Abstract
Humans, Homo sapiens, are a species of social animals. We thrive in families, clans, communities, and cultures. Our offspring cannot survive without immediate intimate interaction with the mother, and our young must experience lengthy periods of socialization and education, longer than any other animal, before becoming effective members of society or responsible citizens. Humans who do not experience these positive aspects of socialization while growing may become antisocial and dysfunctional.
An international group of colleagues introduced in my last editorial (HERD 14.2) has continued to have virtual conversations on topics that relate to their work with issues of design and human health (Figure 1). In the previous editorial, we discussed person-centered care and environments, and in more recent conversations we began to discuss isolation. The need for massive amounts of medical isolation and social distancing due to the pandemic has caused us to recognize issues that seem to be in opposition to person-centered care. Nirit Pilosof, an architect and researcher from Israel, associate of the Judge Business School at the University of Cambridge, observed: The COVID-19 pandemic has caused the isolation of nations, communities, families, and persons. To avoid mass contamination, countries have closed their borders, isolating themselves from close and far nations. Cities and communities are isolated to control contamination of the broad population. Families are required to isolate themselves at homes under lockdowns, and individuals are isolated due to their contamination or contact with a sick person. On all levels, isolation is driven by fear and a will to control the situation, but it often causes significant disparities and distress. Since the outbreak of COVID-19, virtual communication online has accelerated to overcome the sense of isolation. We are constantly “ZOOMing” to connect with our colleagues, friends, and family, taking advantage of the opportunity to easily connect with distant and wider audiences. Yet, the virtual connectivity does not compensate for our physical isolation. We might be more connected today than ever before, but we are feeling lonelier.
Helle Wijk, a nurse and researcher at the Sahlgrenska University and University Hospital in Gothenburg, Sweden, observed that the use of so much virtual communication, instead of real interactions, highlights human inequities. “The pandemic situation increases isolation for many people,” she says, “due to our different prerequisites for keeping up socialization in relation to ethnicity, poverty, and aging.”
Andrea Möhn, a German architect from Rotterdam who works with highly individualized designs for behavioral health, points out that, “After the pandemic has lasted more than a year, many people feel disconnected from the lives they used to live.” She remarked: There is something that connects us with other people. It’s like an invisible net made from thoughts, feelings and sensorial experiences (head, heart and body). Although it’s invisible it’s “the thing” we deeply need to live and feel alive. Feeling connected to others is one of our most essential needs. We all miss “real connections” in a physical and psychological way. Right now the isolation from each other, forced by the pandemic, has shown negative effects on our mental well-being, caused by a lack of real connection. Feeding off what we hear, see and feel every day, creates the base for our lives. In elderly people with dementia as well as clients with mental disabilities, we see that a lack of stimulus due to forced isolation causes a rapid deterioration of their condition.
Our group, representing five nations, is a perfect example of these new types of communication. We have been meeting regularly for periods of 1–2 hr on a monthly basis. Previous to the influence of the pandemic, we would have been fortunate to see each other once a year at some professional conference and would be unlikely to have more than a half hour together in clusters of two or three; never all six for an extended conversation. Convened by Möhn, our recent discussions turned to the issue of increased isolation and loneliness related to the pandemic. Isolation is required for those who have contracted a contagious disease (in this case we are thinking about COVID-19) and quarantine, which separates and restricts the movements of people which is recommended for those who might be sick or have the disease without showing symptoms.
Stefan Lundin, a Swedish architect with White Arkitekter in Gothenburg known for award-winning behavioral health designs, asked us to consider architecture’s role in human emotions. Emotional issues of isolation, depression, and loneliness that result from separation and removal from other humans is something designers need to consider. Lundin continued: Once again infectious diseases become a threat and reminds us of stress and fear. Our immediate reaction is to keep people apart. Your neighbor might be “your enemy”! If we sense solidarity, we still have to take care. With the help of protective clothing and face masks, we distance ourselves physically and our emotions of fear or compassion is even harder to read in eyes and partial faces. The physical distance tends to be increasingly supplemented with a social one as well. And that´s in a situation where compassion and empowerment is more needed than ever. But in our society, we tend not to isolate just those who are infected. If you have dementia, addiction, asocial behavior as an adolescent, or have committed a crime “you might become a case for the care of society.” Those in custody may experience the worst case of solitary confinement. Will they later show belonging and reduced aggression? We may feel sorry for the victims but also dislike the criminals. They increase our anxiety and fear. Often there is also a dose of cultural distance involved. Could I avoid physical contact? Can someone else take care of the problems? Someone with a lower salary than mine? Although we declare positive human opinions, we are also well aware of the fact that we often fail when these are to be implemented. But still I think we mostly show a human face!
Social Isolation
The concept of isolation raises thoughts about depression, loneliness, loss of control, incarceration (involuntary confinement), and an increase in aggressive behaviors. These outcomes of isolation are extremely negative for those who experience them. Social isolation and loneliness are sometimes described as a condition of housing for the elderly and long-term care (National Academy, 2020). What is wrong with different types of isolation and how might the negative aspects be avoided?
The incidence of social isolation is often identified as a contributor to loneliness and depression in the elderly, but the current pandemic is showing that young people are experiencing new, higher levels of isolation and associated negative outcomes (No Isolation, 2017). The pandemic has created a greater need for lockdowns and greater pressure on younger persons who are experiencing significant social separation and the lack of human interactions. How might the negative aspects of social separation and isolation be addressed and reduced? What role does the physical environment play in the negative aspects? What is right or positive about some types of social separation, such as meditative retreat, and how can it be improved or enhanced?
Möhn noted the increased understanding we are gaining as a result of our experiences with the pandemic. She asked us to think about those experiencing isolation: Because we now understand what isolation means, there is a greater empathy for people who are permanently under forced isolation (think of people in closed facilities) and what this means for their lives. Being isolated from society is one of the harshest things people can undergo as it goes against our primal need as humans.
Institutional Isolation
Some members of society are separated or isolated from the larger population as a result of involvement with some form of institutionalization such as prisons or behavioral health facilities. These people are not isolated because of infection. Lundin reminds us that they are “humans who do not experience the positive aspects of socialization.” One could also look at less restrictive separation from larger society on a scale of isolation. This might include service in the military, attendance at boarding schools, housing for the elderly, monastic life, remote rural occupations, or other instances where individuals are not fully connected to broader society, or their families and culture.
The situation in prisons separates the individual from the larger society, but extreme isolation called “solitary confinement” is considered to be an additional punishment. Research suggests solitary confinement causes adverse psychological effects (Metzner & Fellner, 2010) which may indicate something similar is at play during lockdowns to protect us from COVID-19. Not surprisingly, prisoners separated from society by incarceration but living in high-density settings have apparently been infected by COVID-19 at rates that exceed those of the larger population.
The pandemic has affected the situation for vulnerable patients in psychiatric facilities leading a group from the UK to declare that “Respiratory isolation imposes a significant limitation on an individual’s right to liberty and should be accompanied by appropriate legal safeguards” (Brown et al., 2020, p. 1). Pilosof commented on the institutional situation: “Before COVID-19, mental health patients’ isolation was considered an extreme act only taken in cases that put themselves or others at risk.” Can it be done better?
A model from mental and behavioral health facilities includes graduated levels of socialization. Someone who only feels safe and secure in their room may be able to slowly become comfortable with interaction if the environment is suited to providing supportive space. Perhaps there is a space just outside the room for two people to sit and talk. There might be another setting a bit farther away that accommodates three or four persons. A central area offers more variation for social interaction with dining tables for four, six, or eight and group and common rooms that serve 10 or more for therapy or entertainment. The idea is to provide a graduated scale of spaces for increasing levels of social interaction.
Clinical Isolation
We have always had space for clinical isolation in hospitals (required to be 10% of rooms in the United States), but COVID-19 volumes of patients have far exceeded the capacity of designed isolation rooms and have required ad hoc solutions to allow much larger numbers of isolation beds (Dyer, 2020). COVID has caused us to think about the isolation of infectious and contagious patients in critical care settings during the pandemic. Negative pressure isolation uses mechanical ventilation systems to ensure that airborne contagions do not spread to other adjacent spaces. COVID patients in isolation are confronted by hospital personnel in hazmat suits, gloves, masks, goggles, and are removed from almost all human contact. This seems to be a particularly unfortunate, inhuman condition patients should not have to suffer. It certainly is contrary to the philosophy of person-centered care. Pilosof provided a reaction to the issue of extreme medical isolation: In healthcare settings, isolation is challenging the system. Hospitals are required to isolate COVID-19 patients to protect other patients, staff, and visitors. Patients are left alone, apart from their families in times when they need support more than ever. The Personal Protective Equipment (PPE) creates a barrier between staff and patients, enhancing the sense of isolation in the medical unit. The PPE also isolate staff from their peers, restricting communication and collaboration. Here, too, virtual communication is used to overcome patients’ isolation from their families and among medical staff, but it does not compensate for the human touch needed for care. The current situation where many patients are kept locked in hospital units to supervise their medical condition (and behavior) and isolate them from society raises many ethical issues.
It is clear that for conditions like those of the pandemic and infectious diseases, isolation capability is needed. This is certainly the case for COVID-19 (World Health Organization, 2020). Therefore, clinical isolation is absolutely appropriate, perhaps mandatory, for some conditions. We need to understand what is right or positive about clinical isolation and how it can be improved.
Hospital responses to COVID’s need for isolation of contagious cases has led to some interesting adaptations (ASHE, 2020; Burnette, 2020). Ordinary patient rooms have been modified to provide negative pressure and 100% outside air. Holes have been made in corridor walls, so staff could locate physiologic monitors, infusion pumps, dialysis machines, communication technologies, and other devices in the corridor, thus limiting the number of times a staff member would be required to enter the room. Some hospitals have rapidly built multi-bed isolation units in spaces that previously housed meeting spaces or dining halls. Israel is using underground space for COVID patients that was intended for wartime hospital service. Future designs may need to anticipate the need for adaptation to higher levels of clinical isolation.
Can Design Reduce the Negative Impact of Isolation?
Pilosof asks how we can design healthcare units to better support patients in isolation. A group of Dutch architects collaborating with engineers have suggested that an adaptive hospital might be better prepared for a pandemic through the use of modular adaptations and smart technology (Wiegerinck & Deerns, 2020). They suggest an adaptive hospital could accommodate infected patients without disrupting regular care. Their proposal includes a designated zone that can easily be converted for crisis care, as in the case of a viral outbreak or chemical contamination. One suggestion is consideration of a “hospital within a hospital” to address large-scale outbreaks with a separate triage entrance and a closed circuit of required diagnostic and treatment services, leaving the rest of the facility to continue normal operation.
Are there possible alternate designs for medical isolation care that could allow for greater involvement of family members? A group from Singapore notes that “Physical visits, stays, or care by family members in isolation facilities are usually prohibited, discouraged, or limited to exceptional circumstances” (Voo et al., 2020, p. 1). I was reminded of designs for infectious disease hospitals in China built in response to the SARS epidemic in the 1980s. They feature patient rooms facing south for sunlight as required by Chinese regulations and include an external corridor that passes outside each room by which families can connect with the isolated patient through a large window. Staff circulate in a corridor on the interior that provides access to nursing stations, medications, supplies, utility spaces, or offices and never mix with the families and visitors. The circular infectious disease building at Skåne University Hospital in Malmö, Sweden, also features exterior corridors for families and visitors to see patients through large windows. In this case, they are on outdoor balconies fully exposed to fresh air.
Möhn wondered whether there might be technical solutions for separation better than seeing each other through glass. As one possibility worth exploring, she imagined a powerful air curtain to separate the isolated COVID patient from their family. Pilosof asks whether we can enhance connectivity between the patients to support one another when their families are unable to do so. Pilosof poses a provocative question: “Can patients in a unit form a community?” Can that be possible when care is provided in individual rather than group rooms? I wonder whether some patients otherwise isolated can find social interaction and some sense of community among a committed and consistent team of caregivers. Pilosof further asked, “How can the built environment support the staff working in isolation conditions?” The patients, after all, are not the only ones impacted by the sense of separation and isolation. The staff also experience the limits on interaction and communication.
Wijk noted that there are both positive and negative aspects that have arisen as responses to the pandemic. She wrote: Negative in terms of prohibited possibilities to visit your loved ones at hospitals and at institutions in the municipality, or limited access at the birth clinic for the birthing woman’s partner. There are great difficulties in holding infectious patients with cognitive decline apart from the non-infectious, increased isolation for patients cared for under incarceration, and a dramatically increase in all ages of society concerning psychiatric disease. But fortunately, also positive examples of integrated care like mobile teams providing care in the home of the patient and thereby avoiding the risks entailed by visits to the emergency unit, increased quality of teamwork among staff that before were hindered by organizational or physical borders, and an increase of digital care with faster and more effective care processes.
Participants in the dialogue: Möhn, Hamilton, Wijk, van der Zwart, Lundin, Pilosof.
A positive aspect of the pandemic for some has been the increase in virtual communication. Pilosof pointed out that the communication technology has eliminated barriers between work and home which is part of why we all seem to do more work than before. Wijk noted that the absence of commuting to work or transit between meetings has allowed even more time to be productive. The group wondered why we all seem to increase our workloads rather than find ways to have more free time and relaxation. Perhaps we simply do it because we can or to impress others. The group’s perception is that we may not be serving our personal best interests or improving our individual health during these times of constant work.
Personal and Psychological Isolation
The group was particularly intrigued by the emergence of recognition about the impact of separation on the psychology of individuals. Möhn observed that it seems to get worse the longer we find ourselves so separated. “The whole world is learning what it means,” she added, “to be isolated.” In the absence of normal social behaviors involved with casual interactions at the grocery store, a café, or encounters in the hallway, van der Zwart observed that people must rely almost entirely on their internal psyche. A whole set of choices about how and where to work have been removed. Another remark by van der Zwart suggested that “when this is all over, we will have to completely re-socialize everyone.” The group was clear that there is more about isolation to be considered than social, institutional, or clinical isolation; there is also a personal or individual aspect. Our group of international friends finds these conversations as an important way to combat the worst aspects of our personal separation.
There were comments among the group about how the physical environment might be configured to encourage involvement, and bring people together, instead of being experienced as a barrier to human interaction. In an earlier conversation, van der Zwart asked whether our architecture could be more welcoming. He made the distinction between physical architectural design (the walls, floors, finishing, layout, position of doors and windows) that is more or less permanently anchored by decisions in the design process, and social architectural design, the rooms and places whose character is determined by the way they are used by people, and which is much more related to, changed by, or altered through how the “act of caregiving” is performed.
Möhn asked how we might “design our environment to be a supporting factor against physical and mental isolation?” That is a challenging task for the future. Can we pay greater attention to the way physical space is adaptable for socially supportive purposes? If we are more conscious of the important issues surrounding social, institutional, and clinical isolation, perhaps we can begin to create an architecture that is more welcoming and supportive while still addressing the important functional needs of humanity.