Design for Health

Emmanuel Tsekleves, Rachel Cooper, Emmanuel Tsekleves, Rachel Cooper

• Publisher: Routledge
• Year: 2017
• ISBN:
  9781317152491
• Edition: 1
• Topic: Diseño
• Subtopic: Diseño general

One of the most complex global challenges is improving wellbeing and developing strategies for promoting health or preventing 'illbeing' of the population. The role of designers in indirectly supporting the promotion of healthy lifestyles or in their contribution to illbeing has emerged.This means designers now need to consider, both morally and ethically, how they can ensure that they 'do no harm' and that they might deliberately decide to promote healthy lifestyles and therefore prevent ill health.

Design for Health illustrates the history of the development of design for health, the various design disciplines and domains to which design has contributed. Through 26 case studies presented in this book, the authors reveal a plethora of design research methodologies and research methods employed in design for health.

The editors also present, following a thematic analysis of the book chapters, seven challenges and seven areas of opportunity that designers are called upon to address within the context of healthcare. Furthermore, five emergent trends in design in healthcare are presented and discussed. This book will be of interest to students of design as well as designers and those working to improve the quality of healthcare.

Part I

Setting the scene

1A brief history of Western medicine and healthcare

Chris Rust

Non-Western systems of healthcare, particularly those of China and India, have their own important foundation of scholarship and experience, but for most readers of this book, the Western medical tradition will dominate their work and sets a great part of the agenda for designing.¹ To understand the forces at work in that tradition it is a good idea to know something about its history, which might be considered as a play with four acts, each one shorter and more intense than its predecessor.

Act 1 starts in prehistory, finds its feet with the ancient Greek and Egyptian doctors and philosophers and comes to a climax around AD200 with the work of Galen of Pergamum, doctor to the Emperor Marcus Aurelius. In Act 2, Renaissance scientists start to question the body of accepted wisdom inherited from Galen and his predecessors and develop a new understanding of anatomy. Act 3 begins when 19th-century doctors start to develop a modern professional/academic framework and recognise that they do not have effective ‘cures’ for most of the serious diseases. They commit themselves to systematic investigation of illness while developing a tradition of care, which emphasises personal support rather than cure. Finally, around 1940, Act 4 starts when the preceding century of research starts to bear fruit and doctors go on the attack with a growing armoury of drugs, therapies and diagnostic tools that transform their role from carer to technologist.

Today’s healthcare institutions are products of Act 4 but they still carry the imprint of the previous acts and some of the answers to problems in today’s system may well be found in those earlier ideas and practices, as we will see.

The story outlined above does have one serious omission. The art of surgery has strong connections to our four-act play but it has also marched to a different, often military drummer. Surgery is interesting to many designers and it is discussed in more detail later on in this chapter.

Act 1: from prehistory to the Roman Empire

Archaeologists have established that the surgical procedure of trepanning, drilling a hole in the skull to relieve pressure on the brain, was practiced 10,000 years ago when the only tools available were made of sharpened stone. It is fascinating to speculate on the events and ideas that led people to fashion a tool to invade a skull in this way. Whatever the genesis of the practice it is notable that people still undertake it outside mainstream medicine and claim great benefits from a spiritual and wellbeing perspective (Dobson, 2000) as well as an approach to specific illness.

The first well-documented studies of medicine in the Western tradition are found in ancient Greece and include Eristratus’ investigations of anatomy and the empiricists’ focus on identifying successful therapies by reviewing past experience. At that time Egypt and Greece had a wide range of specialist physicians using a variety of surgical procedures and a review of Indian surgery compiled during that period lists 121 different surgical instruments (Porter, 1996: 203). This act culminates in the work of Galen of Pergamum who emphasised both the study of anatomy and a rigorous approach to observing and diagnosing illness. His writings became the principal source of medical knowledge for succeeding generations. After him, the long drawn-out decline of the Roman and Greek civilisations led to an emphasis on preserving and interpreting Greek philosophy and science that came to be seen as the wisdom of the ancients, rather than a living body of knowledge that might be questioned and advanced.

Act 2: the Renaissance

The Renaissance changed all that. In 1543 Andreas Vesalius published On the Structure of the Human Body, a study of anatomy that broke the ancient authorities’ hold on medical knowledge, and anatomical investigation became the foundation of modern medical science. This did not come out of the blue. A series of innovations, including the growth of hospital-based care from around AD400, the establishment of a medical school in Salerno in 1080 and the creation of Italian city ‘health boards’ in the 1400s to develop public health strategies in the face of the Black Death, all point towards new kinds of healthcare and provided an audience for Vesalius’ work. Medieval medicine had been based on communal consensus but these new institutions and rules created a divide between people and practitioners that we can recognise in today’s institutions.

With the rise of anatomy, the new ‘natural philosophy’ of the Renaissance promoted the idea that the body was a kind of machine and Descartes formalised this by asserting that the mind or soul has consciousness but all else obeys mechanical laws. Physics and chemistry became the methods to understand our bodies and our health and by the time the Industrial Revolution was underway we had a large and growing body of scientific knowledge together with evidence, from industry, that it had practical uses.

Act 3: taking stock

Shall we begin by taking it as a general principle – that all disease, at some period or other of its course, is more or less a reparative process… an effort of nature to remedy a process of poisoning or of decay, which has taken place weeks, months, sometimes years beforehand, unnoticed, the termination of the disease being then, while the antecedent process was going on, determined?

(Florence Nightingale, 1860)

Despite the great increases in our understanding of health during the 18th and 19th centuries, little changed in our ability to cure sick people. Infectious diseases were the main cause of illness and death and doctors came to realise that their medicines and therapies could not much affect the course of these infections (Shorter, 1996: 142). This new realism is reflected in the quote above from Florence Nightingale who believed, with good reason, that the outcome of a disease was largely predetermined and all her efforts were aimed at giving the patient the best chance of surviving the process through good nursing care, nutrition and a healthy environment.

The other side of this coin was the growth of the study of illness itself, adding pathology to the established sciences of anatomy and physiology. Increasingly, doctors were expected to apply scientific methods to healthcare and the growth of large public hospitals gave them a laboratory for the study of sick people. As doctors became part of a more unified system of education and licensing they also gained a new idea about their purpose in life. For the leaders of the profession the study of diseases became their priority and patients who came to hospital for care and comfort became statistical examples of their condition, studied in great numbers to gain a better understanding of how each disease worked.

This was not immediately helpful to more humble practitioners who still had to make a living in their communities and whose patients still hoped for a cure. However, it led to a new approach to medical practice from around 1880 to 1940, known as the ‘patient as person’ movement. Doctors might not have had effective cures, although they still prescribed pills since that was what patients wanted, but they could provide a different kind of therapy. By listening to the patient, examining them and paying attention to their condition a doctor provided very practical help to people struggling through illness. This approach, which we now characterise as ‘old-fashioned’ doctoring, was greatly appreciated by patients and has been described by a modern psychotherapist as ‘Practising psychotherapy without ever studying it’ (Shorter, 1996: 143).

The new kind of doctoring was characterised by careful history-taking, physical examination and the use of an increasing range of diagnostic tools including thermometers, microscopes, stethoscopes, x-rays and electro-cardiographs. All of these found their way into the general practitioner’s toolkit and designers should reflect on the way that this widespread use of scientific tools gave patients reassurance and a feeling that their illness was important. However, of equal importance was the role of the doctor in administering the tests and giving personal attention to the patient.

During this period there were great improvements in urban people’s health and life expectancy, but it is usually argued that this flowed mainly from better nutrition, sanitation and living conditions, supported by public health policies and a general concern for improving the quality of life in towns, rather than from any medical treatments developed by science. However, that picture was to change, and very rapidly.

Act 4: doctors go on the attack

Whither Medicine?… Why whither else but straight ahead.

(Lord Horder, 1949)²

In 1935 the first ‘sulpha’ drugs were identified and doctors finally had a treatment for a range of infectious diseases. This was followed by the introduction of antibiotics and successful treatments for cancer and heart disease and the whole emphasis of healthcare changed. Doctors had cures in their repertoire and they had increasingly subtle ways to diagnose illness; the old emphasis on personal contact and support faded away as medicine became more specialised and technical.

The new scientific technique of the clinical trial became ever more important in working out which therapies were most effective and safest, hospitals became dominated by technology and the role of nursing was overshadowed by that of the hospital doctor, an often remote figure who prescribes treatment but may have very little contact with the patient. The design of hospitals has been led mainly by the technical requirements of medical specialisms and a hospital’s ‘mission’ can become confused by modern concerns with productivity or the increasingly uneasy relationship between the medical establishment and patients who want the benefits of modern medicine but find its environment to be alien.

The self-confidence of late 20th-century medicine has led to some well-publicised disasters that add to public concern and make individuals increasingly willing to challenge the authority of doctors and hospitals. The loss of the old-style personal care by general practitioners has led people to look for alternative kinds of healthcare provided by complementary therapists who can still give time and personal attention.

The past 60 years has seen an astonishing change in healthcare and none of us would willingly return to earlier times, especially if we suffer from cancer or need a new hip joint, but the picture is not uniformly positive and there are shortcomings in today’s system that need our attention. Designers can shoulder some of the blame for difficulties that people experience as patients or professionals in healthcare but we also have an opportunity to make a big difference, by creating the environment for all of us to understand what is happening to us, feel supported and cared for and have the conditions we need for good healing. In tandem we can do a great deal to help health professionals to be both effective and satisfied in their work.

The art of surgery

As mentioned already, the development of surgery has not followed the same timetable as other medical practices and in some respects it has led the way.

Until modern times surgeons had lower status than physicians. They did manual work, getting their hands and clothes dirty with blood and pus, and their work was seen as a craft, likened to the work of butchers and barbers, rather than an intellectual profession suitable for educated men. During the 19th century, this situation was gradually reversed and surgeons came to enjoy the highest status of any medical practitioner, casting off the stigma of the ‘barber surgeon’.

It is not true that most surgeons were simply barbers who turned their hand to amputation. Up to the 18th century they might have done some barbering to keep up their income when surgical cases were not plentiful but there were plenty of well-trained, knowledgeable people in the profession. Their work was not as dramatic and bloody as often portrayed. It included dealing with skin complaints, wounds, ruptures, bone setting and the occasional amputation. Most of the surgery we know today was impossible before the mid-19th century although operations had been developed to remove, for example, bladder stones or breast tumours.

That picture was transformed by the twin innovations of anaesthesia and antisepsis (or asepsis as it became once we understood how to sidestep infection rather than just block it with chemicals). With these radical new techniques, operations that would have been excruciatingly painful and accompanied by shock and fatal infections became relatively bearable and safe. A century before the big advances in drug-based therapies allowed physicians to go on the attack against disease, surgeons could embark on a host of inventive new treatments which propelled them to the forefront of medicine.

Before that the main stimulus for surgeons was warfare, which ensured a plentiful supply of interesting wounds and broken bones to test their skills and inventiveness; many leading surgeons learned and advanced their trade in the navy or army. For example, the introduction of firearms led to much more complicated injuries with shattered bones and a greater risk of infection, demanding new surgical techniques. War provided a great number of cases to experiment on and gradually that experience led to better treatments, such as amputation techniques designed for better healing and to ease the fitting of artificial limbs.

When faced with a non-military problem, surgeons used the plentiful supply of poor people for their experiments. In France the huge public hospitals, which had become showcases for the study of pathology, also provided patients for surgeons to practice on. In the southern United States the abundant supply of slaves also stimulated surgical innovation. We may look back on these times and feel that our modern society has put such abuses behind us but it has been argued (Srinivasan, 1998) that practice has merely moved on to reflect changing conditions, using patients in poor countries for medical experiments as the supply...