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Designing for "the Little Convalescents": Children's Hospitals in Toronto and Montreal, 1875-2006 ANNMARIE ADAMS DAVID THEODORE
Abstract.
This paper explores more than a century of changing ideas about the health of Canadian children through the architecture of pediatric hospitals in Montreal and Toronto. As a unique source in the history of medicine, hospital architecture reveals three distinct phases in the construction of children as patients. Early 20th-century children's hospitals remained bastions of older spatial attitudes towards health. The post war hospital was self-consciously modem, with an arrangement more scientific and institutional than its predecessor.
Through references to other typologies, the postmodem hospital marks a curious return to the earlier attitude that children's health is a family affair. Is the hospital a home for children or an institution for science?
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Not everyone thinks the re-integration of children into the general hospital in Montreal is a good one. Planning for the inclusion of children in the MUHC was rocked by the resignation of MCH executive director Patricia Sheppard in January 2000.She left out of concern that pediatrics was not being given enough autonomy within the MUHC structure. The result, she fears, could be a real lowering in the quality of care the hospital can deliver to children. Sheppard and others (like Beaubien at Ste-Justine 50 years earlier) are mostly apprehensive about diminished dministrative authority, about losing control over such things as budgets, medical appointments, and operating room schedules. But that anxiety includes the possible lack of specific child-oriented facilities and architectural identity in the superhospital. In its latest presentations, the MUHC has begun to discuss separate emergency and other services for children. But if the MCH keeps its name and has its own pavilion, why should it move to the new site with the adult hospitals? The problem of designing for children thus threatens to undermine the whole "one-hospital one-site" superhospital concept. The Universite de Montreal has similar plans for a new superhospital. In 1996 its main teaching hospitals merged into the Centre hospitalier de l'Universite de Montreal (CHUM). But Ste-Justine declined to join the administrative merger. The French-speaking children's hospital will thus not be part of the proposed facility set to open in 2006 in the Rosemont district, ironically just across from Ste-Justine's former St. Denis Street location. The difference between the futures proposed for Ste-Justine and the MCH illustrates the continuing difficulty of housing children's health care: what is best for the patient, separate or attached? At a colloquiun entitled "Healing by Design: Building for Health Care in the 21st Century" held 20-21 September 2000 in Montreal, organized by the MUHC, hospital administrator Bmce King Komiske was asked to speak about current trends in the design of children's medical centres. It is not surprising he recommended a "separate but attached" model, illustrating his talk with recent facilities in the United States, including the Hasbro Children's Hospital in Providence, Rhode Island; St. Louis Children's Hospital, Missouri (fig. 23); and the Maria Fareri Children's Hospital in Westchester, New York. Children's health centres must now offer the same range of specialized medical expertise as the adult hospitals, from surgery to psychiatry, but based on the idea that because of the uniqueness of childhood development, medical workers must understand special psychological needs and distinct physiology. Children's hospitals, that is, have to deal with a set of con ditions specific to children, such as congenital and chronic diseases, and the high incidence of respiratory problems, but benefit from close contact to parallel services such as neurology and oncology in adult hospitals. In Canada there are many approaches to negotiating the separate but attached model. Children's hospitals such as Ste-Justine, the BC Children's Hospital, and Izaak Walton Killam in Halifax have joined with other hospitals to become facilities for children and mothers; the Children's Hospital of Eastern Ontario and the HSC in Toronto are now part of a network of pediatric services; and the Winnipeg Sick Children's Hospital and the Alberta Children's Hospital have merged within larger medical centres.lo2 Many of these institutions have undergone name changes in response to this "move away from bricks-and-mortar definitions of health care."'" Like management mergers in other economic sectors, it is difficult to know whether these transformations cut costs or improve care or patient outcomes. But taken together they break down the 20th-century century notion that sick children need separate buildings to suit their special medical and socialneeds. The belief in medical progress and the continual advance of medical technology remains at odds with the attempt to provide environments specifically supportive of children's experience, yet flexible enough to adapt to future changes in medical practice. The main feature of Komiske's model institutions is a complete denial of their function as hospitals. He advises incorporating regional, non-health-related themes,such as the imagery of a village, or the provision of a real zoo, sailboat, or train. "A great children's hos ital should be designed so that it does not look institutional" he said5 In these hospitals, as in the Toronto Atrium Tower, the lobby, not the exterior fa~ade, is key, providing direction and diversion, and allowing children and parents to forget that they are in a hospital. A colourful, playful, childlike atmosphere seems intuitively valuable, yet there is little scientific study to ghow that offering children a hospital dressed up as a Disney theme park actually improves patient outcomes. Moreover, such interior decoration can detract from the search for architectural solutions to real design problems, disguising rather than defiming children's experiences. For example, one important change to children's health services that will affect the NUHC design isthe concept of patient-cmtred care. This approach involves trying to reduce the number of hospital workers a sick child encounters, and making more provisions for keeping patients together with their families. Such changes have been successfully incorporated at the Atrium Tower. There the design of mmswas carefully studied through the construction of full-scale mockups. In the final building, all rooms are private, a,nd include a daybed so a parent can spend night in the room.lW Conversely, the trends to reduce the length of patient stays, to use digital communication tools for long range consultation, and to involve families in hospital care (sometimes called open visiting) all place a greater emphasis on outpatient and ambulatory clinical facilities than on ward design?06 Finally, some of the critical architectural problems of the postwar hospital, such as the nurses' residence and its relationship to the administrative, medical,and service spaces, am now simply irrelevant. To date in public presentations the MUHChas talked about a campus of separate lowrise pavilions as the architectural form of the superhospital. But this image seems meant to allay fears that a university medical centre would be a gigantic, imposing, unfriendly megastructure, rather than to reflect a comprehensive architectural plan for state-of-the-art healthcare design?07 Still, even what's best elsewhere in the world may not meet the requirements of Canadian children's hospitals, especially in light of the 1984 Canada Health Act, which guarantees Canadians universal, free access to insured healthcare. Komiske for instance, draws some funny conclusions. He says good design is important because in the year following the opening of the Hasbro Children's Hospital, the hospital's market share increased 20.5O/0 and emergency visits increased 25%.lMThe measurable result of his "good design" is thus notbetter care but bigger profits. Few details of the new MUHC or the CHUM designs have been determined. In the case of the MUHC, it is even hard to confirm whether children will be treated in the same facility as adult patients, even if they occupy the same site. What is certain is that more children than ever are now admitted to hospitals, albeit for shorter stays.lW Faced with the ongoing difficulty of simultaneously providing spaces for the latest medical care and spaces that reflect our cultural ideas about sick and healthy children, debates over the image, location, and arrangement of Canadian children's hospitals continue.
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