Vaissnavi Shukl
What’s the first thing that comes to your mind when I say the word “care”? Do you think about how you say, “Take care”, to someone? Or do you think about healthcare? But do you ever think of care as a service? Or institutions other than hospitals that provide care? The discourse on care within the field of architecture has recently been gaining a lot of traction, as ideas about health are expanding beyond the Traditional hospitals. I personally had not read enough about care, so I reached out to my old classmate, Fiona Kenney who is currently doing her doctoral research on the spatial expressions of care to talk about the history of residential hospices, long term care facilities, and paediatric respite centres. With the support of the Graham Foundation for Advanced Studies in the Fine Arts, we ask Fione what “care” actually means. And what are these environments within which care is provided?

I am Vaissnavi Shukl and this is Architecture Off-Centre, a podcast where we discuss contemporary discourses that shape the built environment, but do not necessarily occupy the centrestage in our daily lives. We speak to radical designers, thinkers and change makers who are deeply engaged in redefining the way we live and interact with the world around us.

Shall we begin? Doctor-in-waiting since you are the first inaugural episode of Season Five, and we broadly look at the three key words and the three very large discourses in themselves, care, medicine and health and I think we were very mindful of not using healthcare as one word but really separating them out. So, let us actually begin with that word, what is care? How is it different from cure? And, I mean, I was… I was going through your… your dissertation outline, and since you spent so much time researching and reading about it, what struck to me was, I mean, this is my understanding that while care can be a process of cure, it is not necessarily true otherwise, that the idea of cure is not that embedded in the idea of providing care. So how do those two systems care and cure differ in their intentions and their final goals or their successes?

Fiona Kenney
Yeah, I mean, I think this is often the question at the top of any conversation on this topic, and in my opinion, the answer is kind of that care means anything everything and as a result, it sometimes means nothing like it can refer to, like you say, forms of labour, emotion or affective kind of states. It’s an ethical framework. It also can refer to like structures of exploitation. So it’s a really unstable concept that you know, in any different context means something entirely different. I have like a, there’s a really fantastic article that was actually written in the 90s that I’m happy to send along, but it’s…it’s called “Confronting Women’s Caring”, and they talk exactly about this. So you know, it’s been something that people have been confronting for at least 30 years because they, they discuss the fact that care or caring kind of runs a risk of being too broad to be useful at all or can also be too narrowly defined when we understand it solely as kind of like maternal care or like the informal care that’s provided by women in the home to their families. So that’s why it’s so… it’s so great that that’s like kind of your first question, because it is really important to be intentional when talking about this stuff. But at least in the context of in which I use it, there’s an important distinction, firstly, between medical and social care. And so medical care focuses on and I think this is maybe related to the hesitancy to use the word healthcare because I think that kind of aligns itself with… with this medical care idea. So it focuses on kind of fixing the body and we’re trying to get towards a state of cure illness or like being cured. And so care becomes a means towards that end, so we’re going to care for you so that we can get you to a cured state, right. And a lot of care scholars kind of points out that this leads to a really individualistic view of illness. So it’s like health problems in my body, for example, are more easily seen as a result of my own kind of predispositions or actions or anything like that where social or environmental conditions are ignored. So then, in contrast, social care involves the kind of more relational activities so even as simple as feeding or having a conversation with someone bathing, and this… this care is a lot more likely to be carried out by women people see it as less complex. And generally, it’s not as well compensated and people think it requires less formal training, right. So that’s kind of like my outside of architecture, preamble. And then within architecture, I also see even within like that kind of more niche application, there are still a couple different ways that it’s used. So the first is kind of out of science and technology studies where people use care to mean maintenance. So like, synonyms might be preservation or cleaning or repair. So Stephen Jackson’s “Rethinking Repair” uses the word “care” a lot, but it’s not how I would use the word “care”. And then another framing and architecture kind of looks at architecture as a more passive way of kind of housing or providing for these very specific care processes. So writing about kind of the interactions between these two independent domains, so care and architecture on the other hand, right. So scholarship on hospice architecture, I would place under this category, because they kind of asked how does a specific given architecture either hinder or support existing care work, processes or activities, right? And these… These takes, in my opinion, kind of tend to be a little divorced from the larger philosophy of care or architecture. And so the third way that I’m kind of using in my work is attempting to group these different architectures cross typologically so instead of having care and environment or architecture on like to separate and have the conversation, I’m trying to kind of combine them into a third separate entity, so a care architecture, where they are designed to house this explicit care work, but can also kind of contribute to the processes or relations or situations that play out within them? Right. So I guess my answer is like, it’s a lot of different things. It’s complicated outside of architecture, it’s complicated within architecture. And so for that reason, the first step in my work has kind of been just figuring out what… what do I mean, like what do I mean? And I’ve kind of tried to get to that point by mixing and mixing together all these other definitions.

Vaissnavi Shukl
It’s interesting you mentioned the role of gender in doing care work, and we’re going to get to that a little later. But I want to pick up on the last point that you mentioned about the architectures of care and of course your PhD work is looking at centred around the design of care environments. So if you could go into a little bit of depth and talk about what encompasses the care infrastructure, like the physical care infrastructure.

Fiona Kenney
Yeah. So I guess right at the top again, I will just say that I wanted to argue just about anything to be fair infrastructure. But with that in mind, all again, just kind of answered within the context of how I…

Vaissnavi Shukl
Just to poke you a little bit. Do you think a house qualifies as a place for care?

Fiona Kenney
I definitely think there’s a way that… that you could write a paper with that as the argument right. And I’m sure many have. And so I think… I think there’s ways that you could argue that, you know, a school is a care environment, or I don’t know, there’s a lot of care because there’s so many care functions and definitions of care then necessarily, there are so many spaces that could be sort of allied with those functions. But I think… I think it is important to start with kind of the briefest possible historical context. So just to kind of get to this, this place where we’re even able to talk about kind of what I mean by care architectures but so in the English speaking Western world, like at the beginning of the 20th century, the hospital was this place that nobody wanted to go. We were scared of contagion, transmission of disease, people who could afford it would choose to receive private care at home. So you would have a doctor or a nurse come see you at home because you didn’t want to mess with kind of the public dirty hospital that other people if they didn’t have means would have to end up there. Right? And then there was, and I’m simplifying this history, but just in the interest of brevity, there was a huge period where the focus was on kind of technological advance, hospital reform period efficiency was a really important concern at this time, too. And so through kind of the 1920s, the hospital sort of became not a last resort anymore, like people kind of associated these institutions with a really sort of technological efficient scientific cure. So people started to believe actually, it might be better for me to go to this institution, received my keep my care and be cured here and relatedly like at this time, a lot of hospitals started to be affiliated with universities or there were like teaching hospitals and so that kind of also contributed to this image of the hospital as kind of cutting edge at the forefront of, you know, medical advancement. And then the pendulum of course, swings back and by the 60s, the hospitals are seen as too efficient and too scientific and not very caring. Right? So it’s literally kind of a pendulum, the processes become more mechanical. Yeah. And so in the interest of efficiency, maybe people are not getting to spend as much time with the nurse, right, as opposed to the nurses coming to your house. They’re going to be like, really taking care of you focus on you for a given amount of time. So yeah, you can see how things like, you know, technology, science efficiency, when taken to an extreme can kind of contribute to that perception of being in conflict with a certain definition of care, right? And so this is around the same time that new sort of health related facilities besides the hospital came to be and so that’s the moment that I begin my dissertation study. So, I am looking at the 1960s to the 1990s. So right at this period, where these new facilities are emerging, and I am focusing on so, the 60s was a big decade for stuff subsidies or like public long term care facilities. And then in the 70s, you have the first residential hospice in North America. And then in the 80s, the first paediatrics or children’s hospice in the world opened in… in Oxford in the UK, so that’s kind of where I choose that moment. And so, to go back to the cure care dichotomy in the hospital success or like a success has historically been really intertwined with here right because of that, my argument is that the hospital isn’t really an adequate model if we’re talking about care environments, right, like neither philosophically or theoretically, and certainly not architecturally. Because these environments subvert this like medical model of care, and also these older typologies. So it is my sort of proposal that that scholarship should treat them as separate and significant in their own right. So I guess that’s kind of like my framing of character structure and where it comes from. And yeah, just… just carving out place for them to be sort of separate and by virtue of that important.

Vaissnavi Shukl
In the four or five different typologies that you mentioned, I found your observation about the adjacent typology is very important to how we look at care facilities and you kind of note that the design of care environments, whether they are hospices or long term care residences is far removed from the architecture of hospitals and architects who design these care facilities. You are saying that these care facilities actually took cues from domestic architecture and residential building typologies? Can you share a few instances from your research that trace the evolution of these typologies? Because when I was going through stuff, and I extensively went through your bibliography and I was trying to get a hang of things it it seemed like this new emergent typology, or like the multiple variations of it have taken the best from what house or residential typology has to offer and then added a layer of medical care on top of it. So it’s not necessarily medicine at the forefront with care that is more residential, but kind of the other way around. How do you think that that emerged? Was there like a gradual evolution in.. in terms of how they decree what how they eventually took space in a city?

Fiona Kenney
Yeah, I mean, when I mentioned that in the… in the 70s and 80s, there was an entirely new kind of architecture that was emerging. So that being the freestanding residential hospice, so and then the paediatric hospice, so literally a place where people go to receive care for the last usually it’s in a lot I mean, in the States, I believe it’s in the last six months of life. Because of this new or I won’t say because of because that sort of implies a certain dynamic between the two but in relation to a new philosophy, which was the hospice philosophy, this new architectural typology emerged as well. So you know, whatever the relationship was there, I have yet to kind of decide for myself whether it’s sort of a cause and effect thing either way, but essentially, advocates of the hospice movement thought that the traditional health care system wasn’t focused on the right thing. So as we just talked about, like here was always King even when it was very clear that a patient like with cancer, for example, a certain stage and type of cancer, even when it’s clear that a patient would or could not ever be cured, healthcare providers would often still spend their time and resources on attempts at cure, and so advocates for this hospice movement thought that if the patient was the focus instead of of this cure, or instead of the illness itself, that care and kind of alleviating suffering would could then be the primary concern of health care providers.

Vaissnavi Shukl
So just to clarify, was there an alternate do the hospice before the formalisation of hospices in the 1960s? Or was it an entirely new form of an institution that just emerged post like World War Two, if they were ever related?

Fiona Kenney
There were two like I mean, the options before having a dedicated place to spend your end of life the options were either receiving end of life care in the hospital, which is an institution that’s not as we’ve learned, that is not set up for that physicians and healthcare professionals did not receive like specific training in the alleviation of suffering at the end of life with like you know, serious terminal illness, or you would be sick at home, right? And so, we’ll talk I’m sure later about kind of like who that tear work is offloaded onto but so those are the options or you know, as a option B to the hospital, you might end up in a long term care home or you know, like a nursing home, but there was no sort of specialised option where everything was focused on your situation, if that makes sense. Yeah. So it kind of follows that the environments designed to house and support those curative practices and activities would also not be right if we were to shift the focus to the patient or to care at face value. And so like I said, my… My work looks specifically at the architectural results of these changes in attitudes. So the hospice philosophy resulted in the residential hospice and then later the paediatric hospice and public Long Term Care Homes also had their own kind of associated philosophies of care that led to that changing or existing differently. And so the first hospice is explicitly set out to be the opposite of a hospital and a lot of the planners like when I’m doing my archival research, a lot of the people who were not architects but they would be you know, the the champions of the hospice movement, they would specifically say that they would say we don’t want it to look like a hospital. Instead, we want it to be small, comfortable, easy to navigate, like they have all these ideas of what a hospital is, and therefore what they didn’t want, right? And the architecture of hospitals like reflect cultural attitudes about death and dying like the even hospital. Palliative care units are never kind of front and centre on the first floor right by the entrance, right like they’re going to be relegated to a higher floor or the back of the building, like it’s not something that… that any hospital wants to advertise, and even kind of storage space or transportation. space for dead bodies is like, you know, it’s… it’s a whole thing. It’s not going to be sort of front and centre. But as you mentioned, like architects have looked to domestic architecture because they’ve assumed that that’s going to be the most comforting thing, like if you can’t be at home, we’ll try to make this facility look like what we think your home might look like. Right? Things like a lot of sort of decor tricks, like having fireplaces or like certain kinds of furniture or plants or windows. Yeah. Which I mean, opens up a whole other can of worms, sort of in terms of problematics my doctoral supervisor, Anne Marie Adams, she has written about why that’s problematic because of course, who decides like they often lean on a really specific middle class vision of what a home looks like, like who’s to say that that’s going to be comforting to everybody who comes into the hospice, right? This has led to a really, really interesting problem, which for… like a design and conceptual problem, which is the lack of a distinct typology for these environments. And so, the architectural historian Charles Jencks, who was one of the co-founders of the Maggie’s Centres, the mega centres are a series of data centres in the UK for cancer patients. And Charles Jencks being an architect himself kind of started this movement where all these you know, famous starchitects you might call them like design their own sort of Cancer Centre. So like Zaha Hadid did one, so like huge names kind of bringing architectural attention to cancer care, which is, you know, interesting, but he famously referred to these centres as “Non-types”. So, like for Charles James, he presents the…the type is just a Non-type like that’s a proper noun in this context. And so the bulk of the existing discourse around these buildings really focuses on what these buildings should not be and should not represent or like should not reference rather than what they ought to be or what they are in practice. So there’s this tension of like making reference to domestic space to encourage you know, patient comfort, but also referencing institutional space enough so that family members believe that their loved one is in good hands. And so it has to be home like but it’s not a home and it’s hospital like but it can’t be an institution. It’s this whole like tension. And so in order to design for these contexts, you kind of have to know what is missing, you have to know what could have been there, right? So you kind of you have to have an intimate knowledge of domestic architecture or hospital architecture of like these different typologies in order to kind of whittle them away and reveal the hospice Non-type, if you know what I mean. So, my… my work or my interest was kind of born out of that challenge like how would care environments be different if we could even adequately speak about them, right?

Vaissnavi Shukl
Has it changed from when Charles Jencks called it a Non-type to say 2023. Now I’m sure the Zaha Hadid building won’t be that old but in the current discourse of care design, do you think it has now found like a place in terms of being identified as an architectural typology? Or do you still think there’s so much room for interpretation that for the lack of a better definition continues to be a Non-type or has there been? I don’t know. You know, like, have you set out to design a hospital there are now a lot of rules, a lot of guidelines, a lot of bylaws in place that go in simple things like design of an operation, theatre circulation lifts designed for disability, you know, whatever. But is… has there been any progress on… on this front or not?

Fiona Kenney
It’s definitely changing. So even with hospital design, like we’re already seeing some of those things that I mentioned about kind of relegating palliative care to the back corner. We’re seeing changes in that respect, and definitely over the last 10, maybe even less than 10 years, like six, seven years, there’s been a lot more scholarship on hospice architecture and end of life architecture. And I mean, certainly since the pandemic like long term care, infrastructure has… has kind of come into the spotlight and been revealed to be quite problematic, too. So we’re kind of like at an interesting moment where many more people are talking about it. So I anticipate that in the near future, like that will be somewhere that we can, that’s kind of like an endpoint that we can arrive at, but I don’t think it’s there yet. And I think another problem is that there is so little there’s kind of a problem of precision when we’re talking about these environments. Like for example, the Maggie Centres, they’re not residential, like they’re day centres for people with cancer.

Vaissnavi Shukl
So for somebody who wants to go get like chemotherapy or something like throughout the day would go and then leave by night.

Fiona Kenney
Yeah, so it’s not residential. Exactly. So it’s like, there’s day programmes like spiritual care or like, you know, through group discussions, that kind of thing. So it’s like a beautiful place to go receive different kinds of social support during the day, but it’s interesting, because, you know, a lot of the big books on hospice architecture include the Maggie Centres, because they’re probably the most well known kind of cancer architecture in the world. But programmatically, like I say, like they’re, it’s very different from the needs or the requirements of a residential hospice because you know, it’s not 24/7 care so it’s kind of interesting there too, because because there are so few people writing about it and like I say, it is it is kind of coming into the forefront but with so few people talking about it, the discourse just really being at this early stage, like there’s just so there’s really a need for precision and language and kind of collaboration across disciplines to kind of get to a point where we can figure out if a distinct typology is necessary, what that typology would mean, how do we achieve it?

Vaissnavi Shukl
I want to turn back to something that you mentioned early on about the role of gender. And I want to reference something that I saw a couple of weeks ago on Netflix, so there’s this documentary called working. Give me one sec. I’m going to check. I think it’s working. I think it’s working. Yeah. And it is hosted by Barack Obama and he takes a deep dive into the nature of work and he looks at three different industries. So he does like a case study of people working at different levels in a hotel. So that’s the hospitality industry. And he looks like an autonomous driving vehicle company, so the tech industry. And he looks at the nature of work in this organisation, which train staff to go provide care in mostly senior citizen households so that so the care industry and something he talks about it explicitly but it was quite evident that the presence of the men was ubiquitous when it came to the care industry, which was not the case in the other two segments. Hospitality of course, he looks at people right from the CEO to people who are working in housekeeping. So of course, there were women at the lower level housekeeping. Maybe some of them are working in catering, food and beverage, but in this particular company, the care industry it was predominantly women. And this is also something that we spoke about when we were part of the men in design, and we often spoke about the role of care in how labour is acknowledged or recognised and how a lot of care work that women do in their day to day lives is… is not accounted for is… is not compensated for. And so now that you’re looking at care in a slightly more formal manner as a doctoral dissertation, and you’re also looking at its relationship to the feminist theory and the movement that was going on the other day, throw some light on, on the Nexus and, and everything floating in the space.

Fiona Kenney
Well, yeah, I’m happy you brought up women in design. I haven’t had it was like it brings you back for a thesis semester at the… at the GSD which is related. My master’s thesis supervised by John Peterson was kind of an attempt to map care ethics on to the practice and profession of architecture. And care ethics is kind of a moral framework that has in some ways sort of been debunked or problematized. Since but not since my thesis, but since the the care ethics came out, but that sort of argues or comes out of a place where a lot of Western moral thought has kind of foregrounded rationality or like male values, like traditionally associated with men, rationality, logic, these kinds of things. And so the scholars who propose this alternative, so, Nel Noddings, Carol Gilligan kind of argue that there’s there’s a way to foreground instead of empathy and relationality instead of rationality, and more sort of, typically feminine values in the way that we make and the way that we carry out ethical decision making or moral decision making in our day to day lives. But everything that I’ve only because like kind of no matter how you slice care, there’s always a gendered dimension. And so the an important place to start with the Netflix documentary is that not only is the care work, largely carried out by women but even just evident in the sort of microcosm of that documentary like race class, immigration status also plays a huge role in the story and yeah, it’s… it’s not difficult to see how that is very closely related to like the constant under valuation or invisibility of care work and care workers, right? And it kind of mirrors in a way the… the ways that like the architectures of ageing and dying are everywhere in our cities, but like, still remain sort of socially, culturally, literally invisible. And I was just before getting on this call, I was rereading a book called ‘The Care Crisis’, by Emma Dowling, I believe she’s British, but she has this concept that she calls care offloading, whereby instead of production if you picture like a factory instead of production, moving to a place where labour is cheaper, with care work, the workers move or are kind of recruited to move to a place where care work is needed. And it’s often it’s actually kind of gets into the nitty gritty of sort of, you know, the feminist thinking, which is like it’s often white and middle class women who offload their care work. To other women, right, like women of colour or sort of lower class women or immigrants or whatever. So it’s such a complicated conversation, but it is just interesting how, like I say, there are so many definitions to the word care, but sort of no matter how you get at it, there is still this sort of gendered or sort of inequity piece. So like I say, my dissertation takes one care environment from each decade and place. So in the 60s I’m focusing on the work of Canadian architect Pamela Cluff, so she was a big figure in long term care in Ontario, Canada. And then for the 70s. I’m looking at architect Lo-Yi Chan’s design for the first residential hospice in North America, which was in Connecticut. And then, like I mentioned, John Bicknell is designed for Helen House, which was the first paediatric hospice in the world and it’s in the UK. But so what’s interesting with this with the work and kind of, as I said, sort of surprises at every turn, that it does keep coming back to sort of gender and feminist theory and kind of women’s work is that even with the latter two projects and chapters that I’m writing despite the architects being men, I have found that these projects each had non architect women, incredibly involved in the actual architectural processes themselves. So these are women, not with architectural backgrounds, but with backgrounds in either professional caring, so nurses or religious figures or for women with just care roles within their own family. And so a woman who was really involved in the establishment of the paediatric hospice was a woman in Jacqueline Worswick and she was… she cared for her own child who was terminally ill and was because of that really involved in the architecture and the setup of that hospice. So it’s just interesting how, even if I don’t explicitly go out looking for this sort of gendered connection, which I kind of am doing, they still reveal themselves as part of this like narrative about the invisible contributions of… of these women to the resulting care architecture. So not only do women kind of invisibly contribute to care and the care work, but I’m also finding this parallel narrative of women kind of invisibly contributing to the architectures of care themselves.

Vaissnavi Shukl
And I’m sure I don’t know if they will recognise as contributors to the project or were they always still at the… at the back foot as…they are in such…

Fiona Kenney
There’s a range like in the context of the Connecticut hospice, there are a lot of women sort of central characters to that story, but their central for their… Their work, like the literal example is Florence Wald, who was dean of the Yale School of Nursing. She was one of the founders of the first hospice residential hospice in North America. And so she’s very well known and kind of credited for her nursing role, but I think it’s interesting how when I go through the day to day documents of the establishment that hospice she was so incredibly involved in turning the brief into the finalised, like realised architectural project. So she’s recognised as a nurse, but she also had a really sort of central and important hand in the development of the architecture, specifically. And it’s kind of the same thing with the Helen House story of women kind of being credited for their sort of literal on paper role, but then discovering these kind of almost under the table contributions in different ways, and real interactions with the architecture itself and the architect.

Vaissnavi Shukl
So you’re three years into your doctoral study, where are you with the research, what’s next? And what do you plan on doing with this wonderful topic? And if you want to also talk about your engagement, your recent engagement with the new organisation.

Fiona Kenney
Yeah, so yeah, I’m… I’m just finishing my third year so talking along hoping you know, the next year to to have like a full draft put together. I am travelling to the UK in October to do some kind of final archival research on the paediatric hospice out there. So yeah, still still very much getting there. And then yeah, like you mentioned, I also am working with the Canadian Palliative Care Research Collaborative. So I’m doing that kind of is parallel. And it’s really interesting to have that more direct contact with people who do this kind of work. So it’s actually pairing quite nicely with my dissertation of having this real, like architectural history context and working with my supervisor, my, you know, peers at McGill, and then also having this piece where I get to actually work everyday with palliative care providers and researchers and patients and caregivers. So yeah, hopefully like a year or two years, but it’s kind of all coming together quite nicely right now.

Vaissnavi Shukl
Very excited for you and I’m really looking forward to the dream you’re living of having a doctor in front of your name. So good luck with that, and thank you for this conversation.

Fiona Kenney
Thank you, Vaissnavi. So nice to talk with you again.

Vaissnavi Shukl
Special thanks to Ayushi Thakur for the research and design support, and Kahaan Shah for the background score. For guests and topic suggestions, you can get in touch with us through instagram or our website through our website archoffcentre.com, both of which are ‘archoffcentre’. And thank you for listening.