S1Extra7: Rethinking Public Hospitals


Deepika: Over the past month, we’ve explored the idea of the Frugal City and why it’s crucial to revisit principles of living simply. We came to it in the context of how the multiple crises of our times- from the pandemic to the climate crisis – are caused by human over consumption, and therein the need to reintroduce frugality from that perspective.

The pandemic has also put the spotlight on the public health system which is in tatters and deeply inadequate to meet the needs of a population such as ours. It gives us pause on how we can begin to reimagine the public health system so that it’s more vibrant and responsive to the needs of the people. It has in turn led to reflections on how architecture and healthcare services intersect and raised questions on how hospitals and clinics should be designed, and what learnings from the pandemic can be implemented.

In this context, we reached out to Dr. Abraham Thomas in Andhra Pradesh who comes from a family of doctors and has been a Ratan Tata fellow in rural development and community healthcare . He brings together two interesting perspectives: architecture and the design of clinics based on his own practice in Andhra Pradesh, which he shares in this conversation.

Abraham: I’m Dr. Abraham. I’m a rural dentist. I call myself a grameena danthavaidhyudu. That’s like a rural general dentist and I practice in Kodur, which is town, a small frontier Town in the Sheshachalam Valley. It’s a little north of Tirupati, north-east of it.

Deepika: Dr Abraham has also had a major role to play in building a learning centre for children and has adopted a government school in his village.

He’s done this by consciously building and creating spaces that are reflective of our connection to the natural world. So continuing on the theme of sustainable architecture, one of the first questions we asked Dr. Abraham was to describe the design of his clinic – a structure he has built with mud.

Abraham: This is a mud cob structure—there’s no brick in it. So we got local material, local mud, which we like squished under our feet and mixed with various kinds of hay material. And once we thought it was ready and after adding all the jadibootis of the local area like karakkai and kalabanda and cactus and stuff like that, and let it you know, mature for building. And then we built it layer by layer by layer like one and a half feet every day. So the structure is about, the wall is about two feet thick and it accommodates windows.

And then this whole structure supports the thatched roof made out of local grass called Cymbopogon nardus. It’s called bodha here. It gives a beautiful fragrance. Even after the fifth year we can still smell it, and what it does also is that it reduces the outside noise right now. Right now I’m speaking from there.There’s no echo in the building though, you know, some sounds can travel in because we have windows which are not so thick, but there’s no second, you don’t hear the sound produced for the second time. It’s only once. So it actually absorbs all the ricochet possible in cement building painted with emulsions.

Deepika: His motivation stemmed from building a space for his medical practice that created a sense of warmth – much like homes do. The idea, he said, was to go beyond calculations of dimensions to capture the essence of what makes a space inviting. A place that energises.

Listening to him describe it, I forgot for a moment that he was speaking of a clinic, a space that I instinctively find myself shying away from, delaying a visit until absolutely necessary because of the coldness that it evokes. So much so that going to a hospital or clinic can feel disembodied.

It’s also why he chose to build using local materials and tapped into local knowledge–to build a harmonious space. It’s something Anna Heringer, German architect and UNESCO Chair for Earthen Architecture, Constructive Cultures and Sustainable Development, who has worked extensively with local communities in Bangladesh speaks to when she says:

The vision behind, and motivation for my work is to explore and use architecture as a medium to strengthen cultural and individual confidence, to support local economies and to foster the ecological balance. Joyful living is a creative and active process and I am deeply interested in the sustainable development of our society and our built environment. For me, sustainability is a synonym for beauty: a building that is harmonious in its design, structure, technique and use of materials, as well as with the location, the environment, the user, the socio-cultural context. This, for me, is what defines its sustainable and aesthetic value.

He also spoke also of the public health care system in India, reiterating a critique that former Union Health Secretary K. Sujatha Rao writes in her book titled, ‘Do We Care? India’s Health System’. In this book, she analyses the financing and resources allocated to health, pointing to how public health expenditure remains at about 1.2% of the GDP despite repeated election promises to raise it to 2.5-3%. The ‘reduction of public investment and a withdrawal of the state from discharging its obligations of supplying public goods and leaving them to the markets […] and the aggressive pushing of public–private partnerships through demand-side instruments like insurance’, has further weakened the health system, she says. Hence, ‘Today we are witnessing the results of our past neglect.’

Dr Abraham spoke of how worrisome the public health system is in a similar vein. What’s interesting is also what he said about trust and how we feel vulnerable in illness and want to feel seen by the doctors we visit, yet a distance and alienation remains inherent in the system.

Abraham: We need to see how we use our money, first of all, and our allocation should become more sensible and there should be outcomes from it. You see, in my town, hardly anybody walks into the hospital, the government hospital. So why they don’t go there? Why they are go to a private practitioners is because first of all, they do not know who’s sitting inside. They are not they do not the government doctors do not have a public profile. Neither are they published on any book or any website or any newspaper.

So you do not know what their specialty is in the first place. Or you do not know what they’re good at. So they’re not introduced. You wouldn’t go to a doctor you don’t you…understand what I’m saying? So any of us, any of the policy makers who are in sitting in Delhi, Hyderabad, Karnataka, Bangalore, I’m very sure that they and their family members and their grandchildren also wouldn’t go to somebody who they do not know.

Deepika: As part of the reimagination of what healthcare services can look like post the pandemic, he explains why we need to relook at the choices we make given what this crisis has brought up, right from how we build and how resources are allocated for infrastructure to the kind of human interaction it allows for.

Abraham: Even our infrastructure, whether it be public health hospitals or whether it be private clinics, were not meant for this kind of a pandemic. So there was no adequate ventilation. There were many things that were missing. I mean, contact, you know surface contact. So sterilisation, surface sterilisation, chemicals used for those kind of things. It’s a whole gamut of things apart from the barriers we were supposed to be using.

Waiting areas need to be far more open. It need not be in the AC environments or closed wall environments. They can be in sheds or thatch or cement sheds with tree cover. There can be a lot more innovation.

If you look at all the epidemics that happened in the past, during the wall that time, the military was involved. So military barracks were cleared and they were used as hospitals, and they were large and they were area and they had huge windows and you know, that is why they dealt with it better.

Deepika: He then explained how the marriage of local frugal architecture with the public health system can be an advantageous one, by addressing issues of financing the system, adding jobs, and creating structures that might alleviate well-being by incorporating nature.

Abraham: With mud cob and, even if you use rammed earth, you can build structures, rooms that have 14 to 15 feet height like space—your volume of the room increases. So there will be less chance of infection. So infrastructure when done with local materials, the cost will half. Because if you look at it, you have to get gravel from 30 kilometres 40 kilometres. You have to get cement some 300 kilometres. You have to get sand some 40 kilometres and then you have to get people working in shifts. So it’s very impersonal. Also, there is no love in it in, no concern in it for the people who are using these materials. The the high-energy cement is very high on energy. So if you look at all these things and if you look at how many jobs can be created, and how fast things can be done, local materials are better. You don’t need require one year to do this. You can you can have a structure ready. Bamboo can be cut by the time the structure is ready, it can be treated. So I feel there is the thing is that we have not put our mind to it. That’s the first part so he put our mind to it.

Overall the energy consumption reduces. You are insulated from the Rayalaseema heat by virtue of your building. So you do not need air conditioning. You just need some circulation with very small fans, which can be placed in you know in perfect locations and then like strategic locations and you’re dealing with less heat. Number one. Your ventilation is taken care of. It’s well ventilated, this kind of buildings are very ventilated. Number three, is like I said, it’s very warm. Yeah, and number four it’s very cost-effective. This whole structure cost me about a lakh and a half including everything, wiring.

So if you want such a volume of a building, if you want to do it in cement, I would have had to spend three or four times that. With that money extra money that I would have or have spent on those kind of materials—bricks cement water— and then the pollution around this building after the structures constructed, you have so much of waste material and there’s no plant growing because of that. All those kind of things are the side effects.

Deepika: What’s powerful about this imagination and putting it into practice is that having this connection to the earth and natural world has a direct impact on well being. And that’s what makes it so much more important in the healthcare sector because as the World Health Organisation defines it: ‘Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’. In many ways, the pandemic is offering the opportunity to remember this and to go back to the essence of health where holistic well being is front and centre. It means then bringing humanness back to how people are treated by the healthcare system and to the spaces in which recovery is meant to take place.

Abraham: You cannot have the same four pillars, walls, same thing, nurse coming and saying ‘number 61’. That kind of thing should go, you know, we need to call people by name. We need to hold people by the hand. That’s the kind of infrastructure that we need to create, the kind of philosophy that we need to work on.

Health is not medicine, health something else. Medicine comes into the picture when there is a disease. Health is good food, good lifestyle, a lot of Happiness, freedom to express oneself, good interactions in society sharing, caring for one another.

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