The microorganisms that cause tuberculosis scatter through the air from the force of a sick person’s cough. Alighting on a healthy body, the bacilli enter the lungs and multiply, turning surface of the lungs into lesions that resemble soft cheese. A slow deterioration can descend — a transformation of a healthy body into a thin, sickly, pallid soul who coughs bright red blood. The physical threat may sound overwhelming compared to seemingly frivolous architectural elements, but there are those who see disease-halting power in a building’s design.
Archive Global works to prevent numerous infectious diseases through the redesign of urban housing in Haiti, Cameroon, Bangladesh and elsewhere. Founded in 2006, the organization is one of just a few firms worldwide that focuses on preventing disease by exploring the connections between architecture and health.
With tuberculosis lingering from equatorial slums to the wealthy cities of London and New York, some nine million people were newly infected with tuberculosis worldwide in 2013, and 1.5 million succumbed to the disease. While massive efforts to improve access to care, cut drug costs and halt dangerous antibiotic resistance have saved millions of lives, the advent of HIV and chronic overcrowding in many cities lend the problem an unflagging urgency.
To address it, Archive (“Architecture for Health in Vulnerable Environments”) proposes “bringing attention to the built environment and how it is a transmission vehicle for the spread and control of a respiratory illness like TB,” says founder Peter Williams. While he is quick to note the folly of “pushing one strategy against another,” he suggests it is worthwhile to balance “the emphasis that a city places on treatment and case detection” with a cost-effective prevention that focuses on impactful architectural updates.
An architectural framework for preventing the disease starts with examining buildings of our past — such as 1800s New York tenements through which tuberculosis spread. The idea can seem counterintuitive, if only because few common elements appear to unite the New York City tenements of old — tall buildings on narrow lots, crammed with dark apartments and lacking sufficient water, toilets and ventilation — to the shanties, shipping container-based structures and haphazard sprawl of the developing world today. But Archive explicitly builds from architectural history, and the past informs their current innovations.
“Overcrowding is certainly the commonality,” between diverse environments where TB is prevalent, acknowledges Williams. Much of the effort to reduce tuberculosis involves ensuring that the number of people living within a given space does not rise beyond a safe level, generally defined as more than one person per room. His suggestion involves redesign combined with engaging policymakers in funding necessary changes to housing policy.
Ventilation is the other major issue. Because tuberculosis (and other respiratory infections) spreads via the liquid droplets in coughs and sneezes, a design that manipulates airflow to minimize exposure is important. In developing-world settings, Williams concedes, mechanical ventilation is only commonly found in hospital and similar institutional settings. Other buildings tend to rely on natural ventilation, meaning opening windows and doors. As simple as that sounds, “in some situations,” Williams points out, “there may be a lack of even that.”
To address the problem of poor ventilation, Williams explains, architects use three basic concepts of air flow: cross-ventilation (or allowing air to move all the way through a defined area), plus ventilation designs to take advantage of hot air rising and pockets of still air. Used skillfully, options for manipulating airflow to reduce disease spread are “quite cost-effective,” he says, particularly when compared to the high costs of treating tuberculosis. All can be used as effective means to prevent any respiratory illness, as well as toxic inhalations from using biomass-based cooking fuels indoors.
The metamorphic power of the efforts may be great. In New York, this has already been the case. In the early 1800s, about 688 people for every 100,000 were dying from pulmonary tuberculosis in New York each year. In 2013, data from the CDC notes an infection rate of three people for every 100,000 people nationwide, of whom many no longer die. Along with changes in diagnosis and treatment, improvements in the built environment have vastly improved human health.
That said, it isn’t only health but social equality, comfort and pure beauty that justifies transforming housing. And previous designs from New York and Rwanda hint that the work has the potential to be transformative. An emphasis on beauty has also been integral to a Rwandan hospital built by Mass Design, one of only a few other architectural firms focused on global health. And, over the last two centuries, architecture in New York not only embraced health, but wove it into multifunctional and sometimes pleasant designs, like triple-hung windows designed to maximize cross-ventilation in low-cost housing. Although Archive’s work uses well-documented methods to improve respiratory health, building a better house around any person, tubercular or not, makes good sense.
The “Health Horizons: Innovation and the Informal Economy” column is made possible with the support of the Rockefeller Foundation.
M. Sophia Newman is a freelance writer and an editor with a substantial background in global health and health research. She wrote Next City's Health Horizons column from 2015 to 2016 and has reported from Bangladesh, India, Nepal, Kenya, Ghana, South Africa, and the United States on a wide range of topics. See more at msophianewman.com.