There’s a hospital in Skane, just outside Malmo Sweden. Some of you might know its distinctive spherical, doughnut shape. It’s one of a ‘new generation’ of hospitals commissioned and built for what’s described as the ‘post-antibiotic’ era. Its cylindrical ring-like shape is a little like that of an organic orbicular cell. Historically many hospitals have been modelled on a different kind of body. The cruciform or crucified shape. Limbs radiating from a central torso or spine. Or they have ‘wings’ that fan out from the body of the building. That’s why most hospitals have these improbably long central corridors, with wards and departments stretching out from the building’s central spine, or trunk.
But here at Skane, in this cellular or spheroid design, patients, visitors and waste occupy the outer ring of the building. The whole structure is wrapped in glazed open-air walkways from which its temporary residents and the public can enter individual isolation rooms directly from the outside. These external walkways operate a little like a semi-porous dermis or membrane. Gaps between each panel of glazed wall allows fresh air to enter the outer skin of the hospital. It’s like being both inside and outside at the same time. There are also external lifts, peripheral to the skin of the building. These lifts are reserved exclusively for patients, visitors and hospital waste. One doesn’t have to be an anthropologist to spot something interesting in an architecture that puts patients and dirty waste in the same classificatory space.
Then there’s the inner ring of the building. The central disc is designated for clean materials, clinical staff, offices and conference rooms. Internal lifts are designated for professionals, ancillary staff and supplies. A complex system of airlock doors and transitional spaces separate the outer ring of the infected from the inner sterile sphere of the disinfected. In this way, the whole building is bisected between thresholds of an inner purity and an outer danger. Skane is further evidence of the way microbial nonhuman life historically reshapes, ‘infects’ or ‘colonises’ our architectures and buildings.
My interest in buildings like that described above is linked to our new SATSU project exploring the biotic ecologies of buildings, the material relationships between infectivity and the built environment, funded by the UK Arts and Humanities Research Council (PARC: Pathways, Practices and Architectures: Containing Antimicrobial Resistance in the Cystic Fibrosis Clinic, 2018-2020). The project brings together the interests of myself, Sarah Nettleton, Chrissy Buse and Daryl Martin at SATSU in antimicrobial resistance or AMR (Brown and Nettleton 2016, 2017) and healthcare buildings and the ‘materialities of care’ (Buse, Martin and Nettleton 2018; Martin et al 2015). We’re also working with other colleagues including Alan Lewis, an academic architect at the University of Manchester, Lynn Chapman who is a graphic artist, and two respiratory microbiologists, Mike Brockhurst and Craig Winstanley.
In the project and more widely, we’re interested in shifting understandings of biotic life and parallel changing architectural and material forms. How is it that we have historically come to envisage restructuring space for a ‘post-antibiotic age’? Some thirty years or so ago, in the ‘pre-post-antibiotic age’ we might say, the medical sociologist Lindsay Prior (1988) reflected on the relationships between medical discourse and hospital architecture. He focuses on the architectural drawing of a late C19th children’s ward. It’s a hexagonal pavilion shape with beds dotted around the edge. It reminds me of Skane somehow. Each bed has a window opening onto a surrounding veranda. The design is such that the beds can be wheeled outside during the daytime. It’s a variant on a number of designs for ‘fresh air wards’, a medical discourse influenced by a miasmic theory of contagion and infection. Illness here is conceived as a product of chemical processes, fermentation or putrefaction, resulting in airs, vapours and stagnating fumes. Torpid air must move if its not to fester.
Air then gives way to touch, as miasma gives way to germ theory. Antibiotics make way for the reshaping of clinical space, new efficiencies of scale, and densities of healthcare delivery that develop alongside the introduction of antimicrobial medicine throughout the latter half of the C20th (Bud 2006, 2007). The result is a much more recognisably ‘modern’ kind of hospital. The contemporary hospital rooms where we meet with medics in the course of our work on PARC are often windowless. The ceilings are quite low. They’re usually uncomfortably warm and well heated, crowded with AV and computer equipment. It’s in this way that colleagues like Clare Chandler (2016) of the London School of Hygiene and Tropical Medicine speak of antibiotics as ‘infrastructure’, having constituted healthcare spaces in deeply material and physical ways.
Most hospitals, of course, don’t look or feel like that at Skane. They don’t work like that either. But nor indeed does Skane work entirely in the way that was intended for the ‘post-antibiotic era’. That precarious threshold between the inner clean ring and the outer dirty sphere is inevitably leaky. It’s worth thinking carefully about the movement and interaction between people and the biotic as visitors, clinicians and others arrive and depart, board buses and public transport, pick their kids up from the same schools and nurseries, and live the inevitably mixed-up ecological lives expected of people who move, travel and work. It’s very difficult, and materially contingent, to completely maintain that pure threshold between the outer world of patients, their visitors, and the inner world of hospital staff.
Some of the story that follows recently appeared in Discover Society (Brown 2017) but it’s worth retelling here: I’m sat with a clinician. She’s a lung infection specialist. We’re talking windows. Whatever clinic I go to, the conversation always returns to the windows. Rooms without windows. Windows that don’t open. Windows that can’t be closed, or let in a draft. Windows that need replacing, or windows that were better before being replaced. Windows that were never installed. The irony isn’t lost on me. A respiratory specialist talking about the breath of the building. The breeze coming in. The hospital air moving out. In and out. Inhalation and exhalation. The clinic gasping for breath. All a reminder of the window’s early meaning, vindauga, the ‘wind-eyes’ of the building.
She recounts the story of a hot dry summer. In the outpatient clinic, staff and patients are wilting in the heat. Windows are open. It’s the older part of the hospital where it’s still possible to open them. Elsewhere the ability to open a window has been designed out of the more contemporary architecture. Open windows cause aircon chaos. Anyway, here the windows are open, despite the awful noise of construction work below. But at least there’s good clean ‘fresh air’.
Then months later the clinic is thrown into crisis. There’s a new strain of respiratory infection in the cystic fibrosis population. This could easily be fatal for patients already struggling with repeat infections, any one of which could be their last. The inpatient ward fills up with new admissions on high-dose intravenous antibiotics. The labs try to track down the source of the infection and where it could possibly have come from. After much head scratching, suspicion turns to that warm summer, the open windows, construction work going on outside, the digging of foundations below ground level, dust escaping into the air, spores drifting on the breeze. Inhaled by the clinic. Inhaled by its patients. Then coughed up in blood-stained sputum.
In Terror from the Air Peter Sloterdijk (2009) offers a meditation on the material technics of breathing and breath. Respiration is something to be technically accomplished, to be assisted by air conditioning, restrictions on smoking, surgical masks, air quality measures, carbon monoxide monitoring, ducting and ventilation, and so on. But such technics are not evenly deployed. They are striated, unequally offering protections to some that are not enjoyed by others. Respiration takes place, we might say, within economies of respirational scarcity. Breathing isn’t dangerous for everyone, but it is for lots of us.
The PARC project attempts to make sense of the experience of people with cystic fibrosis (PWCF) as they enter and make their way through clinical space. There are around eleven thousand people with CF in the UK, a ‘chronic degenerative’ condition that makes breathing perilous. Extending respiratory life for them hangs on all sorts of things, especially aggressive antibiotic treatment. They’re used to the daily routines of inhaling antibiotics in aerosol form, delivered by nebulisers. Antibiotics as vapour, atmosphere, mist. All this suppresses infections for a while at least, but without getting rid of them completely. Those residual colonies of infection, the biotic remnant, are left to evolve into to potentially fatal, resistant, and transmissible cross-infective pathogens. CF lungs become ‘reservoirs’ of infection, harbouring a constantly changing ‘resistiome’.
Biopolitical reflections on breath were at the forefront of our thinking in putting the project together. Sloterdijk draws attention to the material fracturing and divisibility of air, of atmospheres, the structuring of breath and respiration through spaces, places and architectures. We might call these ‘anatomospheres’ in which respiration is seen to retreat or withdraw from shared atmospheres, into airs that are increasingly private. A proliferation of personal respiratory chambers. Breathing is less likely to take place between and amongst shared and entangled airs, than it is to take place in more hermetically contained, secured and surveilled atmospheres.
It’s not at all uncommon to think of bodies and buildings overlaying and substituting for one another. For Mary Douglas (1966) the building is the body’s original surrogate: ‘Going through the door’ she writes, ‘… express[es] so many kinds of entrance… crossroads and arches… doorsteps and lintels… worked upon the human body’. Bodies and buildings are awkwardly duplicated within one another, both symbolically and materially. Heidegger (1971) thought of buildings as ‘dwelling’ or the embodied finitude of being. Architecture is techne. Buildings lend bodies metaphorical sturdiness (the ‘building blocks of life’). By contrast, bodies give buildings both their liveliness and frailty, their decay, their facades (faces), their permeabilities (vindauga). After the Grenfell tragedy, who could not be wary of architectural clothing, the cladding (cloak) of the body/building? ‘This contrast is at its most intense’, Steven Connor (2004) once wrote, ‘… when the physical processes in question are least material, which is to say those carried on or in the air’. Breath disassembles buildings.
Reflecting on Walter Benjamin, Böhme (1993) suggests that it is through respiration that one ‘breathes’ or absorbs the ‘atmosphere’ of a place. Respiration ‘allows this atmosphere to permeate the self’. He isn’t thinking about infections. Of course not. But he is possibly thinking about the way one might become infected by the atmosphere of a building, for both good or ill.
I have one final story. It’s about waiting. Or rather it’s about waiting rooms. The experience of most people with CF when they enter the architecture of clinical space is one of waiting. This is an acute source of anxiety for people who are told not to share one another’s breath. To sit, at least, ‘two or more chair widths’ from the next person. There must always be a space in which to breathe. A bubble of air around one’s chair. At one of the clinics, designers and architects were commissioned to make waiting more ‘comfortable’ and attractive. They were to give the experience of waiting the atmosphere of leisure, retail, hotel hospitality. Couches and sofas replaced the old 1970s plastic chairs. A new central open-plan plaza, or lobby area, replaced the specialist waiting rooms. Patients, visitors and staff could now move more freely amongst one another, all sharing the same atmosphere. All coming and going from treatment rooms to the communal space, the communitas of the lobby and then back again. That’s what the design of public space is supposed achieve, to optimise interaction, to foster networks, linkages, visibility. All, needless to say, known infection risks for people with CF.
Breath and breathing, together with the spaces that guarantee respiratory existence, become the basis for new forms of sociality. There are degrees of atmospheric entanglement and disentanglement. Timothy Campbell (2011) says of Sloterdijk that it is as if ‘… the former blood ties of family… had been turned outward from one’s person to now include the breathing space of those whose individual immunitary designs most closely match one’s own’ (97). Blood ties become breath ties. I’m thinking of people with CF when Sloterdijk recalls the devastating use of mustard gas at Ypes. We have to breathe. We have no choice but to breath. It’s the involuntary ambient nature of breathing that forces one to become complicit in one’s own destructibility. As Sloterdijk puts it ‘… unable to refrain from breathing, [they/we] are forced to participate in the obliteration of their own life’. The point is to ask, to whom does this respiratory obliteration most apply and under what kinds of lived material conditions? How are the technics of design and architecture tied into breath, breathing and even obliteration?
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Sloterdijk P. (2009) Terror from the Air, Los Angeles, California: Semiotext.