courtesy of New Mexico Health Historical Collection, University of New Mexico.

infections. Design, construction, and the mechanical features of a building all affect air exchange rates. Ventilation, as well as infiltration through various openings, determines the rate. Mechanical ventilation is performed by air handling systems and fans whereas natural ventilation is provided by windows, doors, and other openings to the exterior. In addition to contributing to the regulation of temperature and humidity, and ameliorating odors, outdoor air that flows through an indoor space reduces indoor pollutant levels. In typical buildings, with the exception of hospitals, air exchange rates are ten times lower than the suggested rate to prevent transmission of COVID-19 – four to six changes per hour (Allen & Ibrahim, 2021). Mechanically, air exchange rates can be improved by adding MERV 13 filters to air handling systems, or, if possible, more efficient HEPA filters. Portable air filtration devices outfitted with HEPA filters are recommended for ad hoc air cleaning on a space-by-space basis. Natural ventilation was a weightier consideration in the overall design of pre-electricity buildings. Fenestration, including transom windows, double-hung windows, sleeping porches, balconies, and stairwells that act as air shafts were employed by designers to regulate temperature, humidity, and odors. By contrast, post-electricity buildings of the mid-20th century through the present have been designed with certain assumptions. One is that of undisturbed access to a source of electricity that guarantees regulation of interior environments. Another is that diseases can be controlled through scientific ingenuity – and that the population will be treated with vaccines and antibiotics. The dual crises of the Anthropocene, human-induced climate change and airborne infections that cause life-altering global pandemics, call for new design assumptions and, where possible, buildings retrofitted for natural ventilation. In addition to helping mitigate indoor air pollution, an emphasis

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FIGURE 3.3 Presbyterian

sanatorium cottages

Designed around the assumption that access to clean air was essential to curing TB, dwellings at ­sanatoriums built in the late 18th and early 20th centuries provided abundant natural ventilation. Pictured here are hollyhock-lined cottages at Presbyterian Sanatorium in Albuquerque. Source: Nancy Tucker Pictorial Collection of Southwest Materials, Center for Southwest Research, University Libraries, University of New Mexico

on buildings designed with an abundance of natural ventilation options provides for temperature regulation. This is especially beneficial in urban areas prone to ever more dramatic weather events, whereafter electricity is not always guaranteed. Better natural ventilation may also help to prevent heat-related deaths. The microbiome of a well-ventilated building resembles that of its exterior (Figure 3.3). There is one drawback herein, however, in the form of ambient air pollutants from smoke, smog, and industrial contaminants. This underscores the importance of clean air, as well as air-cleansing exterior agents like green space.

Access to Nature Another component to consider in the mitigation of airborne infections – and the prevention of many poor health outcomes, infectious, chronic, and environmental – is an expansion of access to outdoor community spaces. While weather may prevent gatherings from occurring in public outdoor spaces year-round, places like plazas, neighborhood parks, streets with wide sidewalks, trails, and other greenspaces offer opportunities to decrease the cumulative amount of time spent indoors and therefore the amount of time exposed to biological pollutants. This is emphasized amid COVID-19 public health orders that restrict indoor gatherings, leading many people to opt for outdoor socialization in public spaces. As environmental determinants of health, the trees and vegetation, greenspace, and bodies of water within the natural environment act as health protective factors. Herein, upper-level population approaches to prevention can impact large numbers of people. Evidence suggests that nature has many pathways to benefit health within three domains: harm reduction, capacity restoration, and capacity building (Markevych et al., 2017). There is also evidence of decreased mental distress with

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increased access to bodies of water, or bluespace, which provide opportunities for recreation, social connection, and, in urban areas, mental and physical recuperation (Nutsford, Pearson, Kingham, & Reitsma, 2016). Meanwhile, the stress of physical disorder is thought to undermine mental health in neighborhoods (O’Brien, Farrell,  & Welsh, 2019). While research suggests the natural world positively impacts health and safety, the causal pathways are not well understood, and evidence for practice and policy is lacking. More interdisciplinary research on the built environment is necessary to understand these complex etiologies. One certainty, however, is that public spaces are not equitably distributed, so access to their protective qualities is often out of reach for populations who have the highest disease burdens.

Conclusion Surveillance and infection control measures like testing and treating infectious diseases are fundamental to reducing their spread. This is particularly true for tuberculosis, where treatment takes time and consistency, and antimicrobial resistance poses an additional threat. As COVID-19 has emphasized, biomedical approaches to disease prevention and control alone are not entirely effective. In addition to vaccines, environmental approaches – avoiding time spent inside crowded buildings, improving ventilation, and employing source control using social distancing and masks – are essential to reducing the incidence of COVID-19. But different environments carry different levels of risk, based on building type and quality – a well-maintained single-family home versus an overcrowded studio apartment versus a prison cell. For the 1.6 billion people who live in inadequate housing, the 100  million people experiencing street homelessness, and the 11  million people in prison, most of the environmental approaches to health protection are not an option. The realities of our world, be they the material culture of architecture or the indoor airborne biological pollutants that make some people sick, can be constructed, deconstructed, and built anew. Poverty is too often assumed to be the result of personal failings or immorality on the part of individuals, while the financialization of housing lurks – almost invisible – as an underlying systemic determinant of poverty affecting vast populations. If the commodity-based logic behind global housing markets remains unaddressed, and if markets and governments remain unaccountable to human rights, health outcomes will worsen worldwide as people are pushed into inadequate housing and homelessness, and, subsequently, crowding conditions that give rise to the spread of airborne infections like TB. Human rights–based housing strategies should be adopted by states and cities, while housing models that exist beyond the for-profit system should be created. Some examples of solutions are robust taxes on foreign-owned property and banning mortgage foreclosures that result in eviction into homelessness. Another solution is the Housing First model, which meets people experiencing homelessness where they are by offering access to a subsidized, independent, private, permanent home with no obligations like sobriety or participation in treatment programs. Packing people into shelters, in addition to posing a risk of exposure to airborne and other infections, requires compliance with rules that may have them parting with possessions and pets, undermining individual stability. Thus far, evidence suggests that the Housing First model improves health and housing stability (Baxter, Tweed, Katikireddi, & Thomson, 2019). Designers and planners becoming more involved with the creation and implementation of equitable, health-promoting, upstream, policy-based built environment solutions are essential for a healthier world. To reduce the spread of airborne infections, this may involve working on updates to building codes that reemphasize the importance of natural ventilation. It may also involve advocating for more housing volume, affordable housing, Housing First, and housing policy that is accountable to human rights standards above all else. Ultimately, designers and planners have an opportunity to help dismantle population-level sources of poor health outcomes and reconstruct better circumstances.

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4 DISTANCING AND COLONIAL DESIGN Segregated Asylums to Control Leprosy in Suriname Stephen Snelders, Henk Menke, and Toine Pieters

Introduction Leprosy emerged in Suriname in the 18th century. This ‘new plague’, mainly prevalent in African slaves, was described as devastating, highly contagious, and coming from Africa (Fermin, 1764, Schilling, 1769). A ‘cordon sanitaire’ was constructed around sufferers, most of whom were African slaves. Leprosy sufferers were tracked down and incarcerated in one of the leprosy settlements established in the country from 1790 onward. After the abolition of slavery in 1863, their descendants (as well as Asian indentured laborers) continued to suffer from an oppressive health control system with a focus on segregation aimed at fighting leprosy. Suriname and its capital and most important city, Paramaribo, are situated in the northeastern part of South America (see Figure 4.1). The country is part of the larger Guiana Shield and the Amazon biome, the largest tract of continuous tropical forest in the world. The Guiana Shield, sandwiched between the majestic Amazon and Orinoco Rivers, is a geographical region sometimes referred to as the land of the many rivers. The Surinamese rainforest includes a great variety of flora and fauna. It was in this tropical biosphere that the Surinamese leprosy narrative of the asylums that are the subject of this chapter, Batavia and Bethesda, unfolded. The segregation of leprosy sufferers in Suriname was intimately connected with the perceived threat of the disease to the functioning of the plantation economy and the labor market, as well as the physical proximity of the enslaved and other leprosy sufferers to white colonizers. Plantation owners, colonial administrators, doctors, and surgeons directed their ‘colonial gaze’ to the sufferers, connecting disease conditions with racial identities and ‘othering’ the diseased bodies that had to be segregated (Snelders et al., 2021) Doctors and surgeons routinely emphasized the so-called fatalism and unhealthy, slovenly lifestyle of especially the Afro-Surinamese, claiming these factors contributed to the spread of the disease and making compulsory segregation a perceived necessity for keeping the colony and its economy healthy. An edict of 1790 ordered the compulsory segregation of enslaved sufferers, and the leprosy edict of 1830 ordered the compulsory segregation of all sufferers. Those who were supported by their families and social networks, such as wealthier white sufferers, could isolate themselves in their own homes. Black, enslaved sufferers (and a few poor whites), and, after the abolition of slavery in 1863, the poor Afro-Surinamese, Chinese, and British DOI: 10.4324/9781003214502-4

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FIGURE 4.1  Map

of Suriname with the capital Paramaribo and the leprosy settlements Batavia and Bethesda

Source: Adapted from Hendrik Rypkema, Naturalis Biodiversity Center, Leiden, the Netherlands.

Indian indentured laborers were forcibly relocated to leprosy asylums: Voorzorg, established in 1791; its successor, Batavia, established in 1824 and functioning until 1896; and afterward to the ‘modern’ leprosy asylums Groot-Chatillon, Bethesda, and Majella (Snelders, 2017). Understanding the architecture of the leprosy asylums is essential to understanding the quality and effectiveness of the colonial system of segregation. Three interrelated elements can be distinguished when considering the effectiveness of the architecture of leprosy asylums in colonial times in Suriname: (1) the rainforest, (2) the built structures, and (3) the people (i.e., the patients with their feelings and ideas about their disease and their relationship to the colonizers and the staff). In the following discussion, we focus on these elements in two asylums, one from the period of slavery (Batavia) and one ‘modern’, post-slavery establishment (Bethesda).

Batavia: A Failed Architecture of Isolation The predecessor of the Batavia asylum, Voorzorg, had been insufficiently isolated from nearby plantations and there had been many complaints by slave owners that so-called asylum ‘malingerers’ defied regulations and restrictions and visited the plantations (Snelders, 2017, p. 95). When restructuring its leprosy policies in the 1820s, the colonial government therefore decided to build a new asylum in an even more isolated place in the jungle. Batavia was established on the right bank of the

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Coppename River and was surrounded by jungle on the land side. Even today, it takes almost half a day to reach Batavia from the city of Paramaribo by car to the river and farther on by motorboat. In the 1820s, there was no road to the river and visitors had to sail from Paramaribo to the mouth of the river and then follow the river in a pinnace or rowing boat, a journey that took at least two days. To the government, the asylum was sufficiently distant from the city to send sufferers of leprosy and elephantiasis (filariasis) there, who would have few opportunities for escape (for the founding of Batavia, see Kronijken van het etablissement Batavia, n.d.; a visit to Batavia in 1827 is described in Van Hasselaar, 1835, p. 27). The schematic map of the Batavia asylum shown in Figure 4.2 dates from the last decade of the asylum’s existence. It is simplifying and abstract and does not depict the many curves in the outlay or all the buildings. However, for our purpose, it is a good example of a visual presentation of the colonial gaze in action. This gaze is expressed in three disciplinary regimes: religious, medical, and administrative. From the buildings that house these regimes, the colonial gaze is directed at the dwellings of the sufferers, located on the ‘street’ (a dirt road) leading from the cross on the riverbank to the director’s building at the end of the street. Before reaching the latter building and the dwellings, one passed the physician’s house, the ‘hospital’ (a couple of small rooms that at one time doubled as prison cells for unruly inmates), and the Catholic church (as well as the chapel, which is not pictured on the map). The buildings are enclosed by the river on one side and by jungle on the other side. These natural isolating barriers prevented sufferers from crossing to the world outside. The map, however, is a colonial ideal representation of the leprosy settlement rather than a natural drawing effort. The abstractness and simplicity of the map demonstrate the wishful character of the colonial gaze. To start with, the architecture of Batavia was never designed in this way. The historical genealogy of Batavia shows that most of the asylum grew accidentally within the boundaries of the allotted land. At the beginning, in 1824, there was no cross, no physician, and no church. The colonial establishment of Suriname was predominantly Protestant. Catholics had only received the freedom of worship in 1816. They were not allowed to preach to or attempt to convert

FIGURE 4.2 Schematic

map of the leprosy colony Batavia

Source: Archive Kloosterleven St Agatha, inventory nr. 9301.

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the enslaved on the plantations with only one exception: the leprosy asylum. Work in the asylum therefore became essential for the Catholic religious mission in Suriname: first, to convert and gain followers and, second, to demonstrate to the colonial state Catholic reliability and trustworthiness. Assisting in the care for the leprosy sufferers forged a ‘symbiosis’ between the Catholic Church in Suriname and the colonial state (Bijker, 1993). In 1826, two years after the establishment of Batavia, a Catholic missionary from the Netherlands named Martinus van der Weijden consecrated a hut as a Catholic place of prayer with the support of the government-appointed director of the asylum (who happened to be a Catholic); at the same time, he baptized 120 of the approximate 200 sufferers. Erecting a cross that was directly visible on arriving in Batavia was an essential part of this priest’s baptizing strategy. The cross stood where a kankantri tree had been, a tree that in Afro-Surinamese magical Winti beliefs was considered a dwelling place of spirits. Beneath these trees the enslaved held their secret rites of worship on the plantations. To the missionaries, the trees were sites of devil worship. Van der Weijden had the tree felled (or, in another version of the story, the tree fell during a storm). In its place, he erected a large wooden cross – an essential architectural move in instilling a new Christian identity in the sufferers. Van der Weijden did not survive the felling of the kankantri for long: he succumbed to a fever after returning to Paramaribo; the cross, however, remained in Batavia (Bosser, 1884, pp.  195–196; Snelders, 2017, pp.  97–99). Other Catholic architectural elements followed. A  Catholic burial ground was consecrated in 1827 (Schalken, 1985, p.  14). A church and a rectory were consecrated in 1836 (Inwijding, 1836). This Saint Rochus church also attracted believers from the surrounding region, creating a gap in the wall of isolation around the asylum. In addition, a chapel was built in 1841 (Bosser, 1884, p. 222). For its activities in Batavia of caring for the spiritual and physical health of the sufferers, the Catholics received financial compensation from the colonial government and a priest took permanent residence in Batavia from 1844 onward (Bosser, 1884, p. 231). It took even longer for medical services to be established in Batavia. The first medical doctor, L. A. A. Deutschbein, was only appointed in 1850, years after the arrival of the priest (Snelders, 2017, p. 68). It had thus taken 25 years for the three disciplinary regimes mentioned above to be fully in place in Batavia. Still, these regimes lacked efficacy. To start with, the population was often too large, especially at the height of the leprosy surveillance regime from 1830 to the abolition of slavery in 1863. In the mid-1820s, 200 sufferers lived in the asylum; in 1833, this number had already doubled, and it rose to almost five hundred at its highest point in 1849. In 1863, there were still 380 sufferers in the asylum. After abolition, this number went down and remained stable at less than 100 inhabitants after 1884 (Snelders, 2017, pp. 102–105). But before abolition, Batavia was simply overcrowded. Moreover, not all inmates of the asylum were actually suffering from leprosy or elephantiasis. In 1849, 20 percent of the inmates were not infected at all (Mededeelingen, 1849, pp. 356, 770). Deutschbein observed after his arrival in 1850 that 121 inmates had actually been born in the asylum, of which only 26 had leprosy. Healthy men and women lived with infected partners and even had healthy children with them (Deutschbein, 1852). Furthermore, the hygienic situation left much to be desired. The 1854 report of Deutschbein’s successor K. Ooijkaas stated that the asylum was too close to swamps and the sea, with scorching heat in the daytime alternating with cold and foggy nights and damp mornings; that dwellings were in bad repair (see Figure 4.3); that food allowances were meager because of high costs; and that fresh drinking water was scarce because of the lack of watering holes. People had no woolen blankets to keep them warm at night, and half of the inmates suffered from remittent fevers, while one in fifteen had infections or rheumatic pains. The doctor’s hospital consisted of two small rooms, each with only a tiny window that was barred because the rooms were also used as a courtroom and jail (Schneevogt, 1854). The 1830 regulations for Batavia entitled the director to arrest inhabitants and lock them up for up to eight days with or without chains and to extend the period of arrest according to his discretion (Regulations, 1830).

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FIGURE 4.3 Batavia

dwellings

Source: Drawing by Arnold Borret, c. 1883. Source: KITLV/ Royal Netherlands Institute of Southeast Asian and Caribbean Studies, Leiden, The Netherlands, KITLV 36C 193.

Amid this situation, the asylum turned out to be less isolated than expected. The river was illegally used by inmates to connect to the outside world and to evade Catholic-imposed discipline. One notorious Afro-Surinamese had his own rowing boat in which he frequently left Batavia without permission, running his own smuggling racket to deliver rum to the inmates. When caught in the act of smuggling by the priest in 1849, the priest had the boat sunk. The next day the priest was dead, poisoned by his Afro-Surinamese household on the instigation of the smuggler (Kronijken, n.d., pp. 5–6; Bosser, 1884, p. 237; Snelders, 2017, p. 107). Peerke Donders, who became the priest in Batavia in 1856, genuinely cared for the sufferers’ interests. For instance, he successfully campaigned for the replacement of earthen floors in the huts with wooden ones and for the distribution of beds to sufferers (Klinkers, 2003, p. 53). On the other hand, Donders had his own conflicts with inmates, such as when sufferers smuggled in rum from a nearby plantation and became inebriated and rowdy. Donders tried to calm them down but was cursed and even physically assaulted (Kronenburg, 1925, p. 127). The healthy rowers of the government boats and servants held nightly dance parties with the inmates and drove Donders away when he tried to stop them (Kronenburg, 1925, p. 208). After the abolition of slavery, incidences of violence and frustration continued to be reported in Batavia. But while the disciplinary regimes clearly lacked effectiveness, a report of a visitor to Batavia in 1895 painted a rather nuanced picture of life there. Naval medical officer Peter Lens emphasized the inmates’ practices of mutual aid for each other, whether infected or not. The lack of effectiveness of the disciplinary regimes also had its advantages: mutual sexual intercourse between sufferers and non-sufferers abounded, healthy boat crews and native Amerindians mingled with the inmates, fear of contagion seemed to be absent, and, most remarkably, most sufferers left the premise at will to hunt and fish (Lens, 1895, pp. 531–544). Batavia was very much a failed attempt at isolation. In the new leprosy asylums of the twentieth century, the principles of the isolation regime were therefore more strictly and systematically put into practice.

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Bethesda: An Attempt at ‘Distancing’ Through Design The leprosarium Bethesda,1 which opened its doors in 1899, was located on the Upper Suriname River in the tropical rain forest. Bethesda can be regarded as the answer that Dutch Protestant churches put forward to the Roman Catholics’ dominant position, which had been built up in the leprosy field in Suriname in the 19th century. The Catholics left their mark on Batavia. On top of that, in 1896, they opened their own leprosarium, Majella, in the Surinamese capital of Paramaribo itself. All this was a thorn in the side of the Protestants. Bethesda was a project of three Protestant churches in Suriname: the Dutch Reformed Church, the Dutch Lutheran Church, and the German Moravian Brethren. The care for inmates in Bethesda was placed in the hands of the Moravians, a Protestant denomination founded in Bohemia, which had been involved in missionary work in Suriname since the 18th century (Van Eer, 2021, p. 58). Rev. Henry Weiss, the director of Bethesda from 1901 to 1906, explained that Bethesda was intended to be a small colony, ‘a state within a state’, where ‘those predestined by God’s secret decree to go through the great agony, could meet’ (Weiss, 1915, p. 66). Weiss returned to Europe in 1906, and when he revisited Bethesda in 1914, he was proud to note that the deaconesses were still willing to sacrifice themselves (Weiss, 1915, p. 69). These nurses were disciplined in the Emmaus Deaconess Institution in Niesky, a town in Germany where young women were educated in theoretical and practical nursing but, more particularly, in character building and moral sacrifice (Stern, 2010). Bethesda was built and maintained with funding from various sources, including the colonial government and private individuals of Suriname, the Protestant churches in the Netherlands, the Dutch royal family, the German Moravians, and the Bethesda Leper Home Society in Buffalo, New York (Veertig jaren, 1939; Snelders, 2017, p. 231). The number of patients grew from ten in 1900 to a little over 100 in 1933 (Snelders, 2017, pp. 164–165), when the asylum was moved to a new location just outside of Paramaribo (Snelders, 2017, p. 232). We describe the architecture of Bethesda using the floor plan published in 1916 (see Figure 4.4). It is again not an ideal colonial representation, but it matches more accurately with the situation on the ground when compared with photographs from the asylum (see Figure 4.5), especially those in the Martha Stern collection (1904–1937) made by Augusta Curiel (Menke, 2015).2 Before zooming in on the asylum, we elaborate on the geographical location of Bethesda and the surrounding environment. Bethesda was constructed right next to Groot-Chatillon (from here on, Chatillon), the public leprosy asylum that was the successor of Batavia and opened in 1896. Bethesda and Chatillon were located on the right bank of the (Upper) Suriname River, one of the main streams of the Guiana Shield that flows from the southern highlands to the north and into the Atlantic Ocean. The capital, Paramaribo, is about 40 kilometers to the north, on the left bank of the Suriname River (see Figure 4.1). In the first two decades of its existence, Bethesda could only be reached from Paramaribo by boat. We visited the site where Bethesda was located by crossing the river with a small craft propelled by an outboard motor, departing from Domburg, a village on the left bank of the river.3 We experienced a fast-flowing river with strong waves, especially when the northeast trade winds pick up in the afternoon hours. At Bethesda, the river has a width of 400 meters and a maximum depth of 9 meters (Loose, 2008, p. 13). The earth in that region consists of an elevated, sandy loam soil (Wong, 2021). The location of the asylum on a strong bend in the river gives the impression that one is on an island (see Figure 4.4, inlay). The first Surinamese leprosy colony, Voorzorg (1790–1824) had also been located at a strong bend in a river (the Saramacca River), again suggesting an island. This reminds us that elsewhere (outside of Suriname), leprosy asylums were often deliberately established on islands in order to maintain segregation and prevent the escape of patients; for example, the Iles Saint Louis in the Maroni River in French Guiana (Souza-Arauja, 1945, p. 591) and Kaow Island in the Essequibo River in (British) Guyana (Gampat, 2015), neighboring countries of Suriname.

Distancing and Colonial Design  49

FIGURE 4.4 Schematic

map of the leprosy colony Bethesda

The inlay (top right) indicates the position of Bethesda, next to Chatillon, in a strong bend on the Suriname river. Source: Het Utrechts archief, nr. 895 (Utrecht, The Netherlands). Source of the inlay: Elsevier’s Geïllustreerd Maandschrift 5 (1895), p. 548. The original plans are adapted by the authors.

In understanding the role of location and architecture in the fight against leprosy, it is important to note that although the microorganism causing leprosy had been discovered by Hansen in 1873, there was no effective treatment before the Second World War. The isolation of patients, enshrined in several successive laws, was seen as the only way to combat the disease, and isolation continued to be the primary target of the government’s leprosy policy. This policy remained based on the edict of 1830. Distancing, nowadays (in the coronavirus era) a fashionable word, was also key at the time. Thus, the construction of a ‘cordon sanitaire’ around the patients, can be considered the quintessence of the architecture of the ‘modern’ leprosy asylums like Bethesda. The river and the rainforest constituted a supposedly impermeable natural boundary to civilization. In addition to this cordon sanitaire, there were also barriers enforcing distance within the territory of Bethesda itself, between the staff (healthy people) on one side and the patients with Hansen’s disease on the other. Bethesda was a small community, originally consisting only of a Protestant church, a house for the Moravian director and preacher or ‘teacher’ and his family, and two little houses for the patients (Snelders, 2017, p. 231).4 With the increase in the number of patients, more buildings were constructed. The total inmates reached 20 in 1903, 40 in 1910, and stayed between about 50 and 60

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FIGURE 4.5 Leprosy

asylum Bethesda

The Rev. Henry Weiss, his wife, and two deaconesses are standing on one of the bridges connecting the patients’ side and the staff’s side. In the background are the chapel and the laundry. Photo probably taken between 1904 and 1907 by Augusta Curiel (Stern, 2010). Source: Iris Stern and Carl Hartmut Werner, Curitiba, Brazil.

from 1912 until 1928, when it further expanded to 110 in 1933 (Snelders, 2017, pp. 164–165). In 1908, a large house for the deaconesses and a big kitchen and new apartments for patients were constructed, followed in 1924 by a building for children (Verslag, 1925, p. 20; Snelders, 2017, pp. 231, 244). The houses were all made of wood supported on concrete blocks, which prevented contact with the soil, thus contributing to hygiene. Bethesda was characterized by separation and hierarchy. It consisted of two distinct parts: one part (in the front) for the staff and one part (in the back) for the leprosy patients. A small canal (creek) traversed by two bridges formed a boundary between the two parts. The residences of the director and deaconesses and a guest house were located at the front, near the river. Behind these buildings were houses for servants, a laundry, a kitchen, and a warehouse. A chapel, the Protestant’s signature of Christianity and ‘spiritual hygiene’, was located near the canal at the front (see Figure 4.5). At the back, the homes of male patients and female patients (see Figure 4.6) were separated by a small canal because in Bethesda, as in the Roman Catholic institution of Majella, love affairs and marriages were forbidden. To contribute to the food supply (and intended as occupational therapy), there were chicken coops, a pigpen, and farmland. Furthermore, on the backside, there was a shoemaker and a carpentry workshop. Bethesda didn’t have its own dock, but a bridge over the canal that formed the border between Bethesda and Chatillon allowed access to the landing stage for boats at Chatillon. The location of Bethesda on a river and the hierarchical arrangement of the buildings were reminiscent of the basic structure of slave plantations (Kapper, 2011, p. 38). The houses of the director, the deaconesses, and the other staff exerted their colonial gaze over the separated compounds of the patients and their activities. This arrangement reflected the power relations in Suriname and

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FIGURE 4.6 Leprosy

colony Bethesda

Housing of male patients. Photo probably taken in the first two decades of the 20th century by Augusta Curiel (Stern, 2010) Source: Iris Stern and Carl Hartmut Werner, Curitiba, Brazil.

the continuing dominance of white colonial rule and of racist thought. The majority of the leprosy patients were Afro-Surinamese descendants of slaves (Snelders, 2017, pp. 164, 200). The distancing in Bethesda was a second layer to the preexisting primary layer of social distance which was characteristic of colonial society. Bethesda was situated in the middle of what was regarded as an abandoned plantation area that was overgrown by the jungle. In publications of the Protestant church, a picture was painted of an ideal and even idyllic village. Protestant patients who elected to go to the asylum in the jungle and stay with their religious brethren were praised (Snelders, 2017, p.  230). The protestant preacher Weiss wrote: Bethesda, where the sick who walk through the flower garden forget that they are sick, is not a place to whine and complain all day long. It is the land of joy and sorrow, of children’s play and children’s dreams, a home and a fatherland for many who had no home and no homeland . . . (Weiss, 1915, p. 70) This can be seen as propaganda in the service of national and international fundraising and as a manifestation of the Protestant rivalry with the Roman Catholic asylum Majella, located in Paramaribo. Nevertheless, judging by the photos in the Martha Stern collection, it can indeed be concluded that Bethesda was a well-maintained settlement, with neat wooden buildings connected by cement pathways and decorated with flowering plants. In this well-ordered settlement, discipline, religion, and spiritual and physical hygiene were key concepts put into practice through church

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FIGURE 4.7 Bethesda

Handicraft class led by leprosy patient Celine Mesquita (standing). The deaconess keeps a watchful eye in the background. Photo probably taken in the first two decades of the 20th century by Augusta Curiel (Stern, 2010). Source: Iris Stern and Carl Hartmut Werner, Curitiba, Brazil.

attendance, school attendance, Sunday school, handicraft classes (see Figure 4.7), patient orchestra, and occupational therapy. The spiritual and physical care of the inmates was in the hands of German deaconesses dressed in spotless white attire, whose watchful eyes and colonial gaze were everywhere. Recruited in Germany by the Moravian Church, their numbers increased from two in the early years of Bethesda to six in 1914 and nine in 1933. The deaconesses were assisted by Surinamese servants who were subordinate to them. There was initially a language barrier because the deaconesses did not speak Dutch or Sranang (the local creole language). Later on, in 1930, the deaconesses took a course in tropical hygiene in Amsterdam and learned the Dutch language before they went to Suriname (Stemmen, 1937, p. 11; Snelders, 2017, p. 233). While the disease, the architecture, and social and cultural differentiations stipulated distancing, in the practice of care maintaining this distance could be illusory (see Figure 4.8). There were surely warm and enduring relationships between deaconesses and patients, for instance the special bond between Celine Mesquita (leprosy patient and teacher) and Deaconess Martha Stern. This relationship persisted after Martha’s departure to Germany and later to Brazil, as evidenced by the correspondence between the two (Stern, 2010). Patient–staff relationships were also affected by the relationship between Bethesda and the neighboring Chatillon asylum. In the secular Chatillon asylum, the general atmosphere was quite different from the Protestant care system in Bethesda. Chatillon, however, had amenities that Bethesda lacked, such as two boat landings (one for staff and healthy visitors at the front and one for patients at

Distancing and Colonial Design  53

FIGURE 4.8 Bethesda

Deaconess Martha Stern takes care of the wound of a leprosy patient. Photo probably taken between 1904 and 1907 by Augusta Curiel (Stern, 2010). Source: Iris Stern and Carl Hartmut Werner, Curitiba, Brazil.

the back), a hospital, and a cemetery. The Bethesda personnel and inmates were allowed to use these facilities. People from Bethesda also regularly attended religious services in the Protestant church of Chatillon (Weiss, 1915, pp. 70–71). But there were tensions between the two leprosy asylums, arising from their different characters. In Chatillon, relationships between men and women and even marriages were allowed. These relationships were forbidden in Bethesda. The rules enforced by the deaconesses were strict. If anyone violated them, there was no pardon. It turned out that patients at Bethesda and Chatillon regularly secretly crossed the border (the canal crossed by bridges), something that was actually forbidden. According to the Bethesda staff, this led to ‘fornication and theft’ (Stemmen, 1932, p. 32; Snelders, 2017, p. 234). In the first quarter of the century of Bethesda’s existence, no fewer than 32 inmates were permanently transferred to Chatillon for disciplinary reasons. One female patient who had been transferred was discovered in a man’s apartment (in Bethesda) at night. The close proximity of Chatillon and the potential punishment of transfer might account for a lack of reports of patients actually fleeing Bethesda. Another obstacle to flight was the distance to Paramaribo. This was also perceived as a problem by the families of patients living in the city. From the beginning of Bethesda, the Protestants dreamed of moving their institution closer to Paramaribo (see for instance a report in the colonial newspaper Suriname of 15 September 1905). In 1912, the newspaper De West even reported that a 12-year-old girl was taken back from Bethesda by her mother and transferred to Majella. The child had to change her faith and became a Roman Catholic (De West 31 May 1912).

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It will be clear from the foregoing that the physical and spiritual hygiene pursued at Bethesda could be achieved through architecture (laundry, bathroom, chapel, workshops to counter emptiness) and through the lifestyle and educational power of the deaconesses, whose clean and white clothing symbolized spiritual purity and hygiene. But at the same time, the institution, the cordon sanitaire, and the system of distancing were under constant pressure due to (1) the institution’s distance from Paramaribo and the competition with Majella; (2) contact with the ‘depraved’ neighbors, the inhabitants of Chatillon; and (3) the destructive power of the river. The fast-flowing river eroded the sandy banks above, already threatening the director’s residence soon after the opening of Bethesda. In 1913, this residence had to be rebuilt, but the river continued to threaten the physical existence of the settlement. (Chatillon, on the other hand, was not affected because of the sound revetment on its bank.) In 1928, a bank shear of up to 20 meters was reported in Bethesda. Because of this, as well as the increasing population, the decision was made to move the asylum. Construction began on a new facility in 1932, which included transferring some of Bethesda’s buildings. In 1933, the patients who stayed in Bethesda were given a new place to live just 10 kilometers south of Paramaribo. Patients and staff were happy with the move. The new location was appropriately named New Bethesda (Stemmen, 1932, p. 38).

Conclusion This chapter is about the spatial architecture of leprosy control in colonial times in Suriname. A ‘cordon sanitaire’ was constructed around the patients, mainly African slaves (but from the late nineteenth century, a growing number of Asian indentured laborers) and their descendants. The ‘cordon sanitaire’ was created in the form of stringent and eventually severe leprosy containment policies that can be labeled as chasing and jailing people with boasie (the local name of leprosy), a strategy that was continued until the middle of the twentieth century. The daily life of the patients was linked with both the racially stigmatized microcosm of the leprosy colonies and with the natural environment. The water and jungle around the settlements constituted natural barriers, acting as the envisaged cordon sanitaire and discouraging patients from running away. The building plan of the asylums demonstrated a basically hierarchical arrangement, mirroring the power relations of the colonial plantation society. Illustrative of this is the plan of Bethesda (see Figure 4.4), with the director’s house and office situated prominently in the front, close to the river and clearly visible when arriving by boat. The management buildings (e.g., nurses’ housing) were located next to this house, and behind these buildings at the back of the leprosy village, one would find the dwellings of the inmates. The asylum constituted a microcosm that resembled the social stratification of colonial society with its own customs and rules. Tightening the cordon sanitaire in modern leprosy settlements mirrored the social distancing and stigmatization of leprosy patients within the macrocosm of Surinamese society, while at the same time reflecting social distancing (class and color) in colonial Suriname, related to colonial power relations. The oppressive health control regime was not naturally accepted by Surinamese patients and their families, who – whether incarcerated or not – resisted the cordon sanitaire in one way or the other. This is exemplified in the rather chaotic and unruly situation at the Batavia settlement (‘a battleground in the jungle’), with frequent smuggling of rum and food, busy traffic of people in and out, as well as acts of resistance against the authorities. The river turned out to be not always a barrier but made, at the same time, communication with the outside world possible for the inmates. Running away for shorter and longer periods, romantic and sexual relations, and food riots were all regular practices. The lives of the inmates were intertwined with the natural habitat. This is not surprising if we take into account that the settlements were surrounded by jungles and rivers. The food supply could be supplemented with hunting and fishing. In addition to its role in supplying food and leisure activities, the natural environment also played an important

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role in the inmates’ efforts to treat and cope with their disease. Disobedience and resistance did not stop with the establishment of the far more disciplined and relatively comfortable, modern asylums like Bethesda. Paradoxically, the same isolation in the asylums that the patients resisted also offered them protection against the stigma and anxiety experienced as a result of their disease in the ­macrocosm of Surinamese society.

Acknowledgments The authors would like to acknowledge Frank-Jan van Lunteren, MA, and Elodie da Silva, PhD, for their technical assistance in constructing Figures 4.1, 4.2, and 4.4, and Kathryn Burns for her native language editing services.

Notes 1. Bethesda is used worldwide as a proper name for a diversity of health institutions. It comes from the Gospel of John in the New Testament of the Bible; it is the name of a bath in Jerusalem; from time to time, an angel stirred the water, and the sick person who came in first became healthy. 2. Augusta Curiel worked as a photographer in Suriname from 1904 to 1937. 3. Two of the authors (Henk Menke and Toine Pieters) visited the deserted sites of the leprosariums Bethesda and Chatillon three times between 2016 and 2018. 4. For a pictorial image of Bethesda, see Bethesda (1902); Stemmen uit Bethesda 1900–1951; Stern (2010).

References Bethesda. Een liefdewerk der protestanten in Suriname. (1902). Een liefdewerk der protestanten in Suriname. ­Paramaribo: Protestantsche Vereeniging ter verpleging van Lepralijders in de kolonie Suriname. Bijker, K. (1993). Power, prayer and colonial pacification: The Roman Catholic mission in nineteenth century Suriname. In M. Bax and A. Koster (eds.) Power and Prayer: Religious and Political Processes in Past and Present. Amsterdam: VU University Press. Bosser, A. (1884). Beknopte geschiedenis der katholieke missie in Suriname. Gulpen: M. Alberts. Deutschbein, L.L.A. (1852). Report. Tijdschrift voor de Wis- en Natuurkundige Wetenschappen, 5, 100–105. Eer, E. van. (2021). Conversion of Maroons to Christianity, an important tool towards allopathic health care in the upper Suriname River (1760–1960). In H.E. Menke et al. (eds.) Social aspects of Health, Medicine and Disease in the Colonial and Post Colonial Era. New York: Routledge. Fermin, P. (1764). Traité des Maladies Fréquentes á Surinam et des Remèdes le plus Propres à les Guérir. Maastricht: Jacques Lekens. Gampat, R. (2015). Guyana, from Slavery tot the Present, 2, Major Diseases. Bloomington: Xlibris. Hasselaar, A. van. (1835). Beschrijving der in de kolonie Suriname voorkomende elephantiasis en lepra (melaatschheid). Amsterdam: S. de Greber. Inwijding der kerk op het etablissement Batavia kolonie Suriname. (1836). De Godsdienstvriend, 247–253. Kapper, A. (2011). Plantages langs de Commewijnerivier, de goudkust van Suriname. Vitruvius, 4, 36–42. Klinkers, E. (2003). De bannelingen van Batavia: Lepra-bestrijding gedurende de negentiende eeuw in koloniaal Suriname. OSO, 22, 50–61. Kronenburg, J.A.F. (1925). De eerbiedw, dienaar Gods Petrus Donders C.ss.R. Nieuwe levensbeschrijving. Tilburg: W. Bergmans. Kronijken van het etablissement Batavia. (n.d.). Archive Bisdom of Paramaribo, T1, 3. Lens, T. (1895). Lepra in Suriname. Elsevier’s Geïllustreerd Maandschrift, 10, 521–552. Loose, M. (2008). Morphodynamics Suriname River: Study of Mud Transport and Impact Due to Lowering the Fairway Channel, unpublished MSc Thesis, Delft University of Technology. Mededeelingen nopens de lepra in onze West-Indische bezittingen. (1849). Nieuw Praktisch Tijdschrift voor de Geneeskunde, 28, Nieuwe reeks 1, 546–568, 761–770. Menke, H. (2015). Machtsverhoudingen in een Surinaamse Leprozerie; reflecties naar de aanleiding van de Martha Stern fotocollectie. Academic Journal of Suriname, 6, 561–573. Regulations. (1830). Archive Bisdom of Paramaribo, no inventory number.

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Schalken, A.C. (1985). Historische gids bestaande uit chronologische lijst naamlijsten varia registers. 300 jaar R.-K.-gemeente in Suriname 1683–1983, unpublished document. Schilling, G.W. (1769). Verhandeling over de Melaatschheid, Ph.D. Thesis, Utrecht University. Schneevogt, V. (1854). Verslag op het rapport van den heer Ooijkaas, omtrent het lepreuzen etablissement Batavia, in de kolonie Suriname. Verslagen en Mededeelingen der Koninklijke Akademie van Wetenschappen, 2, 381–388. Snelders, S. (2017). Leprosy and Colonialism: Suriname under Dutch Rule, 1750–1950. Manchester: Manchester University Press. Snelders, S., van Bergen, L., and Huisman, F. (2021). Leprosy and the colonial gaze: Comparing the Dutch West and East Indies, 1750–1950. Social History of Medicine, 34, 611–634. Souza -Arauja, H.C. de (1945). A lepra na Guiana Francesa. O problema da lepra na America do Sul (Memorias do Instituto Oswaldo Cruz), 43, 3. Stemmen uit Bethesda Journal. (1900–1951). Amsterdam: De Bussy. Stern, I. (2010) Sternensaat. Curitiba: Brasil. Veertig jaren protestantsche melaatschen verpleging ‘Bethesda’ in Suriname, 1899–1939 (1939). Veertig jaren protestantsche melaatschen verpleging ‘Bethesda’ in Suriname, 1899–1939. Paramaribo: Protestantsche Vereeniging tot verpleging van lepra-lijders in Suriname (Bethesda). Verslag van bestuur en staat van Suriname. (1925). https://catalogue.nla.gov.au/Record/2154799. Weiss, H.G. (1915). Vier maanden in Suriname. Nijkerk: G.F. Callenbach. Wong, T. (2021). Personal communication.

5 PINE FOREST AND SUNLIGHT Alvar Aalto’s Paimio Sanitorium Virginia Cartwright

Introduction In Finland, as in other countries in the 1920s, tuberculosis was a quietly lethal plague. There were no medicines to cure it before the 1943 discovery of streptomycin by Selman Waksman, and thus, tuberculosis had a devastating effect on populations around the world. Until the 1950s, the primary treatment of tuberculosis was the rest cure in a sanatorium specifically designed for this purpose. In Finland in 1920, the death rate due to tuberculosis was 261 per 100,000 inhabitants, among the highest rates in Europe (Godias, 1945). With independence from Russia, Finland could act quickly in recognizing this public health crisis as early as 1917. Consequently, Finland established funds, through nongovernmental associations, to dedicate to tuberculosis control, including the construction of medical facilities dedicated to its treatment. This initiative coincided with two other significant factors of the time: the particular use of sanatoria to treat tuberculosis based on Hermann Brehmer’s facility for the treatment of tuberculosis in Görbersdorf and the development of “modernism” with its emphasis on functionalism in architecture. The medical community recognized by the late 1800s that dust, dampness, and poor ventilation encouraged the spread of tuberculosis. The new industrial world relied on laborers, who lived in densely populated urban centers, with minimum sanitation and open space, where these unhealthy conditions were rampant. Malnutrition was another contributing factor. Diseases, including tuberculosis, moved freely in these areas. Tuberculosis was particularly significant in that it affected many young people of working age who were critical to the industrial efforts. The first successful treatment leading to a cure for tuberculosis was proposed in 1854. Hermann Brehmer, the acknowledged originator of the sanatorium movement, opened the first-ever high-altitude sanatorium to treat pulmonary consumptives, at Görbersdorf, in the Silesian mountains (today modern Poland). Brehmer’s initial reasoning that the physiological benefits of an active physical life at high altitude would restore health to these patients was faulty. He soon reversed course, however, and switched to a regimen of lengthy rests, chiefly in outdoor lounges, and, when needed, using open-air shelters to provide optimal airy conditions; mild, prescribed exercise; and a healthful diet (Murray et al., 2015). Exposure to sunshine was a critical part of the treatments. Thus, the recognized treatment of tuberculosis patients in 1929 consisted of isolation, to prevent the spread of the disease, and exposure to plenty of sunshine with clean, pure air. Across Europe and in North America, sanatoria were DOI: 10.4324/9781003214502-5

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developed in locations remote from the city and industrial areas, both to prevent the dissemination of the bacterium and to give the patient plenty of unpolluted air. Many sanatoria, although not all, were located at high altitudes, which was thought by some to promote recovery. As complete bed rest, a carefully prescribed diet, and exposure to clean air and sunshine were the primary modes of treating tuberculosis at the time, buildings were designed with large windows and balconies or terraces, where patients spent many hours reclining in the sun and fresh air. Accordingly, a majority of the sanatoria designed using these principles had private, individual terraces or balconies in each patient room. Moderate exercise and, when patients were well enough, socializing to help prevent depression were also part of the regimen. The sanatoria grounds frequently had gardens for light exercise and walking. Patients remained in these sanatoria for quite long periods. The average stay was seven months. While these treatments did not cure tuberculosis, they did help the patients’ immune systems, which, in turn, allowed some patients to recover from tuberculosis. In the early 20th century, adherents of modernism proposed a new architecture, incorporating new technologies, to respond to the new social conditions of the early 20th century, including the treatment or eradication of disease, and the promotion of healthy living. Also thought of as functionalism, architects designed buildings in this mode where the external forms of the buildings took shape based on their internal functional needs. Functionally or programmatically distinct parts of buildings were given unique forms and exterior expressions. One could “read” the distinct functions of a building by the size and proportion of the building volumes and by the windows and other apertures on the elevations. Whereas earlier approaches to building design often compressed the functions together to create a simple singular volume, modernist architects ‘pulled’ the components apart and loosely linked by corridors or other circulation systems. One could say that buildings were composed as one might compose a still life with various forms, each of which was independent of its neighbors to a lesser or greater degree with ‘breathing room’ in between. The adoption of new structural materials such as reinforced concrete opened up the interior spaces through the use of columnar supports with greater spans than were achievable using older systems that used wood or masonry. The new ability to cover large expanses of interior space with minimal ‘point’ loads freed the walls of their traditional load-bearing roles. Without the need for heavy masonry walls at close intervals, the interior spaces composed of light reinforced columns might flow into one another or be separated by partitions that acted as screens but had no load-bearing purpose. The exterior walls of modernist buildings, also freed of their traditional structural role, could thus make full use of the newly developed process of making plate glass in large panels, as well as accommodating large multipaned steel-frame windows. The results were extensive areas of glass and openings to the exterior that could let in as much sunlight as possible. Connections to the exterior, using terraces and balconies and large glazed walls or doors, promoted the new healthy lifestyle. Building surfaces, both exterior and interior, were primarily white stucco or plaster, which promoted cleanliness and served as a symbol of purity and cleanliness. Ornament and detail were stripped away as symbols of the old. New technology, such as centralized heating and electric lighting, freed interiors of the smoke and ash of fires and oil lamps, which might have soiled white surfaces. Clean white walls, sunny rooms, and connections to exterior terraces defined both the modern movement and the sanatorium movement. This new architectural movement corresponded with Finland’s new status as an independent nation, freed of the Russian dominion noted earlier. Finland wanted to be a part of Europe as an independent nation, and Finnish architects Aino and Alvar Aalto wanted to be part of the community of young European architects addressing the problems that they saw in the modern world. As part of the group of young Finnish architects excited by international movements, they were eager to incorporate these new ideas. The Aaltos were “enthusiastic supporter[s] of the new ideas of functionalism, characterized by a white freshness that contrasted with the tired, polluted, old-fashioned atmosphere of the time” as noted by Markku Lahti in Objects and Furniture Design Alvar Aalto.

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The Aaltos Visit to Zonnestraal Sanatorium In late 1929, Alvar and Aino entered and won an architectural design competition for a new sanatorium to be located near the town of Paimio, 30 kilometers from the southern Finnish city of Turku, where the Aaltos had their architectural practice. The Aaltos had just completed the design of a new headquarters building for the Turun Sanomat newspaper in Turku, 1927–29. For this building, they had followed Les Cinq Points d’une Architecture Nouvelle (Five Points for a New Architecture), published by the Swiss French architect and theorist Le Corbusier in 1923 in his book, Vers Une Architecture (published in English as Towards a New Architecture). These five points included the use of pilotis (columns lifting the building off the ground), a roof garden, the free plan (spaces that were not constrained by structural walls), the strip or uninterrupted horizontal window, and the free façade, unimpaired by structural limitations. The Aaltos had traveled to Europe several times to visit new buildings and to meet with the architects that were practicing this new modern architecture. During a 1928 trip to Europe, the Aaltos visited the Netherlands and saw the recently completed Zonnestraal Sanatorium, 1926–28, designed by Jan Duiker. The complex had many features that were to be incorporated by the Aaltos at Paimio. It was sited in a forest near Hilversum. Instead of the more common single building, Duiker separated the program components into discrete building parts spread out on the site. The administration was in a central building with pavilions of patient rooms located to its south. Each patient pavilion was, in turn, composed of a central social space and two connection wings of patient rooms. Duiker’s use of reinforced concrete allowed the external walls to be virtually made entirely of glass. The use of glass walls maximized the amount of sunlight entering the buildings and maximized the view of the exterior grounds. Duiker had designed a series of single-loaded corridor wings, with all patient rooms oriented to either the southeast or the southwest. Each patient room opened to a continuous large balcony through an operable glass wall. Patient beds were rolled directly out of rooms onto the terrace to expose each person to the sun. The characteristics of this project were summed up by Hans Ibelings (2007, p. 38): The building is copybook example of the functionalist ideal of a strict separation between the loadbearing construction – in this case reinforced concrete – and the facades, which here consist mainly of glass in very slender steel frames. The almost total transparency of Zonnestraal satisfied the medical demand for light and well-ventilated rooms while at the same time allowing Duiker and Bijvoet to demonstrate the functionalist character of their building. The Aaltos learned much from this visit to Zonnestraal Sanatorium and from the continuation of their journey into France where they visited a number of Le Corbusier’s buildings, such as Pavillon de L’Esprit Nouveau and Villas La Roche and Jeanneret, to see firsthand how modernist principles were applied. In developing their design for the Paimio Sanatorium, they drew from the precedent of Zonnestraal and incorporated Le Corbusier’s modernist principles.

Paimio Sanatorium As with the Zonnestraal Sanatorium, and other sanatoria of the time, the Paimio Sanatorium was located in a remote pine forest so that “patients could rest for long periods in reclining chairs in the fresh air and receive heliotherapy (sun therapy) while inhaling the scent of the pine woods – an early form of aromatherapy” (Overy, 2007, p. 23). The remote location worked as a way to isolate the infectious patients from other people, and ensured plenty of fresh, clean air, serenity, and quiet for the residents. Paimio, a small town located in the south of Finland, is characterized by long, cold winters with little precipitation and short, cool summers. The winter days are short with only about 6 hours of daylight, and summer days are long with about 19 hours of daylight. The sun angles are

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low, especially in winter. These climate conditions added a layer of complexity to the design of the sanatorium. In the final design for the sanatorium at Paimio, the most notable modernist principle was the separation of the building’s programmatic elements into discrete forms or wings. A  central hub links the patient wing to a social wing containing treatment rooms and dining and leisure spaces, which, in turn, is linked to service components such as the kitchens. By pulling the building apart into distinct wings, the Aaltos were able to construct and orient each according to the needs of its function. Their use of a reinforced-concrete columnar structure freed the walls of a load-bearing role. This, in turn, allowed the use of the strip window and other large areas of glass on the exterior. The structural grid was determined separately for each wing of the building, based on the program and floor area of each. The interior walls were also non-load-bearing partitions. The wall separating the patient rooms from the corridor contained services, such as plumbing and mechanical ducts. While the sanatorium at Paimio was not lifted off the ground on piloti, as Le Corbusier had advised in his five points, it did have a rooftop terrace that capped the entire patient wing. In designing the building and most of its fittings, Aalto considered both the nature of tuberculosis treatment (as it was understood at the time) and the special needs of the person who would be residing there for a prolonged period. Aalto understood that in addition to providing a healthy environment of fresh air and sunshine, providing a dust-free environment was important, as was consideration for the patient’s mental well-being, which included a garden for light exercise and spaces for social gatherings as important parts of the program. The entrance to the facility is a long drive from the west, and the entry court is between two wings of the building. The main entrance is signaled by a large, irregularly shaped port cochere behind which is the central component of the sanatorium with reception, stairs and elevators, and circulation connecting the social wing to the patients’ wing. The social wing to the north of the entrance holds treatment and consulting rooms on the ground floor, dining on the second floor, and the library/reading room on the third floor. At the east end of this wing is an activity room/ lounge for the patients. The next component to the north of the social wing houses the kitchens and living quarters for some staff. Finally, the boiler building is beyond that. To the south of the central component is the patient wing. This wing also includes sun terraces. By orienting the patient wing obliquely to the social wing on the other side of the central entry, it makes a more welcoming entry court that provides better solar access for the dining room and library. The orientation of each component wing of the main building was carefully considered based on the sun and the occupants’ needs for the activity housed in that wing. The sun terraces at the east end of the patient wing were elongated along an east–west axis gaining full exposure to the sun for the course of the day. The large wing that housed the patients’ rooms was oriented south-southeast so that these rooms would receive full sun in the morning but be shaded from the heat and glare of the afternoon sun. The wing containing the social rooms and examining rooms, the dining room and library, similarly to the sun terraces, was elongated along the east-west axis, receiving sun during the length of the day. The library, above the dining room, has north-facing windows appropriate for glare-free reading. At the east end of this wing was the lounge/activity room with views to the east. The kitchen wing stretched to the north with both east- and west-facing windows. Elsewhere on the site, Aalto designed terrace housing for the doctors and medical staff, giving them an opportunity to retreat. The patient rooms are perhaps the most significant part of the design of a sanatorium. Aalto recognized that and in a later lecture described the Paimio Sanatorium, stating that the main purpose of the building is to function like a medical instrument, one of the basic requirements for healing is to provide total peace. . . . The design of the rooms is determined by the state of weakness of the patient lying in his bed. The color of the ceiling was chosen to

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give a feeling of peace and silence, the sources of light are beyond the patient’s field of vision, the air from the heating is at the feet, and the water from the taps makes no noise to ensure that patients do not disturb the person in the next bed. (Aalto in Reed, 1998, p. 29) The largest of the building components is the six-story patients’ wing, housing 286 patients in double rooms. It has a single-loaded corridor, with all the patients’ rooms opening to the southsoutheast. Unlike other sanatoria designers, Aalto did not give each patient room its own balcony but rather collected the balconies into a large terrace structure located at the east end of the patient rooms and articulated as a separate element. Each of these terraces was accessed directly from the patient room corridor and could accommodate 24 patients in groups of four. Having a sun terrace at the end of each floor allowed patients to be wheeled directly outside. By separating the balconies from the patient rooms, the patient rooms received full access to the sun without the shade that a balcony for the floor above would have created. The absence of a balcony also gave better views of the forest to the patients confined to their beds. The patient wing corridor was expressed on the entry court side of the wing by a continuous strip window that runs uninterrupted the length of the wing. Aalto used a reinforced column system for most of the building. In the patient wing, the columns are located asymmetrically in plan: one column line at the south edge of the building and the other at the wall between the rooms and the corridor. This move used the exterior columns to give each patient room a unique window, while the cantilevered corridor has a single strip window. The resulting exterior elevations thus reveal the nature of each side of the building: a continuous circulation along the northern side and a series of individual patient rooms along the other. The interior column line defines the wall between the corridor and the patient rooms and provides a location not only for the structure but also for mechanical systems and plumbing. The window of each patient room was also carefully considered. Each has a large area of glass that is subdivided into three sections both vertically and horizontally. In developing the design of this window system, Aalto considered the need for both sunlight and fresh air. The large amount of glass provided the access to sunlight. The height of the window made the most of the low-angled sun. The window is positioned asymmetrically in the room. This location shades the heads of the beds in the afternoon when Aalto deemed the sun to be too strong and yet allows the adjacent wall to be washed with sunlight, thus giving each room a glare-free indirect source of light. The windows are composed of two layers that operate independently. The outer window opens on the right, and the inner window opens on the left. The air space between the two layers of glass allowed fresh air to be drawn in and warmed by the sun before entering the room itself. The wall beneath the window is sloped to reduce the opportunity for dust to build up where it meets the floor and to facilitate cleaning. External shades permitted the control of the sun when it was not wanted. This was supplemented with curtains in the rooms. Aalto considered the experience of someone confined to bed for long periods: When I received the assignment I was myself ill and therefore had the opportunity to make a few experiments and find out what it really felt like to be sick. I became irritated at having to lie horizontal all the time, and my first observation was that the rooms were designed for people who are upright and not for those who lie in bed day in and day out. (Aalto, 1978, p. 131) From this patient-centered point of view, the windows of the patient rooms were not centered in the room but were pushed to one side, which permitted the early morning sun to reach the patients’ beds and give the bedridden patients the opportunity to see the forest outside while providing relief from too much sunlight in the afternoon. Aalto recognized that the person lying in the bed would

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see primarily the ceiling and so considered the location and character of the electric lighting. The luminaires were mounted high on the wall above the patient bed. This position provided ample light for the nurses to view the patient but was too close to the wall to interfere with the patient’s line of sight. Another technology employed to benefit the patient was the radiant heating panel located on the ceiling above the foot of the beds. These gave radiant heat to the patients without mitigating the fresh air from the windows. The sun terraces were located at the eastern end of the patient wing. Each floor has a corresponding terrace so the patients could be wheeled directly out, or for those who were ambulatory, it was an easy walk without stairs. The sun terraces were oriented to face due south to maximize the sun exposure for the entire day. An innovative aspect of this wing was the structure, which had a single line of supporting columns with cantilevered floors. Thus, there were no vertical structural elements to obstruct the sun and view. The columns, thick at the lowest floor and thinner at the top, served as dividers creating subspaces along the length of the terraces. The back north wall was solid to provide lateral stability and serve as a windbreak. This also screened other parts of the complex from view. The roof of the patient wing, combined with the roof of the sun terraces, was designed as a single elongated terrace, with space for 120 patients in groups of 20. It was a place for resting in the sun during the warmer months. The idea behind the grouping of patients was to give them a small group to promote socializing. There is an elevator to take patients up to this level, but it was reserved for patients who were more ambulatory and could walk from their beds to the elevator and then to the chaise longues positioned in small groups on the terrace. The roof terrace is partially protected from rain and snow by a shed roof and a northern wall, which provided a wind break. At the time the sanatorium was built, the trees of the forest were shorter and views from the rooftop terrace were expansive. The dining room, on the second floor of the wing containing communal rooms had two-story windows facing south. The extra height of the windows allowed the sun deep into the room. These windows also faced the entry court so that one could see the comings and goings as people arrived or departed the complex. Exterior canvas awnings were used to control excess sunlight. Above the dining room was the library. It was treated as a mezzanine and hung from the ceiling above. Its south-facing glass wall looked into the dining room and received “borrowed light” from that space. In addition to the design of the buildings, the Aaltos designed most of the fittings, for the building, including cabinet work, light fixtures, furniture, and even the sinks in the patient rooms, creating a Gesamtkunstwerk, or total work of art, rarely seen at this scale and complexity. Of these, the design that has received the greatest acclaim is the Chair 41, the “Paimio Chair.” The design for this iconic chair demonstrates Aalto’s interest in wood technology, structure, and the ergonomic needs of the tubercular patient. Working with furniture craftsman Otto Korhonen, whose company manufactured furniture, Aalto developed a chair appropriate to the sanatorium and to the person using the chair. Rather than follow in fellow modernist Marcel Breuer’s footsteps and use a tubular steel structure for the chair, Aalto used birch for the frame. Birch is a common tree in Finland, so the use of it in making a chair designed for mass production boosts local economies. The chair is composed of a laminated and bent wood frame that supports a continuously shaped sheet of laminated plywood with scrolls at the top and bottom. The back of the curvilinear plywood sheet is angled at 115°, which was thought to be the ideal angle to ease the patient’s breathing. The scrolls at the head and knee of the chair provide structural support for the chair and give it spring. The slits near the top of the chair were meant to cool the neck of the patient. The birch frames served as armrests and were sturdy enough to support a person pushing herself up out of the chair. As with other designs for this building, the chair was made to be lightweight, sturdy, and easily sanitized. Although designed for mass production, Aalto wanted these objects of wood in the building to humanize what otherwise might be viewed as cold and institutional. This chair was subsequently made for market and is still available today.

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Elsewhere in the building, Aalto did design furniture using tubular steel. The design of the beds, the chaise longues and side tables all incorporated steel. The tubular steel was easy to sanitize and stood up to the weather when outside. Aalto understood that dust created problems for the tubercular patient. It carried the bacteria and made breathing difficult. They designed the building to be as easy to clean as possible. Corners were reduced, becoming curved. Furniture was designed to be easily washed. As in subsequent buildings designed by him, Aalto developed lighting that was an integral part of the building. Room surfaces, such as the southeast interior wall of the patient rooms, became part of the light distribution strategy. Most of the luminaires that Aalto designed for the sanatorium were encased in glass to reduce the surfaces that might catch the dust and facilitate cleaning. The wallmounted sconce for the patient room has a solid base and an opal glass interior filter with a clear glass globe enclosing it. This is mounted so that the light reflects off the ceiling and adjacent wall. The ceiling was painted a lighter color near the light source to aid in reflecting the light. The luminaires for the dining room again involved the design of the fixture and of the architecture. The luminaire is a simple glass globe, but the lower hemisphere is opal glass, making it translucent. The upper hemisphere is clear glass allowing a majority of the light through. This fixture is hung in a domed recess in the ceiling painted a semi-specular color to spread the reflected light broadly into the room. As medicine changed, so did the sanatorium. Aalto designed additions and modifications to the building as they were needed. His office, under the direction of Elissa Aalto, continued to oversee work on the Paimio buildings after his death. Subsequently, when it was no longer needed as a treatment center for tuberculosis, the facility was converted into a hospital. More recently, it has become a center for the treatment of children with physical and emotional disabilities. It has served as a medical facility for almost 90 years. It is currently protected under the Finnish Board of Antiquities and remains an important historic marker of the development of functionalism in architecture. More important, it continues to serve as an exemplar of design that puts the person foremost and the expediency of building second. Diane Anderson, MD (2009), has touted this building as an exemplar of evidence-based design in which the building serves to aid in patient recovery. As noted by Ellis Woodman (2016, p. 111) in an article for Architectural Review, “[p]rivileging the individual’s experience in his approach to every design problem, Aalto produced a building that transcended the brittle architectural doctrines of its period and which continues to radiate a profound sense of human empathy today.” When the Alvar and Aino Aalto started the design of the Paimio Sanatorium, they were in their early 30s. These young architects not only won the competition to design the sanatorium after having completed only one sizable building, but they developed the sanatorium design to include interior fittings, light fixtures, and furniture. Many of these became products that were incorporated in other designs by the Aaltos and were offered for sale individually. What they accomplished in this large, complex project was truly remarkable. Their work not only incorporated the most up-to-date technologies and functionalist approaches but also provided a humane place for people in vulnerable conditions. The buildings of the sanatorium responded to site and to the most intimate scale of human touch and spirit. From the orientation of large building masses to the curve of a chair back, Paimio Sanatorium represents the best of what architecture can be. Structural innovation at both the building and furniture scale is present in this facility. With Paimio Sanatorium these architects in the remote north, were heralded by architectural critics as being at the forefront of modern architecture and set the standard for hospital design that is still acknowledged today. Notably, only Aalto, of all the modern architects, designed a hospital, one that is still used today to help in human healing: As far as we can see, there are three institutional buildings inseparably linked to the rise of contemporary architecture: the Bauhaus at Dessau by Walter Gropius (1926); the project of the League of Nations Palace at Geneva by Le Corubsier (1927); and Alvar Aalto’s sanatorium

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at Paimio (1929–33) in the southwest part of Finland, not far from the former capital of Turku. (Giedion, 1980, p. 629)

References Aalto, A. (1978). Between Humanism and Materialism. Cambridge, MA: Sketches. Anderson, D. (2009). Humanizing the Hospital: Design Lessons from a Finnish Sanatorium. Ottawa: Canadian Medical Association Journal, 21 September. Giedion, S. (1980). Space Time and Architecture. Cambridge, MA: Harvard University Press, Fifth ed. Godias, J. D. (1945). World War I and Tuberculosis, a Statistical Summary and Review. American Journal of Public Health Nations Health, 35(7), 689–697. Ibelings, H. (2007). Zonnestraal Sanatorium. Daylight and Architecture, 6, 34–39. Murray, J. F., Schraufnagel, D. E., Hopewell, P. C. (2015). Treatment of Tuberculosis. A Historical Perspective. Annals of American Thoracic Society, 12(12), 1749–1759. Overy, P. (2007). Light, Air and Openness Modern Architecture Between the Wars. New York: Thames & Hudson. Reed, P. (1998). Between Humanism and Materialism. New York: Museum of Modern Art. Woodman, E. (2016). Revisit: ‘Aalto’s Paimio Sanatorium Continues to Radiate a Profound Sense of Human Empathy’. Architectural Review, 240(1436), 111.

6 LEGIONNAIRES’ DISEASE AND WATER SYSTEMS History and Prevention Michelle Brune

Preventing the spread of bacteria, such as Legionella, is critical to the built environment. Although the first known outbreak of Legionnaires’ disease occurred in 1976, the presence of Legionella bacteria in water systems remains a concern today. According to the Centers for Disease Control and Prevention (2018), the number of reported Legionnaires’ disease cases in the United States has steadily increased during the past 20 years. Over 63,000 confirmed cases were reported to the National Notifiable Diseases Surveillance System (NNDSS) between 2000 and 2017 (Barskey et al., 2020). A 2013–2014 surveillance report indicated Legionella bacteria as the most common cause of waterborne illness associated with drinking water in the United States (Benedict et al., 2017).

Legionnaires’ Disease Legionnaires’ disease is a type of pneumonia caused by a bacteria known as Legionella pneumophila (Bellenir, 2004). Legionella pneumophila is one of about 60 different species of Legionella bacteria that can cause disease (Cooley, 2016). However, clinical studies indicate that Legionella pneumophilia is the species that most often causes Legionnaires’ disease (Cooley, 2016) (see Figure 6.1). Legionnaires’ disease is not the only disease caused by Legionella bacteria. Legionella bacteria can cause a less severe disease, called Pontiac fever (Bellenir, 2004; Centers for Disease Control and Prevention, 2021d). The symptoms of Pontiac fever are milder, usually go away on their own without treatment, and pneumonia is not detected. Although the illness is less severe, it is important to track Pontiac fever cases because the presence of Legionella bacteria in the environment can also cause Legionnaires’ disease (Centers for Disease Control and Prevention, 2021d). Literature related to Legionnaires’ disease often cites a term called legionellosis. This term is used to describe cases of disease caused by Legionella bacteria, which includes Legionnaires’ disease, Pontiac fever, and a rare condition called extrapulmonary legionellosis, which is associated with infection occurring outside of the lungs (Centers for Disease Control and Prevention, 2021d).

Symptoms Symptoms of Legionnaires’ disease can include fever, chills, shortness of breath, cough, headache and muscle aches, tiredness, a loss of appetite, and, sometimes, diarrhea (Bellenir, 2004; Centers DOI: 10.4324/9781003214502-6

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image depicts a group of Legionella pneumophila bacteria magnified 5000 times using a scanning electron microscope.

FIGURE 6.1 This

Source: CDC: CDC/Margaret Williams, PhD; Claressa Lucas, PhD; Tatiana Travis, BS.

for Disease Control and Prevention, 2016). Individuals over the age of fifty with existing health conditions, such as cancer, lung or kidney diseases, and current or former smokers, are at the highest risk of becoming ill (Bellenir, 2004; Centers for Disease Control and Prevention, 2021c). Some individuals are not aware that they contracted Legionnaires’ disease because they never show any symptoms or become ill (Cooley, 2016). Because of this, the number of Legionnaires’ disease cases is often underreported and higher than indicated by the Centers for Disease Control and Prevention. The estimated annual number of Legionnaires’ disease cases varies among experts. According to Bellenir (2004), it is estimated that 8,000 to 18,000 individuals contract Legionnaires’ disease annually in the United States. Popescu (2019) estimates the number of annual cases in the United States to be from 10,000 to 18,000. A recent report completed by a committee of the National Academies of Sciences, Engineering, and Medicine (2020) estimates that the number of annual Legionnaires’ disease cases in the United States could be as high as 70,000 per year.

Contraction, Diagnosis, and Treatment Individuals contract Legionnaires’ disease from breathing in small water droplets that contain Legionella bacteria (Centers for Disease Control and Prevention, 2016). This disease is typically not spread from person to person. However, one person-to-person transmission case was reported in Portugal in 2014 (Correia et al., 2016). If two or more individuals contract Legionnaires’ disease at the same time and place, the cases are defined as an outbreak (Centers for Disease Control and Prevention, 2021h). Many outbreaks of Legionnaires’ disease are initiated by bacteria growth in complex water systems in hotels and health care environments (Centers for Disease Control and Prevention, 2021b) and are often caused by improper maintenance of potable water systems, cooling towers, whirlpool

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spas, and decorative fountains (Suftin, 2018). Individuals who contract this disease are asked questions about their activities during the last two weeks, such as travel, health care, or whirlpool spa exposure (Centers for Disease Control and Prevention, 2016). This allows health professionals to track the disease back to a specific location, determine the source, and verify if additional individuals are at risk of contracting the disease. According to the Centers for Disease Control and Prevention (2021e), approximately 10% to 15% of the individuals who contract Legionnaires’ disease have traveled prior to diagnosis. This life-threatening disease can be diagnosed through x-rays of the lungs, urine tests, and sputum samples and can be cured with antibiotics. However, the disease will be deadly for about 10% of the diagnosed population (Centers for Disease Control and Prevention, 2016). The death rate increases to 25% for patients with health care–associated Legionnaires’ disease (Centers for Disease Control and Prevention, 2020).

Case Reporting Once individuals are diagnosed with Legionnaires’ disease, health providers report cases to local, state, or territorial health departments (Centers for Disease Control and Prevention, 2021e). Local or state health departments then notify the Centers for Disease Control and Prevention through the NNDSS (Barskey et al., 2020). The NNDSS data contain information about the number of cases, demographics, date, and jurisdiction of residence (Barskey et al., 2020). An additional database, called the Supplemental Legionnaires’ Disease Surveillance System (SLDSS), provides a location where states and jurisdictions can voluntarily provide additional information about case severity, exposure history, or laboratory results (Barskey et al., 2020). For reporting purposes, the Centers for Disease Control and Prevention uses the term legionellosis and includes all Legionnaires’ disease, Pontiac fever, and extrapulmonary legionellosis cases into this one group. However, Legionnaires’ disease accounts for 98% of the cases reported in the legionellosis category (Centers for Disease Control and Prevention, 2021d).

History of Legionnaires’ Disease The 1976 Outbreak Legionnaires’ disease was discovered in 1976 following an outbreak of severe pneumonia among American Legion convention participants (Centers for Disease Control and Prevention, 2021g). On July 21, 1976, approximately 2,000 Legion members attended the annual convention, held in Philadelphia, Pennsylvania, at the Bellevue–Stratford hotel. Following the four-day event, the American Legion organization learned that several members who attended the convention had passed away and many were hospitalized with pneumonia-like symptoms (Klein, 2020). By early August, 25 people were dead and more than 130 people were hospitalized (The Philadelphia Killer, 1976). While most of the illness was among individuals attending the convention, several other victims, a bus driver, and a food delivery driver were near the hotel during this time (The Philadelphia Killer, 1976). A pattern among the ill patients was first detected by a Bloomsburg, Pennsylvania, doctor, Dr. Ernest Campbell (The Philadelphia Killer, 1976). Soon after, a group of 150 state and federal doctors, biologists, and chemists were tasked with finding out what caused the illness (The Philadelphia Killer, 1976). The team looked at patient records and biological samples, locations where infected individuals traveled around the hotel, what participants ate and drank, and if they were exposed to pigs or birds to determine any flu exposure (Fraser et al., 1977). It took nearly six months to determine that a newly discovered bacteria, named Legionella, caused the illness (Klein, 2020) (Figure 6.2). A total of 182 individuals contracted the illness, and 29 of those individuals died (Fraser et al., 1977).

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FIGURE 6.2  This

image depicts Joseph E. McDade, PhD (left) and Charles C. Shepard, MD, of the Centers for Disease Control and Prevention. On January  14, 1977, Dr. McDade and Dr. Shepard identified and named the Legionella pneumophila bacteria that caused the Legionnaires’ disease outbreak.

Source: CDC #8232.

Based on their research, Fraser et al. (1977), concluded that the source of the bacteria was likely airborne (Fraser et  al., 1977). Klein (2020) states that a rooftop air-conditioning system at the nineteen-story Bellevue-Stratford Hotel was a probable cause of the illness. He maintains that the air-conditioning system fans likely emitted a mist that fell on pedestrians outside of the hotel and may have entered the lobby through a ground-level vent (Klein, 2020). Individuals breathed in the air particles containing Legionella and contracted Legionnaires’ disease (Klein, 2020).

Pre-1976 Outbreaks Following the discovery of Legionella in 1977, several other mysterious cases of pneumonia were solved (Weiland, 2021). The Centers for Disease Control researchers learned that a similar an outbreak occurred at the Bellevue-Stratford Hotel in 1974, killing two individuals (Chernick, 2015). Another instance occurred in the late summer of 1965, where 81 patients in a hospital in Washington, D.C., experienced pneumonia and 14 of the patients died (Thacker et al., 1978). Clinical testing determined that it was the same bacteria found in Legionnaires’ disease patients and that the bacteria may have become airborne from sites of soil excavation (Thacker et al., 1978). It was also discovered that the Pontiac fever outbreak in 1968 was also caused by Legionella bacteria, although no deaths were reported in the outbreak (Centers for Disease Control and Prevention, 2021g).

Case Trends From the 1980s Through 2018 From 1980 to 1998, there were a total of 6,757 confirmed Legionnaires’ disease cases with a median annual number of 360 per year (Benin et al., 2002). This included reporting from all but two states,

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Oregon and West Virginia. A significant increase in cases occurred between 2000 and 2017. A total of 63,529 cases were reported to the NNDSS from 52 U.S. jurisdictions during this time, excluding Oregon and West Virginia in the 2000 and 2001 data reporting (Barskey et al., 2020). States with the highest percentage of cases reported in 2016–2017 included Ohio, New York, Rhode Island, Michigan, Pennsylvania, Delaware, Indiana, and Illinois (Barskey et al., 2020). The annual number of reported cases of Legionnaires’ disease has increased every year since 2000, with a reported 10,000 cases in 2018 (Centers for Disease Control and Prevention, 2021g).

Recent Deadly Outbreaks Several deadly outbreaks of Legionella during the 2010s sparked concerns around the county. Following a series of deadly Legionella cases at the Pittsburgh VA Medical Center-University Drive Campus in 2011 and 2012, Congress called upon the Veteran’s Affairs Office of Inspector General to review the prevalence of Legionnaires’ disease at facilities across the country (The American Legion, 2013). The inspector general reviewed the status of Legionella prevention at all Veteran’s Affairs facilities, including the number of cases, current Legionella management plans, and compliance with guidelines (Department of Veterans Affairs Office of Inspector General, 2013). Based on this information, a revised Legionella water management plan, Directive 1061, was adopted in August 2014 and updated in February 2021 (Veterans Health Administration, 2021). A large outbreak of Legionnaires’ disease occurred in Flint, Michigan, when the municipal water source was temporarily changed to Flint River and was not properly treated. This change, which took place in 2014, resulted in corrosion of pipes, increased lead levels, and bacterial growth (Kennedy, 2016). Initially, it was determined that the changing of Flint’s municipal water source was to blame for the twelve deaths and 90 illnesses (Childress, 2019). However, a 2019 study by Smith et al. (2019) indicates that the source of the Legionella bacteria could have originated from hospital exposure, city cooling tower exposure, or city water exposure. Another 2019 study indicated that the number of pneumonia deaths during the Legionnaires’ outbreak in Flint was 115 and that it was likely that some of the deaths were undiagnosed and unreported cases of Legionnaires’ disease (Childress, 2019). One of the largest Legionnaires’ disease outbreaks in the United States occurred in New York City during the summer of 2015 (Lapierre et al., 2017). The outbreak occurred between July 2 and August 3. Investigations by multiple agencies, along with clinical samples, determined that the source of Legionella bacteria could be traced back to a cooling tower in the South Bronx borough of New York City. The outbreak resulted in 138 cases, including 128 hospitalizations and 16 deaths (Lapierre et al., 2017). Since its discovery in 1976, Legionella bacteria continues to contaminate water systems within building systems. Outbreaks continued in 2019, with cases related to hot tub displays at state fairs in North Carolina and Texas; multiple health care outbreaks in Ohio, Michigan, and Illinois; and hotel outbreaks in Georgia and Minnesota (News Services, 2020). Understanding the multiple factors that contribute to the growth of Legionella bacteria within the built environment is critical to preventing outbreaks.

Legionella in the Built Environment Legionella bacteria can be found in small, harmless, amounts in natural water systems, such as lakes and streams (Centers for Disease Control and Prevention, 2021c; Ensia, 2020). Legionella bacteria become the most harmful to humans when they multiply in water distribution systems within buildings and then become airborne (Ensia, 2020). This contaminated mist can be emitted from fixtures and systems, such as faucets and showerheads, hot tubs, decorative fountains, water features, air-conditioning systems, cooling towers, and complex plumbing systems (Centers for Disease Control and Prevention, 2021i).

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According to the Centers for Disease Control and Prevention (2018), there are a variety of internal and external factors that can lead to Legionella growth in plumbing systems in buildings. These include changes in municipal water quality, water main breaks, and construction projects; inadequate levels of disinfectant in the building water system and improper water temperatures; and stagnation of water and reduced water pressure, which can result in biofilm growth in pipes. In addition, buildings that have aging plumbing infrastructure, and are over ten stories, are at a higher risk of developing water quality issues (Centers for Disease Control and Prevention, 2021f; Centers for Disease Control and Prevention, 2021k).

External Factors Municipal Water Quality States and local municipalities are required to provide drinking water that complies with the Safe Drinking Water Act (Environmental Protection Agency, 2020a). There are minimum levels of compliance. States and local municipalities have the option of improving water quality based on this minimum standard. Depending on geographic location, lakes, streams, and groundwater are often sources for drinking water (The Watershed Institute, 2018). Changes in quality or source of public water could impact Legionella growth after water enters the building or residence premise plumbing system. The premise plumbing system is the section of plumbing pipes from the public water meter to the fixtures or tap inside the residence or building (Environmental Protection Agency, 2020b). The quality of water can decrease in the premise plumbing system based on multiple internal and external factors, as indicated in the following sections.

Water Main Breaks According to the American Society of Civil Engineers (2021), a water main break occurs every two minutes in the United States. A water main break can cause water pressure to slow and provides an opportunity for dirt and bacteria to enter the water distribution system (Hutchison, 2019). In addition, this break can disturb biofilm in the pipes. These additional contaminants use up disinfectants and lower the water quality. According to a study by Folkman (2018), water main breaks in the United States and Canada increased nearly 30% from 2012 to 2018. It is expected that the number of water main breaks will continue to increase due to aging water main infrastructure, as some piping systems could be up to 125 years old (Folkman, 2018).

Seasonal Trends and Geographic Location Increased outside temperature and longer summers could promote bacteria growth (Kaiser Health News, 2019). A report by the National Academies of Sciences, Engineering, and Medicine (2020) indicates that nearly 80% of the 2016 Legionnaires’ disease cases in the United States occurred between June and December. A recent study by Xiang Han (2019), indicates that some states are at a higher risk of Legionella outbreaks than others due environmental conditions. Han’s study (2019) indicated that the geographic locations of Legionella outbreaks in between 2014 and 2016 corresponded to annual precipitation, amount of ultraviolet radiation exposure, and sunlight hours.

Construction Activity The Centers for Disease Control and Prevention (2021a) estimates that 35% of Legionella contamination issues stem from factors external to the building, such as nearby construction activities.

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According to Scanlon (2018), there are several construction-related activities that can contaminate the water supply. Activities related to soil excavation can cause Legionella to become airborne or attach to piping on the construction site and repressurization of water lines can cause biofilm to loosen and travel through the water supply system. In addition, Scanlon (2018) states that construction projects can take up to a year to complete, in some instances, causing the potential for water contamination and stagnation.

Internal Factors Stagnation Stagnation occurs when there is no or a low level of water flowing through pipes. This is sometimes referred to as standing water. When stagnation occurs, the temperature of the water and the levels of disinfectant can decrease, causing an increase in the risk of Legionella and other bacterial growth (Centers for Disease Control and Prevention, 2021l). There are several reasons why stagnation can occur in buildings. One issue relates to dead legs in the plumbing system. A dead leg is a section of piping that is capped at one end and no longer being used, or just used occasionally. If water no longer flows through the dead-leg area, it can contain stagnant water that can end up seeping back into the pipes with flowing water. To help address this issue, the 2021 Uniform Plumbing Code includes a requirement that all dead legs have a way to drain (International Association of Plumbing and Mechanical Officials, 2020). Some experts recommend removing dead legs, or if they cannot be removed, flush the pipes of stagnant water periodically (Legionella Control, 2021). Reduced building occupancy and building shutdowns can also cause water stagnation. Hotels and hospitals that are not operating at full capacity could have rooms where sinks, bathrooms, and showers are not being used. This decrease in water flow will cause stagnant water to sit in the pipes and could pose a danger if not treated and flushed prior to room occupancy (Centers for Disease Control and Prevention, 2021k). In addition, many buildings became unoccupied due to the 2020 COVID-19 pandemic. It is critical that water in the plumbing systems is checked and monitored prior to building reoccupation to eliminate the risk of Legionella growth (Centers for Disease Control and Prevention, 2021l).

Biofilm Biofilm consists of secreted slime and bacteria that attach to the interior of wet water system pipes and can remain in place for decades (Centers for Disease Control and Prevention, 2018, 2021k). Microscopic organisms, such as Legionella bacteria, produce and inhabit these protective environments, which can provide a shield from heat and disinfectants (Centers for Disease Control and Prevention, 2021k). Biofilm can also impact the taste and odor of drinking water and promote pipe corrosion (Liu et al., 2016). Proper maintenance of building water systems will help prevent biofilm growth, the presence of organic debris, and contamination from pipe corrosion (Centers for Disease Control and Prevention, 2018).

Green Building Design In a recent study, Rhoads, Pruden, and Edwards (2016), found that green building water system design features may increase stagnation, or water age, making these buildings susceptible to opportunistic pathogens in premise plumbing (OPPPs). The authors recommend that further research is needed to determine a long-term solution for maintaining safe water quality in green buildings.

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A short-term solution may include routine flushing to maintain disinfectant residuals, water temperature, and improve corrosion control (Rhoads, Pruden, and Edwards, 2016). Melton (2014) indicates that problem areas related to green design features include the presence of biofilm on aerators and touchless faucets; stagnation of water due to low-flow fixtures and flow regulators; bacteria growth due to low water heater set points or unheated/uncooled water storage tanks. McMenamin (2019) indicates that part of the problem is that a lower rate of water flow is being introduced to piping that was meant for a larger volume. In turn, this low flow of water through a large set of pipes allows biofilm to grow (McMenamin, 2019).

Water Temperatures According to the Centers for Disease Control and Prevention (2021k), the best temperature for Legionella growth is between 77°F and 113°F, but it can also grow in temperatures above or below this range. Increasing the water temperature to control the growth of Legionella may cause another harmful effect – scalding, or burning, of the skin. State and local municipalities have specific temperatures that must be met for anti-scald regulations. It is possible to design a system that mixes some cold water with the hot water at point-of-use areas to avoid scalding building users (Centers for Disease Control and Prevention, 2021k). Another area of concern is that cold water pipes in warm climates may become warm enough to allow Legionella to grow (Centers for Disease Control and Prevention, 2021i).

Levels of Disinfectant Water entering a building or residence from a treated water source most likely contains an appropriate amount of disinfectant residual to limit bacterial growth. However, once it enters the building or residence it travels through piping called premise plumbing. In large commercial buildings, water can travel a significant distance through premise plumbing before reaching a water faucet, shower, or another point of use. This length can allow for stagnation, reduction in water temperature, and reduction in disinfectant levels (National Academies of Sciences, Engineering, and Medicine, 2020). As part of a water management plan, disinfectants would likely need to be added at one or more points in the premise plumbing systems to help control Legionella growth (National Academies of Sciences, Engineering, and Medicine, 2020).

Prevention Efforts There is no vaccine to prevent Legionnaires’ disease, so prevention must take place within the management of water systems in the built environment (Centers for Disease Control and Prevention, 2021i). Preventing the growth and spread of Legionella in the built environment is possible with effective planning and surveillance. Investigations conducted by the Centers for Disease Control and Prevention indicate that 90% of Legionnaires’ disease cases could have been prevented if more effective water management plans were implemented (Centers for Disease Control and Prevention, 2021a). Several organizations have developed plans and guidelines to assist building owners and managers with preventing Legionnaires’ disease within water systems. In 2016, the Environmental Protection Agency Office of Water developed a document to serve as a resource for facility managers (Environmental Protection Agency, 2016), and the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (2018) continues to update ASHRAE Standard 188 as an enforceable code that can be adopted into law by state and local jurisdictions. Developed in 2016 and updated in 2021, the Centers for Disease Control and Prevention (2021k) created a practical toolkit to help building owners and facility managers develop and implement a water management plan.

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Educational Resources Educating building designers, contractors, owners, facility managers, and maintenance personnel is the first step in preventing the spread of Legionella bacteria in buildings. A well-informed team can be instrumental in preventing waterborne illnesses in the buildings that they design, build, own, and maintain. The Centers for Disease Control and Prevention (2021j) provides virtual training and a significant number of educational resources that are written in a practical and understandable format. In addition, the annual Legionella Conference, organized by the National Science Foundation (NSF) Health Sciences and National Environmental Health Association, provides a professional opportunity for industry professionals to learn about the latest information regarding prevention, surveillance, sampling, inspections, and regulatory updates (NSF International, 2021).

Water Management Plans After learning about the risks and causes of Legionella in the built environment, building owners and operators should develop a water management plan. This entails organizing a team of individuals who have knowledge of legionellosis and will help implement and oversee the plan (American Society of Heating, Refrigerating, and Air-Conditioning Engineers, 2018). This may include designers, employees, maintenance personnel, and consultants. A building survey that indicates the systems in which the risk of Legionella growth may take place within the building and a description and diagram of the water flow conditions should be completed (American Society of Heating, Refrigerating, and Air-Conditioning Engineers, 2018). In addition, water management plans should include instructions for monitoring water conditions, locations where control measures are applied, how to implement corrective actions, and the completion of documentation and records (American Society of Heating, Refrigerating, and Air-Conditioning Engineers, 2018).

Progress-Related Federal and State Regulations There are currently two federal regulations that have been enacted to control Legionella growth in buildings operated under federal agencies. In 2020, the Centers for Medicare & Medicaid Services Survey and Certification Group (2017) issued a memorandum to reduce the risk of Legionella growth in hospital and long-term care facility water systems. This memorandum was issued to state agencies indicating that all hospitals, critical access hospitals, and long-term care facilities must develop and implement a water management program to reduce the risk of Legionella (Centers for Medicare & Medicaid Services Survey and Certification Group, 2017). Additionally, the Veterans Health Administration (VHA) implemented Directive 1061 in 2013 and updated it in 2021. The purpose of the directive is to prevent health care–related Legionnaires’ disease and anti-scald injuries in VHA medical facilities with overnight stays (Veterans Health Administration, 2021). The VHA oversees 1,200 facilities, which is considered the largest health care system in the United States. According to Gamage, each facility has a water safety team consisting of clinical staff and engineering staff who oversee the water management plan (Cooley et al., 2019). Between 2015 and 2017, the VHA found that levels of Legionella continued to decrease. Health care–associated Legionnaires’ disease cases in VHA facilities have also declined (Cooley et al., 2019). Several states have implemented regulations for various types of facilities within their states. In 2016, the state of New York adopted Legionella prevention regulations for general hospitals, residential care facilities, and cooling towers (New York State Department of Health, 2016). In 2020, Virginia passed bill SB 410 that requires public elementary and secondary school boards develop and implement, maintain, and validate a water management plan for the prevention of Legionella bacteria (Virginia General Assembly, 2020). A  2019 outbreak of fourteen cases of Legionnaires’

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disease related to cooling towers in a school in Chesterfield, Virginia, prompted the newly formed bill (Fourteen Cases of Legionnaires’ Confirmed in Chesterfield, 2019).

Prevention Challenges Water management programs can be challenging to implement and maintain. As illustrated in the previous section, there are multiple internal and external environmental factors impact Legionella growth in building water systems (Centers for Disease Control and Prevention, 2018). In addition, buildings have varying and complex plumbing systems, so each building needs to be assessed, and the plan should be tailored specifically to each building (Cooley et al., 2019). Developing and implementing a water management plan can be costly due to professional consultations, additional maintenance and engineering staff, potential renovations, and equipment and fixture replacements (Cooley et al., 2019). Water management plans need to be monitored frequently and this takes time and money. For example, officials in the state of Missouri recently tested 61 hospitals, nursing homes, and hotels for Legionella bacteria and found that seven of the facilities tested positive for Legionella even though they each had a water management plan (Weber, 2019). This could indicate that there were failures in the development, management, testing, or validation of the success of the plans. Another challenge is the lack of incentive for building owners and managers to implement a program if they perceive the facility to be at low risk for Legionella growth or there is no policy/regulation (Cooley et al., 2019).

Next Steps and Recommendations As mentioned previously, the Environmental Protection Agency (2016) regulates drinking water and public water systems through the Safe Drinking Water Act. Legionella is specifically regulated under the Surface Treatment Water Rule, which is a section of the Safe Drinking Water Act. These rules do not include regulation of drinking water once it enters the premise plumbing system unless a secondary treatment system is installed in the building Environmental Protection Agency (2016). Currently, there is no universal regulation that governs water quality in premise plumbing systems for all buildings or residences in the United States (National Academies of Sciences, Engineering, and Medicine, 2020). A recent study completed by the National Academies of Sciences, Engineering, and Medicine (2020) provided several recommendations for improving Legionella management in buildings in the United States. These included requiring specific water temperatures for hot water systems, requiring minimal disinfectant residual amounts and monitoring of water in public distribution systems, requiring registration and monitoring of cooling towers, expanding the Centers for Medicare & Medicaid Services Survey and Certification Group Memorandum (2017) to include required periodic testing of water samples, and requiring that states or local municipalities enact codes requiring all public buildings to have water management plans. In addition, the committee recommends providing clarification of Legionella testing and monitoring guidelines and training the individuals responsible for implementing and monitoring the water management program (National Academies of Sciences, Engineering, and Medicine, 2020).

Conclusion During the last 45 years, many of the efforts to prevent the risk of Legionella bacteria in water systems have been conducted in a reactive manner. Diagnosed cases of Legionnaires’ disease are reported to health departments and the Centers for Disease Control and Prevention, then an investigation into the environmental source of the outbreak is conducted. Ideally, the source of the outbreak is discovered, and the facility and equipment are treated. However, not all cases of Legionnaires’ disease can be tied to an outbreak, permitting Legionella bacteria to persist and cause additional illnesses and deaths.

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Illness and deaths associated with Legionella bacteria will continue to increase in the United States if regulations and policies are not enacted to improve water quality in public water distribution systems and buildings. Some progress has been made by several organizations and agencies, and some state health departments are working toward developing prevention policies and plans. The implementation of policies at the local, state, or federal would have a significant impact on reducing the risk of Legionella growth in buildings.

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Centers for Disease Control and Prevention. (2021k, June 24). Developing a water management program to reduce Legionella growth & spread in buildings: A practical guide to implementing industry standards, Version 1.1. www.cdc. gov/legionella/wmp/toolkit/index.html Centers for Disease Control and Prevention. (2021l, July 8). Reopening buildings after prolonged shutdown or reduced operation. www.cdc.gov/coronavirus/2019-ncov/php/building-water-system.html Centers for Medicare & Medicaid Services Survey and Certification Group. (2017, June 2). Requirement to reduce Legionella risk in healthcare facility water systems to prevent cases and outbreaks of Legionnaires’ disease (LD). www. cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-andMemos-to-States-and-Regions-Items/Survey-And-Cert-Letter-17-30Chernick, K. (2015, September 4). Bacteria at the Bellevue: The birthplace of Legionnaires’ disease. https://hiddencityphila.org/2015/09/bacteria-and-the-bellevue-the-birthplace-of-legionnaires-disease/ Childress, S. (2019, September 10). We found dozens of uncounted deaths during the flint water crisis: Here’s how. www.pbs.org/ wgbh/pages/frontline/interactive/how-we-found-dozens-of-uncounted-deaths-during-flint-water-crisis/ Cooley, L. (2016, June  13). Legionnaires’ disease on the rise in US – 2016 update. www.medscape.com/ viewarticle/864189?src=par_cdc_stm_mscpedt&faf=1 Cooley, L., Kunz, J., Burket, T., & Gamage, S. (2019, May 21). Turning the tide: The role of water management to prevent Legionnaires’ disease [Webinar]. Centers for Disease Control and Prevention. www.cdc.gov/grandrounds/pp/2019/20190501-Legionnaires-Disease.html Correia, A., Ferreira, J., Borges, V., Nunes, A., Gomes, B., Capucho, R., Gonçalves, J., Antunes, D., Almeida, S; Mendes, A., Guerreiro, M., Sampaio, D., Vieira, L., Machado, J., Simoes, M., Gonçalves, P., & Gomes, J. (2016, February 4). Probable person-to-person transmission of Legionnaires’ disease. The New England Journal of Medicine, 374(5), 497–498. www.nejm.org/doi/10.1056/NEJMc1505356 Department of Veterans Affairs Office of Inspector General. (2013, August 1). Healthcare inspection prevention of Legionnaires’ disease in VHA facilities. www.va.gov/oig/publications/report-summary.asp?id=2942 Ensia, L. (2020, October 22). Why reports of Legionnaires’ disease are on the rise in the United States. www.smithsonianmag.com/science-nature/why-reports-legionnaires-disease-are-rise-united-states-180976089/ Environmental Protection Agency. (2016). Technologies for legionella control in premise plumbing systems: Scientific literature review. www.epa.gov/sites/production/files/2016-09/documents/legionella_document_master_ september_2016_final.pdf Environmental Protection Agency. (2020a, August  12). Drinking water regulations. www.epa.gov/dwreginfo/ drinking-water-regulations Environmental Protection Agency. (2020b, December  9). Legionella. www.epa.gov/ground-water-anddrinking-water/legionella Folkman, S. (2018, March). Water main break rates in the USA and Canada: A comprehensive study. https://digitalcommons.usu.edu/cgi/viewcontent.cgi?article=1173&context=mae_facpub Fourteen cases of Legionnaires’ confirmed in Chesterfield, health officials say. (2019, October 17). WWBT. www.nbc12.com/2019/10/17/cases-legionnaires-confirmed-chesterfield-health-officials-say/ Fraser, D., Tsai, T., Orenstein, W., Parkin, W., Beecham, H., Sharrar, R., Harris, J., Mallison, G., Martin, S., McDade, J., Shepard, C., Brachman, P., & The Members of the Field Investigation Team. (1977, December). Legionnaires’ disease: Description of an epidemic of pneumonia. New England Journal of Medicine, 297(22), 1189–1197. www.nejm.org/doi/full/10.1056/NEJM197712012972201 Han, X. (2019, October 30). Solar and climate effects explain the wide variation in legionellosis incidence rates in the United States. https://journals.asm.org/doi/10.1128/AEM.01776-19 Hutchison, R (2019). 11 factors that cause legionella growth in industrial water systems. https://hohwatertechnology. com/blog/legionella-growth-industrial-water-systems/ International Association of Plumbing and Mechanical Officials. (2020). 2021 uniform plumbing code. https:// epubs.iapmo.org/2021/UPC/ Kaiser Health News. (2019, November  5). Record Legionnaires’ cases risk lives, cause cleanup headaches. Kaiser Health News. www.usnews.com/news/healthiest-communities/articles/2019-11-05/ record-number-of-legionnaires-cases-in-2018-risk-lives-cause-cleanup-headaches Kennedy, M. (2016, April 20). Lead-laced water in flint: A step-by-step look at the makings of a crisis. www.npr. org/sections/thetwo-way/2016/04/20/465545378/lead-laced-water-in-flint-a-step-by-step-look-at-themakings-of-a-crisis Klein, C. (2020, July  21). Remembering the Legionnaires’ outbreak. www.history.com/news/the-discovery-oflegionnaires-disease

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Lapierre, P., Nazarian, E., Zhu, Y., Wroblewski, D., Saylors, A., Passaretti, T., Hughes, S., Tran, A., Lin, Y., Kornblum, J., Morrison, S., Mercante, J., Fitzhenry, R., Weiss, D., Raphael, B., Varma, J., Zucker, H., Rakeman, J., & Musser, K. (2017). Legionnaires’ disease outbreak caused by endemic strain of Legionella pneumophila, New York, New York, USA, 2015. Emerging Infectious Diseases, 23(11), 1784–1791. https:// doi.org/10.3201/eid2311.170308 Legionella Control. (2021). Removing dead legs from hot & cold water pipes to prevent legionella. https://legionellacontrol.com/legionella/removing-dead-legs-water-pipes/ Liu, S., Gunawan, C., Barraud, N., Rice, S., Harry, E.,  & Amal, R. (2016). Understanding, monitoring, and controlling biofilm growth in drinking water distribution systems. Environmental Science & Technology, 50(17), 8954–8976. https://doi.org/10.1021/acs.est.6b00835 McMenamin, E. (2019, February 6). Plumbing industry takes harder look at legionella threat. www.pmengineer. com/articles/94107-plumbing-industry-takes-harder-look-at-legionella-threat Melton, P. (2014, December 1). The surprising connection between water conservation and deadly infections. www. buildinggreen.com/primer/surprising-connection-between-water-conservation-and-deadly-infections National Academies of Sciences, Engineering, and Medicine. (2020). Management of Legionella in water systems. The National Academies Press. http://doi.org/10.17226/25474 New York State Department of Health. (2016). Volume A (title 10) part 4 – protection against Legionella. https:// regs.health.ny.gov/content/part-4-protection-against-legionella News Services. (2020, January 5). 2019 Legionnaires’ outbreaks: Another busy year for Legionella. www.legionnairesdiseasenews.com/2020/01/2019-legionnaires-outbreaks/ NSF International. (2021). About the legionella conference. www.legionellaconference.org/about/ The Philadelphia Killer. (1976, August 16). The Philadelphia killer. Time Magazine, 108(7), 64–68. https:// time.com/vault/issue/1976-08-16/page/70/ Popescu, S. (2019, August  9). Combatting legionella and carbon footprints. www.contagionlive.com/view/ combatting-legionella-and-carbon-footprints Rhoads, W., Pruden, A., & Edwards, M. (2016). Survey of green building water systems reveals elevated water age and water quality concerns. https://doi.org/10.1039/C5EW00221D Scanlon, M. (2018, March 29). Raising awareness about water safety during construction. www.workingpressuremag. com/water-safety-during-construction/ Smith, A., Huss., A., Dorevitch, S., Heijnen, L., Arntzen, V., Davies, M., Holle, M., Fujita, Y., Verschoor, A., Raterman, B., Oesterholt, F., Heederik, D., & Medema, G. (2019). Multiple sources of the outbreak of Legionnaires’ disease in Genesee County, Michigan, in 2014 and 2015. Environmental Health Perspective, 127(12). https://doi.org/10.1289/EHP5663 Suftin, L. (2018). Michigan experiencing increase in legionellosis cases. Michigan Department of Health & Human Services. www.michigan.gov/mdhhs/0,5885,7-339-501322-,00.html Thacker, S., Bennett, J., Tsai, T., Fraser, D., McDade, J., Shepard, C., Williams, K., Stuart, W., Dull, H., Eickhoff, T. (1978, October). An outbreak in 1965 of severe respiratory illness caused by the Legionnaires’ disease bacterium. The Journal of Infectious Diseases, 138(4), 512–519. https://doi.org/10.1093/ infdis/138.4.512 Veterans Health Administration. (2021, February  16). VHA publications, directives. www.va.gov/vhapublications/publications.cfm?pub=1&order=asc&orderby=pub_Number Virginia General Assembly. (2020, April 7). SB 410 public school buildings; water management program; prevention of Legionnaires’ disease. https://lis.virginia.gov/cgi-bin/legp604.exe?201+sum+SB410 The Watershed Institute. (2018). Do you know where your drinking water comes from? https://thewatershed.org/ where-does-our-drinking-water-come-from/ Weber, L. (2019, November 5). Seven Missouri facilities tested positive for Legionella bacteria after a recent state investigation. St. Louis Post-Dispatch. www.stltoday.com/business/local/seven-missouri-facilitiestested-positive-for-legionella-bacteria-after-a-recent-state-investigation/article_4aa17f96-e62a-5476a010-a88130330ed6.html Weiland, S. (2021). Legionnaires’ disease: COVID 19 for buildings? FMJ, 31(2), 90–94. http://fmj.ifma.org/ publication/?m=30261&i=699223&view=articleBrowser&article_id=3974947&ver=html5

7 INFECTION CONTROL THROUGH ENVIRONMENTAL DESIGN Udomiaye Emmanuel, Eze Desy Osondu, and Cheche Kalu

Introduction Infection prevention and control (IPC) is a scientific process and hands-on solution intended to prevent harm or health dangers originated by infection to patients and health workers (Kim, 1998). Human health and well-being are intrinsically linked to a sustainable built environment. Therefore, the purpose of sustainable design is to find environmental design responses that promote the well-being and coexistence of inorganic elements, living organisms, and humans that make up the ecosystem (Van-Khai, 2016). In addition, sustainable environmental design is the adoption of efficient energy and material resources in buildings, the incorporation of the dwellers into micro-climate control within the building, and the natural environment. Health care settings in an environment where both infected persons and persons at increased risk of infection meet or congregate. Existing studies and investigations have constantly established that the health care environment can be a reservoir for organisms with the potential for infecting patients. For example, a study conducted in Iran by Tajeddin et al. (2016) supports that a contaminated environment is a risk factor for hospital-associated infections (HAIs). Moreover, in the epidemic of widely drug-resistant tuberculosis that occurred in Tugela Ferry, South Africa, in 2006, the architectural design of the hospital building took a significant share of the blame (WHO, 2020). Although improvements have been seen in overall rates of infection prevention and control in health care facilities, there has been an increase in intensive care unit infections caused by drugresistant pathogens, particularly those that contaminate the environment. (Weiner et al., 2016). Hence, the need to understand the nexus between IPC and environmental design. According to a recent report by the Centers for Disease Control and Prevention (CDC) regarding the mode of COVID-19 mode of transmission and in collaboration with Lateef (2009), achieving a balance between the concept of open-access design and the need for control measures to decrease the rate of infections is imperative. Van-Khai (2016) added that the goal of sustainable environmental design for health care facilities, apart from low energy and carbon emissions, must integrate design strategies to mitigate the effect of infectious diseases. Investigations revealed that climate change and unstable climate not only influence the built environment but also play a key role in driving the global emergence, resurgence, and redistribution of infectious diseases (Wu, Yongmei, Zhou, Chen, & Bing, 2016). DOI: 10.4324/9781003214502-7

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Although there is the quest for more ventilators, personal protective equipment (PPE), and extensive behavioral change, professionals of all credentials need to come together to fight the COVID-19 pandemic. There is a paucity of effective and contextual design strategies to support infection control and make health care workers much safer. In developing countries, the magnitude of the problem remains undervalued or even unidentified mainly because HAI diagnosis is multifaceted and surveillance activities to direct interventions need expertise and resources (Allegranzi & Pittet, 2008). For instance, IPC has been a neglected area in many health care facilities despite many policies related to IPC in Nigeria (Federal Ministry of Agriculture, Environment and Health, 2017), and available local studies only focus on handwashing as an IPC strategy (Bishara et al., 2019). Njuangang, Liyanage, and Akintoye (2018) added that with most of the research on this topic carried out by clinicians, the role of the health care environment in IPC is under-researched. This has made it tough for research on nonclinical or environmental aspects of health care topics to be published in clinical domains (May & Pitt, 2012). However, according to Nejad, Allegranzi, Syed, Ellis, and Pittet (2011), the relevance of HAI studies has started to gain recognition in Africa. An Algerian study by Atif et al. (2006) documented how the introduction of a prevention program at the facility level in 2001 reduced the overall hospital-wide prevalence of HAI over five consecutive years (2001–2005). Therefore, this chapter aims to examine how the space we occupy can be made safer from an architectural design perspective with the view of developing guidelines for policymakers and highlighting the architect’s role in tackling the infections. The objectives include examining the evolution of medical architecture and the nexus between infectious diseases and architectural space and suggesting design approaches for IPC. The study relied on existing works of literature, interviews, and interactions with health workers. Without a doubt, the present or current pandemic has revolutionized our thoughts regarding hospital architectural design and planning.

Evolution of Medical Architecture and Infection Control The history of medical architecture spans many centuries. The evolution of medical architecture and infection control could be seen as comprising initial, formative, and advanced stages, corresponding to the premodern, modern, and contemporary eras (Njuangang, Liyanage, & Akintoye, 2018). According to Marlene (2015) and National Center for Disease Control (NCDC, 2019), there exists a long-recognized relationship between health care and architecture, they added that the relevance of a suitable building in the healing process is well known to both medical and architectural professionals. In the early Middle Ages, after the fall of the ancient states, hospitals functioned more as a social centers than medical activities, owing to the low level of medical knowledge (Guenther & Vittori, 2008). Nevertheless, in western Europe, between the 6th and 8th centuries, numerous hospitals were launched. Well along, the understanding of classical and Eastern healers began to infiltrate Europe around the 12th and 13th centuries. The earliest chronicles of health care in Egypt and Greece are knotted to spiritual tenets, with priests and sanctuaries playing key parts in an attempt at disease identification, analysis, and care. Many of the early hospital designs resembled schools structured around a courtyard often located at the edge of villages or cities and monastic orders were the caretakers of the sick (Cameron, 2010; Tesler, 2018). A good example of such a building is “Schola Medica Salernitana founded in the 9th century under the auspices of the monastic hospital in Italy” (Guenther & Vittori, 2008). Tesler (2018) added that until the 13th century, this institute remains the pioneering epicenter for training health care personnel, scientists, and the issuance of practice licenses in Europe. Costeira (2015) posited that the aspect of the contemporary hospital was configured between the 17th and 18th centuries in Europe. This is evident in the Hotel-Dieu, one of the earliest and biggest hospitals in Paris in the mid-1700s. The facility depreciated to horrifying conditions. The facility

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was characterized by a dark, poorly ventilated, unsanitary ward frequently located head-to-head with other wards with infectious patients. A commission was, therefore, set up to examine architectural design suitable to the circumstance, directing studies and researches to find a decisive solution to the hospital (Retief, 2006). The confluence of events, the outcome of the commission, and the notable works of Dr. Tenon gave birth to a solution to the problem known as the “pavilion” plan, which was first applied in the Hospital Lariboisiere built in 1854 (Burpee, 2008). Another crucial factor that revolutionized medical architecture was the discovery of the transmission of germs in 1860 (Retief, 2006). This resulted in the isolation of disease and patients in particular pavilions. The work of Louis Pasteur confirmed the need to tackle infection and disease transmission, with the separation of patients and sterilization of medical devices (Costeira, 2015). These philosophies, isolation of pathologies, lead to a true revolution in medical architecture. The emergence of the pavilion model and the rise of scientific medicine coupled with the specific task of giving attention to the environment of health care gave birth to contemporary hospital architecture. Worthy of mention is Florence Nightingale (1820–1910) – born in Florence, Italy. Through her revolutionary activities in nursing, writing, and statistics, hospital development was significantly influenced (Gormley, 2010). Her experience in the Crimean War (1853–1856), established bases for health care with pavilion models that provides ventilation, circulation of patients, lighting, and hygiene. This further enhanced patient recoveries and lessened the rate of infections. This model retained the multiple-patient ward concept, which was often called the Nightingale Ward, and is still applicable in today’s practice. More studies on the works of Florence Nightingale revealed that in the military hospital in Turkey during the Crimean War, the number of soldiers that died from nosocomial infections (typhus, cholera, dysentery) is than the number of soldiers who died as a result of injuries sustained in battle (Gormley, 2010). As a result of her discovery of the link between environmental/space factors and patients’ healing, death rates were drastically reduced (from 42% to less than 3%; Berche, 2012). Interestingly, although the causes of diseases were primitively and nonscientifically explained, early health care practitioners and architects need to be applauded for establishing a nexus between the environment and the incidence of HAIs. According to Njuangang, Liyanage, and Akintoye (2018) to clarify the contagiousness of diseases, 18th-century physicians categorized ‘bad air’ into two groups: ‘inanimate human contagions’ and ‘inanimate nonhuman miasmata’. As reported by Alexander (1985) contagious stemmed from patients suffering from such diseases as smallpox and spread to those around them. Miasmata, on the other hand, were believed to originate from nonhuman causes such as swampy ground and to cause febrile diseases, such as typhoid, malaria, and yellow fever. Alexander (1985) added that it was believed that the air contained unseen minute poisonous particles (miasmas), which when inhaled into the body can cause illness. This led to the consideration and emphasis on ventilation for new health care institutions (Platt, 1978). Three epidemics of the recent past (tuberculosis [TB], severe acute respiratory syndrome [SARS], and coronavirus), to some degree, have some things to explain to us with regards to how architecture can be integrated into the fight against the spread of Coronavirus.

Summary of the Links Between a Health Care Environment and Infection Control The health care environment does not just describe the structure of the hospital but comprises or includes the fixed apparatuses within the facility with which health care workers, patients, and visitors interrelate being a share of the health care procedure (Zimring et al., 2013). The hospital environment serves as an ecological forte in which health care workers and patients, as well, might become infected with HAIs, also known as nosocomial infections. The Centers for Disease Control and Prevention (CDC; 2003) posited that the way hospitals are designed and built significantly

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affects the rates of HAIs. Interestingly, health care facilities in developing countries or low- and medium-income countries are often not purpose-built and may have experienced wide-ranging changes in layout and clinical activity over the years (Ogunsola & Mehtar, 2020). In the outbreak of Tugela Ferry, South Africa, in 2006, the hospital management reported that the health facility was not designed to handle airborne infection; rather, it was designed with bloodborne infections in mind. As a result, it never had an airborne infection control policy at the time extremely drug-resistant TB surfaced in patients (WHO, 2020). Such a report underscores the distinctive part architecture plays in contributing to health care delivery. Previous studies by Rubin, Owens, and Golden (1998), Ulrich et al. (2008), and Jamshidi, Parker, and Hashemi (2020) agree that there are expressive suggestions that features of the designed environment have a significant influence on clinical outcomes for patients. Xiao, Jones, Zhao, and Li (2019) used simulation to examine how methicillin-resistant Staphylococcus aureus (MRSA) is transmitted across various surfaces in a medical ward in a Hong Kong hospital. Using graphics to illustrate the network in which MRSA travels, they found that apart from surfaces of the adjacent and the index patients, the public surfaces were found to have higher MRSA concentrations and these public surfaces are surfaces of toilet door handles, toilet lids, the nurse station desk, and the water dispenser. In another study by Rimi et al. (2014) of a health care facility, high concentrations of airborne bacteria were found in densely populated locations such as the pharmacy, lobby, and other areas with densities of 0.5 to 1 cfu per m− 2 of airinward areas, and these concentrations increased in proportion to the number of people in the room, resulting in a weightier bioburden. According to Ulrich et al. (2008) and Kramer, Schwebke, and Kampf (2006), health care centers could be a probable reservoir of nosocomial pathogens, and such pathogens could have the ability to survive for a few days to several months. Such contaminated floors, walls in toilets, water taps, door handles, and rallies could be potential spots for settlement of pathogens and transmission through hand contact of diseases such as cholera (Goh, Lam, & Ling, 1987), hepatitis A (Rajaratnam, Patel, Parry, Perry,  & Palmer, 1992), vancomycin-resistant enterococci (Noble et al., 1998), and puerperal fever (Teare, Smithson, Efstratiou, Devenish, & Noah, 1989). For ease of understanding the nexus, it is important to appraise the modes of disease transmission in the health care environment.

Methods of Infectious Diseases Transmission Transmission of microorganisms in health care facilities is through several routes, and the same microorganism may be transmitted by more than one route. The five main modes of transmission are: The four key methods of transmission are 1. airborne and droplet, 2. contact (direct and indirect), 3. waterborne (common vehicle), and 4. vector-borne.

Airborne and Droplet Built environments, such as homes, offices, schools, workplaces, hospitals, and transport terminals have potentially harmful pollutants (Currie, 2007). Airborne transmission happens when fine microbial particles comprising pathogens stay suspended in the air for a long period, or dust particles containing the infectious agent and then are spread extensively by air currents and inhaled, which may cause infection when a vulnerable person inhaling the infectious airflow (Lateef, 2009). Airborne transmission is very hard to control; this is because it requires the regulation of airflow through special ventilation systems. There is concern that the coronavirus is aerosolized, meaning

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that, like the bacteria that causes TB, it can remain suspended in the air and be inhaled by susceptible persons. Viruses are small (20–400 nm), obligate intracellular parasites, and they exemplify a common cause of infectious disease acquired indoors, as they are easily transmitted mainly in crowded, inadequately ventilated spaces or environments (Young, De Smith, Chambi, & Fin, 2011; Guiseppina, Marta, Simonetta, Marcello, & Michelo, 2013). Droplet transmission occurs when viruses travel on relatively large respiratory droplets (>10 µm) that people sneeze, cough, or exhale during conversation or breathing – primary aerosolization (Currie, 2007) – and talking during the performance of certain procedures, such as suctioning and bronchoscopy (Ministry of Health, Ghana, 2015). Guiseppina, Marta, Simonetta, Marcello, and Michelo (2013) added that a single cough in a corridor, lobby, or passage can discharge hundreds of droplets, a single sneeze thousand (up to 40,000) at speeds of up to 50–200 miles per hour, each droplet containing millions of viral particles. Droplet transmission is not the same as airborne transmission; droplets do not remain suspended in the air, and aerosol droplets travel only short distances (1–2 m) before settling on surfaces (Verreault & Moineau, 2008). For transmission to occur, the source and the susceptible host need to be within approximately 1 m (3 ft) of one another (Ministry of Health, Ghana, 2015).

Contact or Surface Transmission Contact or surface transmission is the most significant and most frequent mode of transmission of HAI and can be categorized into two groups: direct-contact transmission and indirect-contact transmission. Direct contact refers to a person-to-person spread of diseases through physical contact between an infected person or infectious agents, including contaminated hands, gloves, or mucous membranes of the recipient (Lateef, 2009). Direct transmission can also occur between two patients, with one being the source of the infectious microorganisms and the other a susceptible host. Indirect-contact transmission involves contact of a susceptible host with a contaminated intermediate object, often inanimate. Examples of such intermediate objects include contaminated instruments, needles or dressings, or contaminated unwashed hands and unchanged gloves. Some organisms can live on objects for a short time. For instance, coronavirus (COVID-19) can live for 72 h on a plastic surface, 24 h on a cardboard surface, and 4 h on a copper surface (Verreault & Moineau, 2008). The implication is that, if you touch an object, such as handrails, doorknob, or handles, shortly after an infected person, you might be open to infection. However, transmission occurs when you touch your mouth, nose, or eyes before washing your hands.

Waterborne Transmission (Common Vehicle) Common vehicle transmission applies to microorganisms transmitted by contaminated items such as diseases related to water, which are classified into four groups: waterborne, water-washed, waterbased, and water-related diseases (Baker, Stevens, & Bloomfield, 2001). Waterborne transmission is a highly effective means for spreading infectious agents to a large portion of the population. There are several water-related modes of transmission of infectious diseases. Large quantities of an enteric organism can be introduced into the aquatic environment through the discharge of infected persons’ feces into the sewer or unprotected waterways (Doremalen et al., 2020). Second, infectious agents from bedridden infected persons can play a role in waterborne disease transmission because pathogens in soiled bedding and clothing may be released into the water during laundry activities (Gleick, 2002).

Design Strategies for IPC One of the ways space can promote or aid the inhibition of infectious diseases is when IPC concepts are integrated into the space conceptualization and design process. This was first experimented

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with by Florence Nightingale, when she launched the hospital ward model and stated that natural daylight and cross-ventilation are significant components to disinfect and lessen the infection occurrence in hospitals (Young, De Smith, Chambi, & Fin, 2011). Following are some design strategies to be employed in adapting our domestic, commercial, residential, and hospital spaces for IPC.

Design for Social Distancing Provide adequate spacing in consulting rooms, waiting for areas, corridors, hallways, stairs, and entrance lobby to support social distancing or the safe distancing of at least 1,000  mm apart as required by the CDC. This will not only reduce contact transmission but will create safe distancing since current research reveals that aerosol droplets travel only short distances of 1,000 mm to 2,000 mm before settling on surfaces (Baker, Stevens, & Bloomfield, 2001). Corridors should be designed to discourage informal conversations by eliminating nooks with benches or ledge as shown in Figure  7.1. The ledge corridor design had been introduced earlier to the hospital design by Carthey (2008) to encourage interactions among team members. Avoid closed-end lobbies, waiting areas, double bank corridors, and other spaces designed with little or no airflow. It has become obvious that corridor and lobby design considerations need to be reviewed to accommodate not only wheelchairs, crouches, trolleys, and beds but also safe distancing as required by the CDC. As seen in Figure  7.2, a corridor width of 1,500  mm recommended by the UK Department of Health (UKDH, 2013) is inadequate with regard to safe distancing within a hospital space. Hence, this study suggests a minimum of 2,600 mm width for corridors as shown in Figure 7.3. This is to allow for 1,000-mm minimum interval in social distancing and more than 500 mm as bilateral freeboards since human movement is not exactly in a straight line.

Design to Enhance Natural Ventilation Ventilation is the movement of air within a space, often shaped by variance in air pressure. Ventilation is very critical in mitigating nosocomial and other infectious diseases. Ventilation procedures are well defined in terms of air volume per minute per occupant and are based on the hypothesis that occupants and their actions are accountable for most of the contaminants in the conditioned space (Heb, 1997). Ventilation rates for health care facilities are often expressed as room ACH (air change per hour).

FIGURE 7.1 Example of corridor nook earlier proposed and being used by some hospitals (Carthey, 2008)

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FIGURE 7.2 Corridor

width as recommended by the UKDH (2013)

FIGURE 7.3 Suggested

minimum corridor width (Author)

Peak efficiency for particle removal in the air space occurs between 12–15 ACH (Nath et  al., 1994; Hermans & Streifel, 1993; Memarzadeh & Jiang, 2000). Recent studies have shown that an appropriate ventilation rate can effectively decrease the cross-infection risk of airborne infections in health care facilities and public spaces (Zhao, Zuo, Wu, & Huang, 2019; Hua et al., 2010). Natural ventilation can provide a higher ventilation rate than power-driven ventilation in an energy-efficient manner. A study of isolation wards in Chinese hospitals revealed that those with a high percentage of openable openings were found to be better in preventing the plague of SARS among health workers than other available designs (Wang et al., 2003). The ventilation rate requirement – ACH – by the CDC is 12 ACH (Ninomura & Bartley, 2001); the implication is that when the ventilation rate increases, the infection risk would be significantly reduced.

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FIGURE 7.4 Example

of an open-end corridor

FIGURE 7.5 Example

of the courtyard approach

A study by Hua et  al. (2010) revealed that the decay of droplet nuclei concentration is significantly influenced by ventilation rate. Hua et al. (2010) with the concentration decay equation, observed that it requires 20 min to lessen the concentration to 1.8% with 12 ACH; on the other hand, it takes only 10 min with 24 ACH.

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In another study, Escombe, Eduardo, Victor, Manuel, and David (2019) adopted the carbon dioxide tracer-gas technique to analyze the pre-and post- modification scenarios of a room. The aim was to examine the change in TB transmission risk in the consulting room and waiting room. The result indicated an average 72% decline (interquartile range 51–82%) in estimated TB transmission risk for patients and health care personnel. Thus, adequate ventilation could be a panacea for curbing the spread of infectious diseases such as COVID-19 in hospitals, schools, offices, and other public spaces. Moreover, providing clean, filtered air (high-efficiency particulate air [HEPA] filters) and efficiently controlling indoor air pollution through natural ventilation are two vital features of maintaining good air quality. According to Anjali (2007), HEPA is at least 99.97% efficient for removing particles ³0.3 μm and has proved effective in stopping the occurrence of infection among immunocompromised and high-acuity patients. Also, the study suggests the following design measures: • •



Adequate cross-ventilation in health care facilities is necessary. Corridors should have an open end to ensure an appropriate ventilation rate as shown in Figure 7.4. As much as possible, corridors or hallways with a closed end should be avoided. Provide an upper ventilation window on the dividing wall in the hallway and a ventilation louver on the doorstop to lessen hot-air circulation. Integrate the courtyard design to establish a cohesive ventilation passage, use the courtyard space as the ecological interchange space, conduct overall design on building structure layer/ open space, and create an integrated ventilation channel to enable the natural ventilation of hospital building as shown in Figure 7.5. The design approach (open-end corridor and courtyard) increases ventilation rate (ACH) thereby reducing the risk of infection significantly. Where natural ventilation is inadequate, a mixed-mode (hybrid) approach and approved mechanical ventilation should be adopted.

FIGURE 7.6 Coronavirus

Source: Singh (2021).

survival on different surfaces

Infection Control Through Design  87

However, there is no proof that mechanical ventilation has aided the spread of infection in houses even though a wide variety of microorganisms is said to have been found in vent outlets (Escombe, Eduardo, Victor, Manuel, & David, 2019).

Design to Enhance Daylight or Sunlight There are indications that good fenestrations and daylight in structures can sway the spread of airborne pathogens. The average annual temperature of tropical West Africa rainforests is above 20 °C with lots of sunshine (about 12 h of sun a day) due to their location around the earth’s equator. Evidently, before the advent of antibiotics, ventilation, and sunlight were thought to be significant safety measures against infectious diseases (Nightingale, 1868). Solly (1897) added that direct sunlight through glass may well kill the bacteria Bacillus in a few minutes or hours subject to the thickness of the layer of bacteria exposed; moreover, diffuse sunlight found near windows in buildings may well kill bacteria in 5–7 days. Advanced studies indicated that sunlight can kill a variety of bacteria such as anthrax, TB, and others (Hockberger, 2000). A more recent study by Strong (2020) posited that a diffused sunlight or daylight over two layers of glass from a north window was discovered to be very effective in killing hemolytic streptococci within 13 days without antibiotics, with a similar strain surviving in the dark, at room temperature for 195 days. Another study by Yajia, Li, Zhang, and Liu (2020) found a potential relationship between latitude (as an indicator of sunlight) and vitamin D standing and the number of COVID-19 cases and associated mortalities. Daylighting is a good germicidal factor and can inhibit infection (Lateef, 2009). Lytle and Sagripanti (2005) added that sunlight or, more specifically, solar radiation (ultraviolet [UV] radiation) acts as the principal natural virucide in the environment. The standard for measuring daylight or sunlight is UV index and the germicidal effectiveness of ultraviolet C (UVC) peaks at about 260–265 nm (Rauth, 1965; Ayse & Sanlidag, 2020). It is important to note that the most effective and commonly used wavelength for UV germicidal irradiation (UVGI) is UVC (Kowalski, 2009). Unfortunately, only a small percentage of it reaches the Earth’s surface as most are absorbed by the ozone layer (Pozo-Antonio & Sanmartín, 2018). It simply follows that as part of infection prevention and control, there should be adequate openings that will allow daylight into hospital wards, rooms, offices, corridors, stairwells, and balconies. Designing buildings with better exposure to sunlight and outdoor air may inhibit the survival and transmission of infectious diseases, resulting in health benefits for dwellers.

Design With Adaptive Finishing Materials Surfaces in health care facilities such as floors, walls, door handles, and the like are very critical in an IPC strategy. Recent studies on coronavirus (COVID-19) suggest that the virus behaves differently and possesses different life spans with different material surfaces. A study by Doremalen et al. (2020) shows that coronavirus is steadier on plastic and steel (up to 3 days) than on spongy fabrics, like cotton, leather, and even cardboard (