Michael Graves used to tell a story about what sparked his interest in healthcare. He recounted waking up in a hospital bed in February 2003 after collapsing from a spinal cord infection that left him paralyzed from the waist down, and staring up at the acoustic tile and fluorescent lights of a banal suspended ceiling. “I can’t die here,” he said to himself. “It’s too ugly.” He devoted the next dozen years to the design of hospital furnishings. Earlier this year, Graves passed away in the familiar surroundings of the Warehouse, his distinctive Princeton, N.J., home.
Hospitals are depressing places. They are settings for intensely personal experiences, yet they are anonymous and impersonal; they are refuges for the sick and dying, yet they are full of alienating machinery; they are places of purposeful activity, yet the atmosphere is one of anomie and boredom. These are public buildings whose occupants would rather be elsewhere; the first thought of most people entering a hospital is, “How soon can I go home?” As Graves observed, soulless architecture doesn’t help. My local hospital has all the charm of a suburban Holiday Inn. Too many healthcare facilities built today are uninspired and generic, plain vanilla designs without architectural ambition or attention to detail.
It could be otherwise. The bar for modern hospital design was set more than 80 years ago by the landmark Paimio Sanatorium, which is the subject of an exemplary new monograph edited by Esa Laaksonen, the director of the Alvar Aalto Academy in Finland. Alvar Aalto Architect Vol. 5: Paimio Sanatorium 1928–33 (Rakennustieto Publishing, December 2014) includes a history of tuberculosis sanatoria in Finland and elsewhere, background on the building, selected sketches and working drawings, recent views, archival photographs (Aalto on the construction site in plus-fours), and a useful description of other projects that his office was engaged in while working on Paimio (including a little-known competition entry for a large hospital in Zagreb). The monograph is part of an ambitious series, projected to be 28 volumes (six have been released so far) that will provide a comprehensive record of Aalto’s architectural and planning work. Anyone interested in the Finnish master will want this set.
Completed in 1932, Paimio Sanatorium is located in a forest in southwest Finland, outside the city of Turku, where the young Aalto—he was only 30 when he started work on this project—had his office. The client was a federation of local municipalities, and the project was the result of a competition—there were 13 entries. Aalto’s spread-out plan owes a debt to the Dutch modernist Jan Duiker’s Zonnestraal Sanatorium in Hilversum, which Aalto visited shortly before the competition. Because tuberculosis is highly contagious, sanatoria had to be self-sufficient. Paimio was organized in discrete wings, each housing a specific function: south-facing patients’ rooms; open-air sunning terraces; an entrance lobby, stairs, and elevators; communal spaces (library, lounge, hobby room), doctors’ offices, and treatment rooms; and service areas (kitchen, bakery, laundry). Staff housing was in separate low-rise structures.
In the second edition of Space, Time and Architecture, published in 1949, Sigfried Giedion judged Paimio to be among the “three institutional buildings inseparably linked to the rise of contemporary architecture” (the other two were Walter Gropius’ Bauhaus at Dessau, and Le Corbusier’s proposed League of Nations Palace in Geneva). An interesting detail revealed by the Paimio monograph: the competition rules imposed a height limit of four floors. Shortly after the winner was announced, the program was enlarged from 186 to 286 beds. Aalto’s solution was to simply add two floors (and a roof terrace) to the patients’ wing, turning a horizontal scheme into a distinctly vertical one. The result was a modernist slab lyrically poking out of an Arcadian pine forest. One wonders if Giedion’s appraisal would have been the same had the building been shorter.
Paimio established Aalto as a major figure in the modernist movement. The exterior incorporated all the de rigueur hallmarks of the International Style: ribbon windows, white plastered walls, flat roofs, dramatic cantilevers. In fact, most of the structure was distinctly conventional: a commonsense short-span concrete frame with a flat slab and brick infill. This modernist icon “was erected without machinery—simply by man- and horse power,” as the monograph wryly notes.
It is the interior of the sanatorium that is the most impressive. No detail escaped the Aaltos’ attention (Alvar’s architect-wife Aino was his active collaborator). They designed the lighting fixtures, the clocks, and the opening mechanisms for the windows. Even special door handles that would not catch on doctors’ lab-coat sleeves, anticipating Aalto’s lifelong fascination with door hardware. At Paimio, the push/pull bars of the dining hall doors were tubular steel, but the touched portions were ebony. Similarly, the handrails of the stair balustrades—steel pipes in most International Style buildings—were wood. The detailed architectural drawings for the sanatorium were the work of only six people: Alvar and Aino, assisted by two Finnish and two Norwegian architects.
The Aaltos were responsible for all the furniture: tables, easy chairs, library chairs, and outdoor recliners for the patients; side chairs for the staff dining room; chairs and desks for the physicians’ offices; stools for the laboratory. Best-known is probably the so-called Paimio Chair, a patient’s lounge chair that uses curved plywood for the seat and steam-bent birch for the supporting frame.
Until antibiotics were discovered, tuberculosis was treated by exposure to sunlight and fresh air—at Paimio, ambulatory patients could go up to the roof terrace, others could be assisted to the sunning terraces that were directly accessible from each floor. The outdoor terraces were oriented due south, but the patients’ wing—single-loaded so that all the rooms received sunlight—was turned slightly southeast to maximize sun in the mornings and reduce it in the afternoons. Most of the rooms were double occupancy. Heating was by means of flat radiant panels on the ceiling, to minimize drafts. The individual washbasins were designed to reduce splashing noise. Wardrobes of curved plywood were fixed to the wall and raised off the floor to facilitate cleaning. The ceiling was painted a restful dark green and the linoleum floor was brown. Brighter colors were used in public areas, though not the cloying “cheerful” colors that are common in so many hospitals today. The stairs and hallways were warmed in the cold winters by canary yellow rubber-coated floors; doors were teal green. The windows of the doctors’ wing were shaded by colorful canvas awnings.
Aalto was a self-styled functionalist who referred to Paimio as a “medical instrument,” and he designed the building as purposefully as a scalpel. But his architecture was grounded in a profound humanism. The sanatorium is the least formalist of buildings and it functioned well, but one never has the feeling that it was designed for the benefit of the doctors or administrators, or even the cleaning staff, like so many modern hospitals. The well-being of the individual patient was paramount. “The room design is determined by the depleted strength of the patient, reclining in his bed,” Aalto was quoted as saying in Göran Schildt’s Alvar Aalto: The Complete Catalog of Architecture, Design and Art (Wiley, 1994). “The color of the ceiling is chosen for quietness, the light sources are outside the patient’s field of vision, the heating is oriented towards the patient’s feet, and the water runs soundlessly from the taps to make sure that no patient disturbs his neighbor.”
The Paimio monograph includes a description of the changes that have been made to the building since it opened in 1933. Like all hospitals, Paimio has undergone periodic upgrading and technical improvement, as well as regular maintenance and repairs. It is a credit to the administration that the Aalto office was kept involved until the death of Elissa Aalto, Alvar's second wife, in 1994. This does not mean that the landmarked building was treated with kid gloves. When the sanatorium was converted into a general hospital in the 1960s, the open sunning decks were enclosed, and a new wing containing operating rooms was added. Today, Paimio serves as a rehab center for children and young people. What is most impressive is that in its 80-plus years, the building has never ceased to function as a healthcare facility. Tellingly, modifications were implemented so as to preserve the underlying spirit of Aalto’s design.
“While the changes required by the hospital operations have been carried out so as to ensure maximum functionality where possible, each individual detail has been implemented in a way that helps move closer to the original solutions,” points out architect Ola Laiho, whose firm has been responsible for repairs and modifications to Paimio since 1996. In other words, the hospital buildings have been treated as valuable architectural heritage, not as pieces of medical equipment to be discarded and replaced, like an outdated X-ray machine.
Aalto had no hospital experience when he designed Paimio. In fact, it was his first large commission; his major previous project had been a small newspaper plant in Turku. But perhaps that was an advantage. He was not an expert with a kit bag of preconceived, pre-packaged solutions. Instead, with the benefit of medical advice, he reasoned his way through each problem. In a 1998 essay for a Museum of Modern Art show about Aalto, the Finnish architect Juhani Pallasmaa, Hon. FAIA, wrote that the Paimio building “exudes a rare atmosphere of optimism, healing and inspiration.” That, surely, is what all hospitals should manifest.