gooood would dig into projects which are appropriate for deeper report, in order to present the project in a more comprehensive way.
本次专辑带来的是 瑞士瑞盟设计 Lemanarc SA 设计的南京市公共卫生中心（全球最大的传染病医院）。gooood与瑞盟设计创始人及主创建筑师张万桑进行深度对话，就疫情背景下中国医疗建筑现状进行了交流，期望了解现状并收获有益医疗建筑发展的见地。
Nanjing Public Medical Center is the biggest infectious diseases hospital in the world. In this episode, we interviewed Vincent Zhang, founder and chief architect of Lemanarc SA who designed Nanjing Public Medical Center, to discuss on healthcare architecture in current China during the outbreak of coronavirus in Wuhan. We hope it will provide some useful ideas for improving the present situation of healthcare architecture.
出品人：向玲 Producer: Xiang Ling
编辑团队：武晨曦 陈诺嘉 刘丹阳 周诗若 董甜婉雨 Editor: Wu Chenxi, Chen Nuojia, Liu Danyang, Zhou Shiruo, Dong Tianwanyu
Mr.Vincent Zhang, after graduating from the École polytechnique fédérale de Lausanne (EPFL), got his master’s degree in architecture and urban planning from the University of Geneva (IAUG). He was one of the first Chinese architects to graduate from the École polytechnique fédérale de Lausanne and to obtain the Swiss Society of Engineers and Architects(SIA).
What are the rigid requirements of site selection for hospital in China, especially for the special hospitals like those in Xiaotangshan and Huoshenshan?
Generally, we select the site of a hospital according to its functions and the situation of the chosen city. For the temporary infectious hospitals such as Xiaotangshan Hospital, there are several requirements as following.
First of all, we should investigate the contamination condition of the site to other districts. Such hospital should not be built in the area that could pollute the water source. Secondly, considering this kind of hospital is always for respiratory disease, the building should locate on the leeward side of the city. For instance, if the prevailing wind direction of a city is northeaster, the temporary hospital should be built on the southwest side to reduce air pollution to the city. Thirdly, we should avoid building this kind of special infectious disease hospital in densely populated areas and ensure it could stay away from the crowd. Wind direction, water source and pollution discharge are the main considerations in site selection.
The site for temporary infectious hospital should be as flat as possible because this kind of hospital is prefabricated, which requires for construction speed. If the ground is uneven, it will be difficult to quickly assemble the components onsite. Relatively convenient transportation condition is also important for temporary hospital. When large-scale epidemic occurs, large amount of transportation work would be required to send the patients to the hospital. Last, we should also consider disaster prevention. The hospital should better not be built in the flood zone or near the oil depot, avoiding any other possible risks.
Is there any uniform standard of architectural design for fever clinic and infectious department in China? Should fever clinic be designed in a separated building?
So far, there is only a very abstract principle design standard in China for infectious hospital or infectious department in general hospital. We lack strict, authentic and detailed requirements to control our design, resulting in lack of practice ability. It is also the situation of the construction specifications of infectious hospitals in China.
Infectious department in general hospital is different from fever clinic as the former must be arranged in a separated building, keeping a certain distance from the other departments of the hospital. In contrast, we could set fever clinic in the main building of the hospital. Consider the current epidemic of coronavirus pneumonia, it was out of control in the early stage, which brought about large-scale of infections. Facing the outbreak of infectious disease, it is impossible to rely on the Grade A first-class hospitals to control the situation, which is also impossible for any other country in the world. It would cause a series of superimposed effects. We cannot slow down or stop treating basic diseases because of the epidemic. If we bring these departments to rest, it might cause more death than that of the infectious disease.
The current construction standard of infectious hospital needs to be improved in many aspects. It calls for further and more detailed research in infectious hospitals.
What are the special requirements in sewage treatment system of hospitals? How to deal with the medical waste and how does it reflect in architectural design?
Medical sewage and medical waste are different things in infectious hospitals. In the design and construction of infectious hospitals, there are strict controls of medical sewage. All the waste water should be specially collected and disinfected. It could be discharged until it reaches the standard for urban water usage. However, sanitary wastewater from ordinary hospitals could be discharged to the city water supply pipe network in a faster process.
Medical waste is more common in infectious hospitals. Compared to ordinary general hospitals, there would be more polluting waste with risk of infection in infectious hospitals. However, except for requirements of using trained people to collect the medical waste and send to special department to process, there is no other standard that we could refer to. We have to pay attention not to leak anything during the transportation process in waste disposal.
Take Nanjing Public Medical Center for example. It is the largest infectious hospital in the world with 1200 beds. We carefully categorized the waste from the infected area in the design phase, strictly distinguishing it from the ordinary medical and sanitary waste. We also underlined the leakproofness of the space. In addition, cleaning and disinfection of the equipments to transport and storage waste from the infected area are also different.
Medical waste disposal system is included in the entire design of the hospital. The design of a hospital reflects the whole process of medical treatment. Thus we should take contaminant from infected area, ordinary medical and sanitary waste, biological waste and all the other wastes into consideration, and create a system to separate them from each other. If we skip this process and try to add it after construction, it will cause a lot of conflict and increase the risk of cross infection.
▲瑞盟设计的南京市公共卫生中心，Nanjing Public Medical Center by Lemanarc SA ©LEMANARC SA
Design of health care buildings
What are the requirements of space division and plan layout in the design of general hospitals?
The systemic design rules are advancing with the times. It is closely related to the progress of medical science and medical engineering. The rules could be developed when the medical equipment improves. Thus there is no standard layout. Even if it exists, it will change according to the development of medical techniques. The core function of medical architecture is to service for medical treatment. As medical treatment is in a constantly changing process, there is no standard form for medical architecture. Different types of hospitals has different features and architects should focus on solving problems in each specific project. There is no simple, standardized and duplicable solution.
We could see the trends of floor layout according to the development of medical treatment. Generally, the arrangement of different departments is often decided by the organ system. For example, the department of cardiac surgery would be placed close to the cardiology department because they are both about heart disease. Traditional departments are divided in a relatively rough way as internal medicine department, surgery department, gynecology department and pediatrics department. In this way, the internal medicine and surgery departments are separated, which would cause inconvenience to the patients. Modern department devision is becoming more and more patient driven. The departments are arranged according to organs and body systems (like nervous system and blood system) so that patients could find their way based on their symptoms.
Another possible layout is to divide the departments by different types of people. We could establish geriatric department or geriatric hospital focusing on the diseases mostly strike senior people. In foreign countries, there are also many women’s centers. Although some diseases could strike both children and adults, the diagnostic method and therapies would be different. Thus we could set up children oriented departments.
Translational medicine is also a possible development direction, which means that the relationship between research, teaching and medical treatment would be closer. In the treatment for the coronavirus pneumonia, drug study and clinical trial are connected more tightly than before. This will also be an important development direction of medical treatment.
There are also changes in working method. In traditional hospital, every doctor has his/her own office. However, working together in a common office is more welcomed in modern facilities because it could enhance communication and meet requirements of multi departments. As diagnosis and therapy of disease would involve various disciplines, communication is indispensable in the hospital. It also shows the importance of cooperation between different departments. During the epidemic of coronavirus pneumonia, many patients are suffering from various problems apart from lung disease, which requires for multi-discipline knowledge.
How to keep effective transportation and ensure the isolation between infected area and other areas?
This characteristic obviously embodied in the design of Nanjing Public Medical Center. There are no clear national instructions for isolation. In the existing regulation, we have contaminated area and semi-contaminated area, which could mislead people to think that semi-contaminated would be relatively safer. In fact, when people are in the semi-contaminated area, they are completely exposed to the threat of disease. In medical buildings like Xiaotangshan hospital, architects designed partitions between the ward and the corridor to the semi-contaminated area, which could make some of the doctors, nurses and works to think that the corridor belongs to the semi-contaminated area and reduce their attention on protection work, exposing themselves to the disease unconsciously. When the hospital is in use, this corridor is a space with diverse people and materials, which are easy to cause cross infection. It reflects the fact that the principle concept in the current regulation is not clear and thorough enough.
In the project of Nanjing Public Medical Center, we made more accurate division between different types of spaces. We did not simply divide the space as polluted and unpolluted. Firstly, we cleared the concept of infected area and uninfected area. In infected area, we further divided the space according to disease categories and route of transmission as requirements of avoiding contact infection and respiratory infection are totally different. In addition, contaminated waste from different infectious diseases should also be disposed separately from other medical waste, which is different from ordinary hospitals. In uninfected areas we also set clean zone and soiled zone. The clean zone in uninfected area, which is so-called working space for medical staffs, could be interconnected.
Disinfection and separation of the space between the infected and uninfected areas are significant because it ensures the different areas to operate under their own characteristics.
Generally, uninfected area could be interconnected while in infected area the space should be further divided according to disease categories and route of infection. The uncontaminated materials should be separated from the contaminated materials in different infected areas. Even in uninfected space, there should be partition between clean zone and soiled zone. After several levels of division, we came up with four to eight space partitions. Only by accurate space division, could we reduce the risk of cross infection and superposition of infection in the hospital.
It is important to avoid cross infection in infectious hospital. How to meet the requirements of fire protection and prevent cross infection?
The rigid requirements for fire protections are clear. First, we should ensure the fire protection of the site. When there is a fire, firefighters could get into the building from outside. Second, we should ensure the escape distance and fire protection units, which differ from countries. It is possible to run from uninfected area to infected area as we would set escape doors on certain positions. The normally closed doors at the medical technology department would automatically open in emergency. We should take escape in the first place and cross infection is inevitable under such situation. Last, we should use building materials that could meet the requirement of burning time. It is easy to realize according to relevant regulations.
How to decide the distance between beds in the limited space of the hospital?
Distance between beds and distance between inpatient units are two different concepts. In the design of inpatient ward for infectious diseases, we still use multiple bedded rooms in China. It is almost impossible to avoid cross infection between patients. In western countries, single bed room is more often used for patient with infectious disease. In addition, the treatment equipment is movable so that it could be moved to the bedside according to requirements.
As mechanical ventilation is mainly used in the inpatient wards, the distance between inpatient unites is not that important. Many regulations are established basing on early situations with natural ventilation, such as the rule that the windows should be operable. If the window is opened, there will be great air pressure at the opening and destroy the designed positive-negative pressure relationship. It is to say, positive-negative pressure design is based on the situation that the windows of the inpatient ward are rarely open.
The virus could be effectively controlled by adjusting the temperature and humidity of the ward. However, the newly built wards could hardly ensure the interior temperature. As the virus is weak to high temperature, it will be hard to defeat the disease in cold weather.
▲瑞盟设计的南京鼓楼医院的病房内部，a patient room of Nanjing Drum Tower Hospital designed by Lemanarc SA ©LEMANARC SA
A reflection about the epidemic in Wuhan
How to avoid cross-infection in mobile cabin hospitals (方舱医院) built for the Wuhan epidemic?
The form of mobile cabin hospital, actually, reproduces the earliest model of medical care in the Middle Ages. The earliest hospitals and ICUs were just centralized in similar way. The advantage is that more patients could get efficient care with relatively small number of medical staff. However, the defect is that, which is obvious, the cross-infection in this kind of closed environment is inevitable. But in fact, we are all different individuals, which means the influence on everyone impacted by the same infectious disease would be different, so we could not discuss future medical treatment without precision medicine. For now, both the mobile cabin hospitals and the Xiaotangshan Hospital were all remedies after the break of mass infection. There is no perfect method to avoid cross-infection in the same space or provide more careful and personalized services.
What do you think of the Huoshenshan Hospital and Leishenshan Hospital built in such short time?
The Huoshenshan Hospital and Leishenshan Hospital are the imitation of the Xiaotangshan Hospital built during the SARS period happened 17 years ago. Either the construction technique or the design strategies has not experienced visible development. Actually, it is unrealistic for the design to get obvious improvement in such a short period of time. More consideration should be put on what kind of preparation the states could conduct in advance of infectious disease. When disappointed accidents have already happened, building temporary hospital as quickly as possible seems to be the only solution. This kind of low-quality buildings could only be an emergency and would be abandoned after once.
After the epidemic, what will be the development trend of the design for the infectious department?
This question should be discussed from two perspectives. In terms of the territorial or even national public health, larger amount of equipment and preparation is in demand. Nanjing Public Health Center, which was built after SARS happened in 2013(built in 2016), is also been used as a general hospital. When magnitude public health incident occurs, there would be less panic in Nanjing since there would be no need of building prefabricated house and the patients could be provided with better medical treatment. This is the benefit of sufficient preparation. I think this mode is worth implementing and promoting national wide.
And also, in my opinion, it should not be the 3 grade A level(三甲) hospitals that take the whole responsibility facing the infectious diseases. According to the situation after the break of Wuhan epidemic, it is not difficult to aware that the doctors in community medical unit have failed to take efficient actions while they were supposed to immediately help isolate patients within specific places in the community, such as the auditorium, schools, gyms, hotels, exhibition centers and so on. Even the largest fever clinics and epidemiology clinics could not hold crowds of people waiting in limited general hospital. Normal general hospital dose not have capability of treating Public-level epidemic incident. Community should help relieve the excessive stress by integrating social resources.
Of course, the general hospitals could also be improved. In many hospitals, areas of clean and contaminated are not completely divided while doctors and patients do not possess separated spaces either. So, once the incidents occur, they are too difficult to reconstruct. On the contrary, if the spatial division of the hospital was operated thoroughly on usual, transformation on urgent circumstance could be conducted rapidly. Take the Nanjing Drum Tower Hospital for example (there is no infectious patient in it till now), it completely takes modern standard of architectural flow design and spatial division, the arrangement of which help the hospital deal with the incidents better. It can also prevent the hospital from inoperable condition. Recently, a great number of domestic hospitals had been built very quickly, but many of them were the duplication of old mode. Neither do this kind of design deliberately concern the future of medical development, nor do they deliver humanistic care or farsighted thinking.
There are two characteristics of the Nanjing Drum Tower design by your team. On the one hand, you express the humanistic care by gardening that psychologically comfort the patients. On the other hand, you paid a lot of attention to historical and cultural meaning of the building, culturalization in other words, and helped the hospital resume its historical role, the “church hospital”.
Currently, the design of medical buildings seems to realistically focus more on the fundamental issues, such as the flow organization and the functional arrangement. For you, what is the meaning of the humanistic care as well as culture of medical architect design?
First of all, I think there is some misunderstanding. Primarily, Nanjing Drum Tower Hospital is a medical institution, the function and flow arrangement of which were designed according to deep research. Over these years, many designs of hospitals claimed to focus on functional demands, but I just found constant imitation of what was called function standardization decades ago. If this kind of simulation could be regarded as positive response to functional demands, our understanding of functionalization seems to be outdated. There is no actual difference, for instance, between the Huoshenshan Hospital with Xiaotanshan Hospital. So I feel a little confused about the meaning of function you mentioned before. Spatial division, control of air circulation, the ability of emergency response, and other issues I referred above, should all be analyzed and studied meticulously.
The design of Chinese hospital relies too much on one mode, the result of which is that hospitals are becoming more and more similar with each other. It may take years for a hospital from design, construction, operation to improvement. The development of medical standards, including medical equipment, theory and technology is much faster than the development of medical buildings, so we really need to be more addicted to further research. It is ridiculous to just regard some standard mode as functionalization.
▲南京鼓楼医院中庭，the atrium of Nanjing Drum Tower Hospital ©LEMANARC SA
（点击查看项目详情，Click to check more details）
Take Switzerland as example, large infectious disease hospital is not demanded in Switzerland. It is the public health and contagion experts would that travel around hospitals and communities rather than patient themselves. When contagion occurs, all the social resources would be utilized. When people are forced to go out for medicine while the transportation system is closed, secondary disaster would beyond imagination.
In conclusion, though there is no better treatment under the present situation, it is not the first time we facing similar situation. From general perspective, more comprehensive policy and laws may help establish better preparation strategies, such as facility construction and professional training of relative people, so that we could make some progress. And also, deep thinking and research do not mean slow down the progress. Building in haste could only prove the stock of manpower. Whether the quality of the buildings could be guaranteed is still suspicious. The quality of medical buildings should not be sacrificed for construction speed. Only the farsighted and high-quality architecture could stand up for public health in the long term.
More about Nanjing Public Medical Center
▼南京市公共卫生中心概览，Nanjing Public Medical Center ©LEMANARC SA
▼建筑外观，exterior view ©LEMANARC SA
Nanjing Public Medical Center, surrounded by hills, with one thousand and two hundreds’ beds, is located in the Qinglong Mountain, which lies to southeast of Nanjing. It has a total floor area of about 150,000 square meters.
As the most traditional isolated living quarters for infectious diseases treatment, it is even very difficult for constructions of ordinary project because of the complex mountain topography, water system, and vegetation conditions. What’s more, a conjoint design of various infectious diseases hospital and general hospital is very rare on a global scale.
▼总平面图，site plan ©LEMANARC SA
▼清洁区和污染区分布示意，layout of the volumes for clean area and soiled area ©LEMANARC SA
▼南京市公共卫生医疗中心 – 入口广场，Nanjing Public Medical Center – entrance square ©LEMANARC SA
As the biggest infectious diseases hospital, the building group include a downwind building of tuberculosis, a building of infection of various touch diseases and miscellaneous diseases, and a common non-infectious disease hospital running independently. These three buildings constitute the core medical zone.
The lower part of these three medical zones is joined by a united medical and technique service zone, where polluted area and unpolluted area are separated and disinfected strictly. On the one hand, this way divides the different infection areas; on the other hand, it realizes the intensive utilization of medical resources to maximize. The clean underground storage, disinfection area, and logistic zone can dispose pollutants according to zones and control pollutants uniformly.
▼剖面图：三个病区的下部的由一个统一的医技服务块联结起来。Building sections: the lower part of these three medical zones is joined by a united medical and technique service zone ©LEMANARC SA
The emergency center using the quarantine of valley realize that the center can close automatically, and the infection can expand in a safe area, when it happens sudden infections. The self-contained resting area for employees in the north high area protects the staff from infection further.
▼多种传染病综合楼，the building of infection of various touch diseases and miscellaneous diseases ©LEMANARC SA
According to the features of the hospital, from the whole hospital to each office and each ward, it realizes the separation of doctor and patient, clean and dirty, polluted area and unpolluted area. And it realizes respective separation and control of pollution area among different infections.
▼平面局部 1：detailed plan 1 ©LEMANARC SA
▼内部庭院，the inner courtyard ©LEMANARC SA
While taking advantage of the vertical space, taking the centre area of building group as pollution area, it offers safe and comfortable evacuation square for medical workers and common patients of general hospital. And it protects the clean and independent management for general hospital. The flow line of access for infection patient is designed in the bypass road to avoid the entering of infection. And it offers good external conditions for deep separation of internal flow.
▼室内日光井，view to the indoor patio ©LEMANARC SA
And last , the project design take full advantage of natural conditions ,such as the protective screen (mountains), vertical space, the shape of mountain and river system ,as well as the local wind direction , sunlight and so on , and it design successfully a resources sharing , safe, independent and large-scale infectious disease hospital , by a in-depth study of management features of different infections treatments.
▼整体鸟瞰，project overview ©LEMANARC SA
A light wave shape system with sunshade is a way of energy-saving; it also offers soft lighting and privacy atmosphere for indoors. The scenery surrounded by mountains and quiet lake formed by using the area to release the floodwater bring the patient the sense of safety and yearn for life. It seems like creator’s caring embrace.
▼立面效果图，Nanjing Public Medical Center – facade rendering ©LEMANARC SA
▼南立面图和北立面图，south elevation and north elevation ©LEMANARC SA
▼1层和2层平面图，1F and 2F plan ©LEMANARC SA
项目名称 : 南京市公共卫生中心
设计单位 : 瑞士瑞盟设计 LEMANARC SA
设计师：Vincent Zhengmao Zhang 张万桑, Daniel Pauli
瑞士瑞盟设计 LEMANARC SA正在招聘人才，详情请点击这里